Reducing Tracheostomy-Related Acquired Pressure Injury by Flipping the Ventilator Circuit Position Study.

BACKGROUND: Tracheostomy-related acquired pressure injuries (TRPIs) are one of the hospital-acquired conditions. We hypothesize that an uneven ventilator circuit load, leading to non-neutral tracheostomy tube positioning in the immediate post-tracheostomy period, leads to an increased incidence of TRPIs. Does switching the ventilator circuit load daily, in addition to standard post-tracheostomy care, lead to a decreased incidence of TRPIs? METHODS: This is a prospective quality improvement study. Study was conducted at two academic hospital sites within tertiary care hospitals at Emory University in different ICUs. Consecutive patients undergoing bedside percutaneous tracheostomy by the interventional pulmonary service were included. The flip the ventilator circuit (FLIC) protocol was designed and implemented in selected ICUs, with other ICUs as controls. RESULTS: Incidence of TRPI in intervention and control group were recorded at post-tracheostomy day 5. A total of 99 patients were included from October 22, 2019, to May 22, 2020. Overall, the total incidence of any TRPI was 23% at post-tracheostomy day 5. Incidence of stage I, stage II, and stages III-IV TRPIs at postoperative day 5 was 11%, 12%, and 0%, respectively. There was a decrease in the rate of skin breakdown in patients following the FLIC protocol when compared with standard of care (13% vs. 36%; p = 0.01). In a multivariable analysis, interventional group had decreased odds of developing TRPI (odds ratio, 0.32; 95% CI, 0.11-0.92; p = 0.03) after adjusting for age, albumin, body mass index, diabetes mellitus, and days in hospital before tracheostomy. CONCLUSIONS: The incidence of TRPIs within the first week following percutaneous tracheostomy is high. Switching the side of the ventilator circuit to evenly distribute load, in addition to standard bundled tracheostomy care, may decrease the overall incidence of TRPIs.

Intensive care unit rounding checklist implementation. Effect of accountability measures on physician compliance.

RATIONALE/OBJECTIVES: Checklist utilization has been shown to improve multiple processes of care in the intensive care unit (ICU). The ICU setting makes checklist implementation challenging, particularly when prompters are unavailable to ensure checklist compliance. We performed a prospective analysis on physician compliance reporting as a means to improve attending physician compliance with checklist use during ICU rounds. METHODS: We performed a prospective analysis of 14 attending physicians' compliance with checklist use before and after accountability measures employed at two urban academic hospitals in the United States. The accountability measures were bimonthly publication of physician checklist compliance via division e-mail and during a multidisciplinary division conference. MEASUREMENTS AND MAIN RESULTS: A total of 5,812 patient days of ICU care were assessed from April 2013 through March 2014. Compliance with checklist use during ICU rounds improved at both academic hospitals during the intervention phase. Initial compliance rates were 67% at both institutions and subsequently improved to 90 and 81%, respectively, after accountability measures were employed. During a 3-month washout phase in which no public accountability measures were employed, compliance was maintained at 89 and 78% at the two hospitals. Foley catheter, central venous catheter, and ventilator utilization rates decreased after initiation of public accountability at both hospitals. CONCLUSIONS: Physician compliance reporting can be used to improve ICU physician compliance with rounding checklists when prompters are unavailable. Improved physician compliance translated into decreased rates of Foley catheter, central venous catheter, and ventilator use. These results highlight the impact physician accountability can have on patient care in the ICU.