Clinical quality improvement: eliminating unplanned extubation in the CCU.

PURPOSE: This article aims to explore coronary care unit (CCU) extubation structures, processes and outcomes. There were 13 unplanned-extubation cases (UE) among 251 intubated patients (5.2 per cent) in a cardiologist-led CCU in 2008. Seven did not require re-intubation, implying possible earlier extubation. A quality improvement project was undertaken with a goal to eliminate CCU UE within 12 months. DESIGN/METHODOLOGY/APPROACH: Using the clinical practice improvement (CPI) method, the most significant root causes were missing sedation/analgesia protocol, no ventilator weaning protocol and absent respiratory therapist during the CCU morning rounds. Non-physician directed sedation/analgesia and ventilation weaning protocols were created and put on trial in Plan-Do-Study-Act cycles before formal implementation. Arrangements were made to allocate a respiratory therapist to the CCU daily for morning rounds. FINDINGS: For 12 months after fully implementing the interventions, UE incidence dropped from 5.2 per cent to 0.9 per cent (p = 0.006). There were no adverse outcomes, re-intubation and/or readmission to CCU within 48 hours. PRACTICAL IMPLICATIONS: Through a multi-disciplinary CPI approach, adopting non-physician directed protocols has successfully streamlined and improved airway management in mechanically ventilated patients in a cardiologist-led CCU. ORIGINALITY/VALUE: There is little published data on improving intubated patient care in cardiologist-led CCUs. Previous studies centered on intensive care units managed by critical care specialists.

3D printed patient specific customised surgical jig for reverse shoulder arthroplasty, a cost effective and accurate solution.

INTRODUCTION: The reverse shoulder arthroplasty is a common orthopaedic procedure, where placement of the initial guiding wire is paramount to the implant instrumentation and position. To improve the position of the guiding wire, navigation and patient specific instrumentation have been used. These are however expensive and lengthy with many logistical issues. MATERIAL AND METHODS: We utilised in house 3D printing to create a surgical guide to help with positioning of the central guiding wire. Pre and post op CT scans were utilised to determine positioning of the central screw. RESULTS: Position of the screw tip was a mean of 3.3 mm away from the central point of the thickest portion of bone in the scapula with good bony purchase. There were no complications reported. DISCUSSION: We report our experience in creation of the 3D printed surgical jig and the pearls of its creation, detailing from CT scan image acquisition to creation of surgical guide to intraoperative usage. 3D printing is a cost effective and accurate solution for the positioning of orthopaedic instrumentation. This can be easily applied to other operations in our institution, even with a low start up cost.