University of Manchester
Multidisciplinary Tracheostomy Care: How Collaboratives Drive Quality ImprovementJoshua R. Bedwell, MD, MS, FAAP, FACSBaylor College of Medicine/Texas Children’s HospitalJoshua.Bedwell@bcm.edu6701 Fannin St., Ste. 650Houston, TX 77030Vinciya Pandian, PhD, MBA, MSN, RN, ACNP-BC, FAANJohns Hopkins School of Nursingvpandia1@jhu.edu525 N Wolfe St, Rm 442, Baltimore, MD 21205David W Roberson, MD, MBA, FACS, FRCSHarvard University/Children’s Hospital BostonDavid.Roberson@childrens.harvard.eduADDRESSBrendan A. McGrath, MBChB, MRCP, FRCA, DICM, EDIC, PGCertMedEd, AHEA, FFICM, PhDUniversity Hospital of South ManchesterNHS Foundation TrustBrendan.Mcgrath@manchester.ac.ukADDRESSTanis S. Cameron, MA-SLP (C) CCC-SLPAustin HealthTanis.Cameon@.auMichael J. Brenner, M.D., F.A.C.S. (Corresponding Author)Associate ProfessorDepartment of Otolaryngology- -- Head & Neck SurgeryUniversity of Michigan School of Medicine1500 East Medical Center Drive SPC 53121904 Taubman CenterAnn Arbor, MI 48109-5312Phone: 734-936-9178University of Michigan School of Medicinembren@med.umich.eduDisclosures: None of the authors have any commercial or financial disclosures.Synopsis: There have been reports of successful quality improvement initiatives surrounding tracheostomy care for over a decade, but widespread adoption of best practices has not been universal. glacial. Five “key drivers” have been found to improve the quality of care for tracheostomyof such patients: (1) Multidisciplinary synchronous ward rounds, (2) Standardization of care protocols, (3) Appropriate staff training and allocation, (4) Patient and family involvement and (5) Use of data to drive improvement. The Global Tracheostomy Collaborative is a Quality Improvement Collaborative dedicated to improving the care of tracheostomy patients worldwide through communication, dissemination, and implementation of proven strategies based on these five key drivers.Key Words: Tracheostomy, Tracheotomy, Quality Improvement, Collaborative, Patient SafetyIntroductionIn the United States of America (USA), >100,000 tracheostomies are performed annually; about 4000 of these are performed in children.PEVuZE5vdGU+PENpdGU+PFllYXI+MjAxNDwvWWVhcj48UmVjTnVtPjcyNDwvUmVjTnVtPjxEaXNw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=
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PFllYXI+MjAxNDwvWWVhcj48UmVjTnVtPjcyNDwvUmVjTnVtPjxEaXNw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=
ADDIN EN.CITE.DATA 1,2 The in-hospital mortality for patients who undergo tracheostomy is approximately 20%, with the majority of these deaths caused by the underlying disease rather than directly due to the tracheostomy.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFoPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaGFoPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj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ADDIN EN.CITE.DATA 3 Extrapolation of survey data suggests a crude annual estimate of approximately 1,000 catastrophic events and approximately 500 tracheotomy-related deaths in the United States. ADDIN EN.CITE <EndNote><Cite><Author>Das</Author><Year>2012</Year><RecNum>465</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>465</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1441228373">465</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Das, P.</author><author>Zhu, H.</author><author>Shah, R. K.</author><author>Roberson, D. W.</author><author>Berry, J.</author><author>Skinner, M. L.</author></authors></contributors><auth-address>School of Clinical Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge, UK.</auth-address><titles><title>Tracheotomy-related catastrophic events: results of a national survey</title><secondary-title>Laryngoscope</secondary-title><alt-title>The Laryngoscope</alt-title></titles><periodical><full-title>Laryngoscope</full-title></periodical><pages>30-7</pages><volume>122</volume><number>1</number><edition>2011/12/21</edition><keywords><keyword>Catastrophic Illness</keyword><keyword>Data Collection</keyword><keyword>Humans</keyword><keyword>Postoperative Complications/epidemiology/etiology</keyword><keyword>*Quality Improvement</keyword><keyword>Tracheotomy/*adverse effects/*standards</keyword><keyword>United States</keyword></keywords><dates><year>2012</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1531-4995 (Electronic)
