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The Global Tracheostomy Collaborative (GTC) Impact of a Quality Improvement Collaborative in Otolaryngology – Head & Neck Surgery

Karen Watters 1,2,3; Hannah Zhu1,4 Michael Brenner1,5; Tanis Cameron1,6; Anthony Narula1,7; David Roberson1,2,3 ; Rahul Shah1,8

1The Global Tracheostomy Collaborative, 2Boston Children’s Hospital, Boston , USA; 3Department of Otology and Laryngology, Harvard Medical School, Boston, USA; 4 King’s College Hospital NHS Foundation Trust, London, UK; 5Department of Otolaryngology, University of Michigan School of Medicine, Michigan, USA ; 6Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia; 7ENT Department St. Mary’s Hospital NHS T, London, UK;

8Children’s National Medical Center, Washington, DC, USA. .

Karen Watters, MB BCH BAO, MPH Boston Children’s Hospital Email: karen.watters@childrens.harvard.edu

Contact

References

Objective: The Global Tracheostomy Collaborative (GTC), established in 2013, is an international

multidisciplinary Quality Improvement (QI) collaborative established to improve processes and

outcomes in adult and pediatric tracheostomy care (www.globaltrach.org). The aim of this study is

to evaluate the initial effectiveness of such a collaborative in Otolaryngology – Head & Neck Surgery.

Study Design: Observational. Qualitative Interviews.

Methods: Analysis of GTC membership and attendance at three international kickoff meetings was

performed. Qualitative interviews were conducted either face-to-face or via telephone with care

teams from GTC member hospitals.

Results: 570 individuals representing 125 institutions attended kickoff meetings in Boston (April

2014), London (July 2014) and Melbourne (October 2014); 1000 additional individuals from more

than 20 countries and all continents except Africa attended a kickoff meeting using virtual

technology. Attendees were from a range of disciplines; otolaryngology, anesthesia, neonatology,

pulmonary, critical care, respiratory therapy/physiotherapy, nursing, speech pathology, and hospital

management. As of October 2014, over 35 hospitals in the United States, United Kingdom, Sweden,

Singapore, Qatar, and Australia have joined, and another 7 hospitals are considering

joining. Preliminary data collection has been successful with >380 new tracheostomy cases entered

in an international, HIPPA-compliant REDCap database within the first 6 months of launch.

Qualitative interviews reveal that many sites have instituted new practices in response to joining.

Conclusion: It is widely recognized that there is a need to improve the speed at which successful

care models disseminate. Quality Improvement collaboratives have been successful at accelerating

improvement in many disciplines. The GTC may be an exemplar of this new methodology in

Otolaryngology.

Abstract

GTC Timeline shown in Figure 1.

Kick-Off Meetings:

• 570 individuals from over 125 institutions attended GTC kick-off

meeting in Boston (April 2014), London (July 2014) or Melbourne

(October 2014)

• 1,000 individuals from 20 countries attended via live webcast

• Disciplines represented - anesthesia, critical care, pulmonary,

respiratory care, physiotherapy, speech therapy, nursing, social work,

quality/safety, family/patient and hospital management

• 3 webinars and online discussion groups held.

Membership:

• First member hospital enrolled in January 2014

• 35 hospitals have joined (UK, Sweden, United States, Singapore,

Qatar, and Australia)

• 75 hospitals preparing to join

Data Collection:

• Data entry went live in August 2014, HIPPA-compliant database

• >380 new tracheostomy cases has been entered

Member Hospital Interviews:

• Interviews with 16 member sites to identify deficiencies and new

practices in tracheostomy care

Reasons cited for joining;

• Desire to learn from others and share experiences (88%)

• Need to standardize care (69%)

• Need support for change initiatives (56%)

• Need for maintenance of staff education (50%)

• Recent adverse tracheostomy events (>50%)

• Need to create a Multi-Disciplinary Tracheostomy (MDT) program

56% of interviewed hospitals do not have a MDT program

New tracheostomy practices planned/instituted:

• Weekly MDT ward rounds

• Standardization of protocols

• Mandatory training modules for staff and families

• Improved discharge planning

• Improved patient/family feedback with “Family Tracheostomy Days”

• All member hospitals reported a staff commitment to work for change

Background

• Analysis of GTC membership and attendance at 3 international

kickoff meetings.

