Effectiveness of interprofessional tracheostomy teams: A systematic review.

AIM(S): To systematically locate, evaluate and synthesize evidence regarding effectiveness of interprofessional tracheostomy teams in increasing speaking valve use and decreasing time to speech and decannulation, adverse events, lengths of stay (intensive care unit (ICU) and hospital) and mortality. In addition, to evaluate facilitators and barriers to implementing an interprofessional tracheostomy team in hospital settings. DESIGN: Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Johns Hopkins Nursing Evidence-Based Practice Model's guidance. METHODS: Our clinical question: Do interprofessional tracheostomy teams increase speaking valve use and decrease time to speech and decannulation, adverse events, lengths of stay and mortality? Primary studies involving adult patients with a tracheostomy were included. Eligible studies were systematically reviewed by two reviewers and verified by another two reviewers. DATA SOURCES: MEDLINE, CINAHL and EMBASE. RESULTS: Fourteen studies met eligibility criteria; primarily pre-post intervention cohort studies. Percent increase in speaking valve use ranged 14%-275%; percent reduction in median days to speech ranged 33%-73% and median days to decannulation ranged 26%-32%; percent reduction in rate of adverse events ranged 32%-88%; percent reduction in median hospital length of stay days ranged 18-40 days; no significant change in overall ICU length of stay and mortality rates. Facilitators include team education, coverage, rounds, standardization, communication, lead personnel and automation, patient tracking; barrier is financial. CONCLUSION: Patients with tracheostomy who received care from a dedicated interprofessional team showed improvements in several clinical outcomes. IMPLICATIONS FOR PATIENT CARE: Additional high-quality evidence from rigorous, well-controlled and adequately powered studies are necessary, as are implementation strategies to promote broader adoption of interprofessional tracheostomy team strategies. Interprofessional tracheostomy teams are associated with improved safety and quality of care. IMPACT: Evidence from review provides rationale for broader implementation of interprofessional tracheostomy teams. REPORTING METHOD: PRISMA and Synthesis Without Meta-analysis (SWiM). PATIENT/PUBLIC CONTRIBUTION: None.

COVID-19: Implications for Nursing and Health Care in the United States.

PURPOSE: COVID-19 and other recent infectious disease outbreaks have highlighted the urgency of robust, resilient health systems. We may now have the opportunity to reform the flawed health care system that made COVID-19 far more damaging in the United States (U.S.) than necessary. DESIGN AND METHODS: Guided by the World Health Organization (WHO) Health System Building Blocks framework (WHO, 2007) and the socio-ecological model (e.g., McLeroy et al., 1988), we identified challenges in and strengths of the U.S.' handling of the pandemic, lessons learned, and policy implications for more resilient future health care delivery in the U.S. Using the aforementioned frameworks, we identified crucial, intertwined domains that have influenced and been influenced by health care delivery in the U.S. during the COVID-19 pandemic through a review and analysis of the COVID-19 literature and the collective expertise of a panel of research and clinical experts. An iterative process using a modified Delphi technique was used to reach consensus. FINDINGS: Four critically important, inter-related domains needing improvement individually, interpersonally, within communities, and for critical public policy reform were identified: Social determinants of health, mental health, communication, and the nursing workforce. CONCLUSIONS: The four domains identified in this analysis demonstrate the challenges generated or intensified by the COVID-19 pandemic, their dynamic interconnectedness, and the critical importance of health equity to resilient health systems, an effective pandemic response, and better health for all. CLINICAL RELEVANCE: The novel coronavirus is unlikely to be the last pandemic in the U.S. and globally. To control COVID-19 and prevent unnecessary suffering and social and economic damage from future pandemics, the U.S. will need to improve its capacity to protect the public's health. Complex problems require multi-level solutions across critical domains. The COVID-19 pandemic has underscored four interrelated domains that reveal and compound deep underlying problems in the socioeconomic structure and health care system of the U.S. In so doing, however, the pandemic illuminates the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to better serve the health care needs of the entire population. This article highlights the pressing need for multi-level individual, interpersonal, community, and public policy reforms to improve clinical care and public health outcomes in the current COVID-19 pandemic and future pandemics, and offers recommendations to achieve these aims.

