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.

Cardiopulmonary rehabilitation after treatment for lung cancer.

Lung cancer is the leading cause of cancer-related death in women and men in the United States. As of 1987, lung cancer deaths in women exceeded deaths caused by breast cancer. Despite years of research and improvements in surgical, chemotherapeutic, and radiation treatments, this fact remains unchanged. Equally dismal is that the expected 5-year survival rate for all patients with lung cancer is 15%. Although hidden in this number is improved survival for many patients who have early disease, it still translates into significant morbidity and early mortality for many patients. Although prevention is key, optimizing the care of these patients with lung cancer is also paramount. Cardiopulmonary rehabilitation programs have been shown to be effective in treating patients with chronic heart and lung diseases, among other illnesses, regardless of prerehabilitation functioning. Not only do morbidity and mortality from cancer hinge directly on premorbid functioning, health, and status, but functional status as a measure of baseline health is a reliable prognostic indicator for patients with lung cancer. As a result, including a program of exercise in any treatment regimen for cancer is sensible. However, rehabilitation in patients with lung cancer has not been studied well. Data on rehabilitation in patients with other cancers and illnesses (eg, chronic obstructive pulmonary disease) are clear in the beneficial effects of supervised exercise on quality of life (QOL). To assess the role of cardiopulmonary rehabilitation in patients with lung cancer undergoing treatment, it is necessary to meld studies regarding patients with noncancerous conditions with studies addressing rehabilitation in patients with cancer. This fusion of information demonstrates that rehabilitation results in significant improvements in QOL in patients who participate, regardless of the disease in question. Although QOL may not always have been an obvious endpoint for treating patients with lung cancer, it is apparent from studies of the patients themselves that an improved QOL is far more important than other goals of therapy.