McKeon Mallory, Munhall Daphne, Walsh Brian K, Nuss Roger, Rahbar Reza, Volk Mark, Watters Karen
Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts.
Department of Respiratory Care, Boston Children's Hospital, Boston, Massachusetts.
Laryngoscope. 2018 Oct;128(10):2419-2424. doi: 10.1002/lary.27251. Epub 2018 May 14.
OBJECTIVES/HYPOTHESIS: Advancement in neonatal and pediatric intensive care has increased the need for chronic-care interventions, including tracheostomy. It is well established that children with a tracheostomy are at a high risk for adverse events, many of which are preventable. Despite this, there is no standardized method of monitoring tracheostomy-related adverse events (TRAEs). Our objective was to describe and assess a standardized, closed-loop system for monitoring TRAEs.
Prospective Study.
A specific tracheostomy-related category was established within the adverse event reporting system in January 2015. Monthly TRAE reports were supplied to the multidisciplinary tracheostomy team (MDT) with descriptions of event type, severity, and preventability. The MDT reviewed events and discussed necessary follow-up. The frequency of events was standardized by inpatient tracheostomy days (ITDs) using an automated monthly list. Adverse events were tracked using a control chart. Aggregated data were divided into biannual reports for analysis.
Eighty-five TRAEs were reported between January 2015 and June 2017, averaging 5.75 per 1,000 ITDs. Most common events include unplanned decannulation (50%) and improper use of tracheostomy supplies (21%). The frequency of all preventable events has decreased by 76% since the second half of 2015. During this timeframe, minor events have decreased, moderate events have maintained a frequency of less than one per 1,000 ITDs, and only one severe event occurred.
This standardized, closed-loop reporting method, modeled after other successful intensive care unit reporting systems, accurately tracks TRAEs. We have observed a decrease in preventable TRAEs without a negative impact on rates of severe events. Results suggest improved quality of care for patients with tracheostomy.
目的/假设：新生儿和儿科重症监护的进步增加了对包括气管造口术在内的长期护理干预措施的需求。气管造口术患儿发生不良事件的风险很高，其中许多是可以预防的。尽管如此，目前尚无监测气管造口术相关不良事件（TRAEs）的标准化方法。我们的目的是描述和评估一种用于监测TRAEs的标准化闭环系统。
前瞻性研究。
2015年1月在不良事件报告系统中设立了一个特定的气管造口术相关类别。每月向多学科气管造口术团队（MDT）提供TRAE报告，描述事件类型、严重程度和可预防性。MDT对事件进行审查并讨论必要的后续措施。事件发生频率通过住院气管造口术天数（ITDs）进行标准化，使用自动生成的月度列表。使用控制图跟踪不良事件。汇总数据分为半年报告进行分析。
2015年1月至2017年6月期间共报告了85例TRAE，平均每1000个ITDs发生5.75例。最常见的事件包括意外脱管（50%）和气管造口术用品使用不当（21%）。自2015年下半年以来，所有可预防事件的发生率下降了76%。在此期间，轻微事件减少，中度事件的发生率保持在每1000个ITDs少于1例，仅发生了1例严重事件。
这种标准化的闭环报告方法，以其他成功的重症监护病房报告系统为模型，准确地跟踪了TRAE。我们观察到可预防的TRAE有所减少，而对严重事件的发生率没有负面影响。结果表明气管造口术患者的护理质量得到了改善。
4。《喉镜》，128:2419 - 2424，2018年。