• Qualitative interviews with 16 GTC member hospitals from 3 continents.

Methods

• Tracheostomy care is high risk with significant morbidity and

mortality.1

• Patients and families with tracheostomy experience extremely

disorganized, fragmented care.

• The Global Tracheostomy Collaborative (GTC), 2013, is an

international multidisciplinary Quality Improvement Collaborative

(QIC) initiated to improve patient outcomes in tracheostomy care.

THE GTC WORKS THROUGH 5 KEY DRIVERS;

1. Coordinated Multidisciplinary Tracheostomy Care Team

2. Coordinated interdisciplinary staff education

3. Institution-Wide Interdisciplinary Tracheostomy Protocols

4. Patient and Family centered Tracheostomy Care

5. Create outcome-based metrics and gather data using a HIPAA-

compliant database

• Exemplar institutions have demonstrated that care can be

dramatically improved and tracheostomy related adverse events

radically reduced through integrated tracheostomy care teams (Table

1, 2).2, 3

• GTC is the first international Quality Improvement Collaborative in

Otolaryngology -- Head & Neck Surgery

• GTC has received a robust international response, reflecting the

global need for improving tracheostomy care

• Membership of GTC offers the opportunity to standardize

tracheostomy processes and improve outcomes

• Qualitative interviews have shown very favorable feedback and that

the program makes a positive difference for patients and families

Conclusions Results

SeriousTracheostomyClinicalIncidents

27%

20%

10% 10%

4% 0%0

5

10

15

20

25

30

2003/4 2004/5 2005/6 2006/7 2007/8 2008/9

Year

Pro

po

rtio

n O

f S

evere

Clin

ical In

cid

en

ts

CareBundleintroduced

TracheostomyMul disciplinaryWardRound

Auditini ated

St.Mary’sHospital,London;usedbypermission

Improvingtracheostomymanagementthroughdesign,implementa onandprospec veauditofacarebundle:howwedoit.He geR,etal.ClinOtolaryngol.2008Oct;33(5):488-91.

The Global Tracheostomy Collaborative has received unrestricted educational grants from Smiths Medical, Boston Medical, and Boston Children's Hospital Department of Otolaryngology.

This poster has been submitted on behalf of all the members of the Steering Committee of the Global

Tracheostomy Collaborative: Asit Arora, Jo Harrison, Linda L Morris, Neil Bateman, Jay G Berry, Melissa

Ciardulli, Preety Das, Stacey Halum, Haytham Kubba, Christine Milano, Melody Paine, Alon Peltz, Rosh Sethi,

Margaret Skinner, Joanne Sweeney, Stephen Warrillow, Ralph Woodhouse, Hannah Zhu.

Financial Disclosure

1. Tracheotomy-Related Catastrophic Events: Results of a National Survey. Das P, Zhu H, Shah RK, Roberson DW, Berry J, et al. Laryngoscope, 122:30–37, 2012 . 2. Improving tracheostomy care: a prospective study of the multidisciplinary approach. Cetto R, Arora A, Hettige R, Nel M, Benjamin L, Gomez CM, Oldfield WL, Narula

AA. Clin Otolaryngol. 2011 Oct;36(5):482-8. 3. Outcomes of patients with spinal cord injury before and after introduction of an interdisciplinary tracheostomy team. Cameron TS, McKinstry A, Burt SK, Howard ME,

Bellomo R, Brown DJ, Ross JM, Sweeney JM, O’Donoghue FJ. Critical Care Resusc. 2009;11:14-19.

“Majority of patients are decannulated before discharge, but those who

aren’t are a major issue since we don’t have a procedure for what

happens on discharge with a trach. “

“The 2am test –making sure that at 2am there are staff who can sort out

problems with trachs,”

“Families don’t trust staff when kids are inpatient and stay 24-7 to provide

care for their child”

“nursing staff in certain areas of the hospital are still uncomfortable

taking care of tracheostomies”

“We constantly evaluate our services, have weekly meetings, have

streamlined our care coordination and discharge planning. For example,

we’re currently developing a protocol for discharging trach patients…

Table 2: Effect of Integrated Tracheostomy Bundle on Adverse Events

Table 1: Decrease in Critical Tracheostomy Events

Comments from Member Interviews