The current COVID-19 pandemic is threatening global health. Rates of infection outside of China are rapidly increasing, with confirmed cases reported in over 160 countries as of 19 March 2020 [1]. During the Severe Acute Respiratory Syndrome (SARS) epidemic, 21% of the global cumulative case total were healthcare workers [2], while a recent study from Wuhan, China reported that 1716 healthcare workers were infected with COVID-19, representing 3.8% of confirmed cases [3]. During the SARS epidemic, it is likely that a lack of awareness and preparedness put healthcare workers at risk [4]. Thus, delivering rapid, reliable information that addresses critical infection control issues is of key importance, and tracheal intubation is known to be associated with a high-risk of transmission of viral infections to healthcare workers [5, 6].

Social media for rapid knowledge dissemination: early experience from the COVID-19 pandemic.

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance.

Summary There is growing recognition of the need for a coordinated, systematic approach to caring for patients with a tracheostomy. Tracheostomy-related adverse events remain a pervasive global problem, accounting for half of all airway-related deaths and hypoxic brain damage in critical care units. The Global Tracheostomy Collaborative (GTC) was formed in 2012 to improve patient safety and quality of care, emphasising knowledge, skills, teamwork, and patient-centred approaches. Inspired by quality improvement leads in Australia, the UK, and the USA, the GTC implements and disseminates best practices across hospitals and healthcare trusts. Its database collects patient-level information on quality, safety, and organisational efficiencies. The GTC provides an organising structure for quality improvement efforts, promoting safety of paediatric and adult patients. Successful implementation requires instituting key drivers for change that include effective training for health professionals; multidisciplinary team collaboration; engagement and involvement of patients, their families, and carers; and data collection that allows tracking of outcomes. We report the history of the collaborative, its database infrastructure and analytics, and patient outcomes from more than 6500 patients globally. We characterise this patient population for the first time at such scale, reporting predictors of adverse events, mortality, and length of stay indexed to patient characteristics, co-morbidities, risk factors, and context. In one example, the database allowed identification of a previously unrecognised association between bleeding and mortality, reflecting ability to uncover latent risks and promote safety. The GTC provides the foundation for future risk-adjusted benchmarking and a learning community that drives ongoing quality improvement efforts worldwide.

Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/anae.15120

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP).

ObjectiveThe coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy....

https://journals.sagepub.com/doi/pdf/10.1177/0194599820961985

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

Background Inconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. Quality improvement strategies described by exemplar hospitals of the Global Tracheostomy Collaborative have potential to mitigate such problems. This 3 yr guided implementation programme investigated interventions designed to improve the quality and safety of tracheostomy care. Methods The programme management team guided the implementation of 18 interventions over three phases (baseline/implementation/evaluation). Mixed-methods interviews, focus groups, and Hospital Anxiety and Depression Scale questionnaires defined outcome measures, with patient-level databases tracking and benchmarking process metrics. Appreciative inquiry, interviews, and Normalisation Measure Development questionnaires explored change barriers and enablers. Results All sites implemented at least 16/18 interventions, with the magnitude of some improvements linked to staff engagement (1536 questionnaires from 1019 staff), and 2405 admissions (1868 ICU/high-dependency unit; 7.3% children) were prospectively captured. Median stay was 50 hospital days, 23 ICU days, and 28 tracheostomy days. Incident severity score reduced significantly (n=606; P Conclusions This guided improvement programme for tracheostomy patients significantly improved the quality and safety of care, contributing rich qualitative improvement data. Patient-centred outcomes were improved along with significant efficiency and cost savings across diverse UK hospitals. Clinical trial registration IRAS-ID-206955; REC-Ref-16/LO/1196; NIHR Portfolio CPMS ID 31544.