Implementation of an evidence-based accidental tracheostomy dislodgement bundle in a community hospital critical care unit.

BACKGROUND: Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency. AIM: To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD. MATERIALS & METHODS: A multidisciplinary team with expertise in tracheostomy developed a 3-part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID-19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post-implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self-Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE). RESULTS: Twenty-four participants completed pre-test and post-test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR = 1.0) pre-test to 5.0 (IQR = 1.0) post-test. The median comfort level score increased from 38.0 (IQR = 7.0) pre-test to 40.0 (IQR = 5.0) post-test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU. DISCUSSION: This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians - definitive management of ATD should adhere to comprehensive multidisciplinary guidelines. CONCLUSIONS: ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events. Relevance to Clinical Practice A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.

Effects of a Dedicated Inpatient Diabetes Management Service on Glycemic Control in a Community Hospital Setting.

BACKGROUND: Community hospitals account for over 84% of all hospitals and over 94% of hospital admissions in the United States. In academic settings, implementation of an Inpatient Diabetes Management Service (IDMS) model of care has been shown to reduce rates of hyper- and hypoglycemia, hospital length of stay (LOS), and associated hospital costs. However, few studies to date have evaluated the implementation of a dedicated IDMS in a community hospital setting. METHODS: This retrospective study examined the effects of changing the model of inpatient diabetes consultations from a local, private endocrine practice to a full-time endocrine hospitalist on glycemic control, LOS, and 30-day readmission rates in a 267-bed community hospital. RESULTS: Overall diabetes patient days for the hospital were similar pre- and post-intervention (20,191 vs 20,262); however, the volume of patients seen by IDMS increased significantly after changing models. Rates of hyperglycemia decreased both among patients seen by IDMS (53.8% to 42.5%, P < .0001) and those not consulted on by IDMS (33.2% to 29.9%; P < .0001). When examined over time, rates of hypoglycemia steadily decreased in the 24 months after dedicated IDMS initiation (P = .02); no such time effect was seen prior to IDMS (P = .34). LOS and 30DRR were not significantly different between IDMS models. CONCLUSIONS: Implementation of an endocrine hospitalist-based IDMS at a community hospital was associated with significantly decreased hyperglycemia, while avoiding concurrent increases in hypoglycemia. Further studies are needed to investigate whether these effects are associated with improvements in clinical outcomes, patient or staff satisfaction scores, or total cost of care.

A polymicrobial fungal outbreak in a regional burn center after Hurricane Sandy.

OBJECTIVE: To describe a polymicrobial fungal outbreak after Hurricane Sandy. DESIGN: An observational concurrent outbreak investigation and retrospective descriptive review. SETTING: A regional burn intensive care unit that serves the greater Baltimore area, admitting 350-450 burn patients annually. PATIENTS: Patients with burn injuries and significant dermatologic diseases such as toxic epidermal necrolysis who were admitted to the burn intensive care unit. METHODS: An outbreak investigation and a retrospective review of all patients with non-candida fungal isolates from 2009-2016 were performed. RESULTS: A polymicrobial fungal outbreak in burn patients was temporally associated with Hurricane Sandy and associated with air and water permeations in the hospital facility. The outbreak abated after changes to facility design. CONCLUSIONS: Our results suggest a possible association between severe weather events like hurricanes and nosocomial fungal outbreaks. This report adds to the emerging literature on the effect of severe weather on healthcare-associated infections.

Pseudo-outbreak of Penicillium in an outpatient obstetrics and gynecology clinic.

We report an unusual pseudo-outbreak of Penicillium that occurred in patients seen in an outpatient obstetrics and gynecology clinic. The pseudo-outbreak was detected in late 2012, when the microbiology department reported a series of vaginal cultures positive for Penicillium spp. Our investigation found Penicillium spp in both patient and environmental samples and was potentially associated with the practice of wetting gloves with tap water by a health care worker prior to patient examination.