/pdf/improving-tracheostomy-care-in-the-united-kingdom-results-of-3arzb6w8px.pdf

Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals

Traditional methods used to disseminate educational resources to front-line healthcare staff have several limitations. Social media may increase the visibility of these resources among targeted groups and communities. Our project aimed to disseminate key clinical messages from the National Tracheostomy Safety Project to those caring for patients with tracheostomies or laryngectomies. We commissioned an external media company to design educational material and devise a marketing strategy. We developed videos to communicate recommendations from the safety project and used Facebook, Twitter, YouTube and LinkedIn to deliver these to our target users. We recorded 629,270 impressions over a paid 12-week campaign. Our YouTube channel registered more than a five-fold increase in views and watch time during the campaign as compared with the previous year. Around two-thirds of views across all platforms were from peer-to-peer sharing. We spent £4140 on social media advertising, with each view and click costing £0.02 and £0.67, respectively. This intelligence-led approach using social media is an effective and efficient method to disseminate knowledge on the principles of safe tracheostomy care to front-line clinical staff. Similar strategies may be effective for other patient safety topics, especially when targeting groups that do not use medical journals or other traditional means of dissemination.

From smartphone to bed-side: exploring the use of social media to disseminate recommendations from the National Tracheostomy Safety Project to front-line clinical staff.

Background
Tracheostomies are artificial airway devices used predominantly to manage airway obstruction and to facilitate weaning from prolonged mechanical ventilation. Whilst a lifesaving procedure, tracheostomy can also lead to significant morbidity and mortality. Associated vocalization and swallowing problems lead to anxiety for patients, families and healthcare staff. The Global Tracheostomy (Quality Improvement) Collaborative can improve the safety and quality of care in participating institutions, leading to a large-scale UK-wide evaluation. However, whilst individual strategies have proved effective in single centres, it is unclear which tracheostomy quality improvement program elements should be prioritized in the UK’s National Health Service’s (NHS) diverse hospitals.
Aims
Through a unique consensus and prioritisation exercise using front line staff and leaders from 20 participating UK hospitals, we aimed to develop a national strategy for tracheostomy quality improvements.
Methods
Following national research ethics committee approval, representative multidisciplinary staff groups were interviewed and completed bespoke questionnaires regarding their experiences of tracheostomy care and associated quality improvements. Qualitative evaluation techniques were applied to develop key themes, further refined by group consensus and prioritisation exercises, creating a ranked list of important quality improvement interventions that should be implemented.
Results 
Thematic analysis yielded 22 statements regarding tracheostomy care. Highly ranked priority interventions included multidisciplinary staff education, standards and competencies, multidisciplinary ward rounds, equipment standardisation and structured care bundles.
Conclusion 
Prioritising distinct quality improvement interventions will allow providers to focus on improving the quality and safety of tracheostomy care using resources and strategies that are important to frontline healthcare staff.

/pdf/improving-tracheostomy-care-collaborative-national-consensus-ikndujtrtu.pdf

Improving tracheostomy care: collaborative national consensus and prioritisation of quality improvements in the United Kingdom

s e27 nine scoring systems generated significant differences between pre and post scores, with five scoring systems producing a one or more category difference with over 50% of comparisons. Table 6 Comparisons between different positions. Scoring system Different scores pre/post Median scores Wilcoxon p N (total 1⁄4 70) % Insertion (pre) Nursing (post) L3 29 41.4 3 3 0.15 L5 39 55.7 4 4 0.57 T% 26 37.1 75 75 0.045 T Quad 27 38.6 3 3 0.46 T Quad Grid 20 28.6 3 3 0.02 Mean scores Paired T p L VAS 66 94.3 75 68 0.04 T% eyeball 53 75.7 72 64 0.02 T Grid % 57 81.4 70 64 0.04 T VAS 55 78.6 72 67 0.07 Whilst the merits of the different scoring systems require further evaluation, what this study does demonstrate is that changing the patient’s position following tracheostomy insertion leads to a difference in the majority of scoring systems used. This likely represents genuine change in the tube position relative to the trachea. The clinical significance of this is unknown, but endoscopic evaluation of the tube in both hyper-extended and sitting positions would seem a sensible precaution following tracheostomy.

Mike Firn

Papers

Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals

From smartphone to bed-side: exploring the use of social media to disseminate recommendations from the National Tracheostomy Safety Project to front-line clinical staff.

Improving tracheostomy care: collaborative national consensus and prioritisation of quality improvements in the United Kingdom

Collaborative national consensus and prioritisation of tracheostomy quality improvements in the United Kingdom

Measuring multidisciplinary staff engagement in a national tracheostomy quality improvement project using the NoMAD instrument