0023-852X (Linking)</isbn><accession-num>22183626</accession-num><urls><related-urls><url> reported national overall complication rate associated with tracheotomy is 3.2%, but there is marked under-reporting of complications such as emergency tracheostomy tube obstruction or accidental decannulation . Tragically, many catastrophic events and deaths are preventable. ADDIN EN.CITE <EndNote><Cite><Author>Das</Author><Year>2012</Year><RecNum>480</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>480</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1444244003">480</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Das, P.</author><author>Zhu, H.</author><author>Shah, R. K.</author><author>Roberson, D. W.</author><author>Berry, J.</author><author>Skinner, M. L.</author></authors></contributors><auth-address>School of Clinical Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge, UK.</auth-address><titles><title>Tracheotomy-related catastrophic events: results of a national survey</title><secondary-title>Laryngoscope</secondary-title><alt-title>The Laryngoscope</alt-title></titles><periodical><full-title>Laryngoscope</full-title></periodical><pages>30-7</pages><volume>122</volume><number>1</number><edition>2011/12/21</edition><keywords><keyword>Catastrophic Illness</keyword><keyword>Data Collection</keyword><keyword>Humans</keyword><keyword>Postoperative Complications/epidemiology/etiology</keyword><keyword>*Quality Improvement</keyword><keyword>Tracheotomy/*adverse effects/*standards</keyword><keyword>United States</keyword></keywords><dates><year>2012</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1531-4995 (Electronic)
0023-852X (Linking)</isbn><accession-num>22183626</accession-num><urls><related-urls><url> in Australia, the UK and the USA have demonstrated impressive reductions in untoward outcomes in tracheostomy patients, with up to 90% decrease in in-patient critical events (Reference needed). Despite very different healthcare environments, five key elements were found in each successful program: (1) Multidisciplinary synchronous ward rounds, (2) Standardization of care protocols, (3) Appropriate staff training and allocation, (4) Patient and family involvement and (5) Use of data to drive improvement.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DZXR0bzwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl
Y051bT40NTY8L1JlY051bT48RGlzcGxheVRleHQ+PHN0eWxlIGZhY2U9InN1cGVyc2NyaXB0Ij41
LTc8L3N0eWxlPjwvRGlzcGxheVRleHQ+PHJlY29yZD48cmVjLW51bWJlcj40NTY8L3JlYy1udW1i
ZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ0dnR3emZwZTg5dHNkNmV3d3J1
cHhlc2Jldnh2d3AwZmF6ZGQiIHRpbWVzdGFtcD0iMTQ0MTIyNzI4OSI+NDU2PC9rZXk+PC9mb3Jl
aWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxj
b250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5DZXR0bywgUi48L2F1dGhvcj48YXV0aG9yPkFy
b3JhLCBBLjwvYXV0aG9yPjxhdXRob3I+SGV0dGlnZSwgUi48L2F1dGhvcj48YXV0aG9yPk5lbCwg
TS48L2F1dGhvcj48YXV0aG9yPkJlbmphbWluLCBMLjwvYXV0aG9yPjxhdXRob3I+R29tZXosIEMu
IE0uPC9hdXRob3I+PGF1dGhvcj5PbGRmaWVsZCwgVy4gTC48L2F1dGhvcj48YXV0aG9yPk5hcnVs
YSwgQS4gQS48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5E
ZXBhcnRtZW50IG9mIE90b3JoaW5vbGFyeW5nb2xvZ3ksIFN0LiBNYXJ5JmFwb3M7cyBIb3NwaXRh
bCwgSW1wZXJpYWwgQ29sbGVnZSBIZWFsdGhjYXJlIE5IUyBUcnVzdCwgTG9uZG9uLCBVSy4gcmF1
bC5jZXR0bzEwQGltcGVyaWFsLmFjLnVrPC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+SW1w
cm92aW5nIHRyYWNoZW9zdG9teSBjYXJlOiBhIHByb3NwZWN0aXZlIHN0dWR5IG9mIHRoZSBtdWx0
aWRpc2NpcGxpbmFyeSBhcHByb2FjaDwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5DbGluIE90b2xh
cnluZ29sPC9zZWNvbmRhcnktdGl0bGU+PGFsdC10aXRsZT5DbGluaWNhbCBvdG9sYXJ5bmdvbG9n
eSA6IG9mZmljaWFsIGpvdXJuYWwgb2YgRU5ULVVLIDsgb2ZmaWNpYWwgam91cm5hbCBvZiBOZXRo
ZXJsYW5kcyBTb2NpZXR5IGZvciBPdG8tUmhpbm8tTGFyeW5nb2xvZ3kgJmFtcDsgQ2Vydmljby1G
YWNpYWwgU3VyZ2VyeTwvYWx0LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxl
PkNsaW4gT3RvbGFyeW5nb2w8L2Z1bGwtdGl0bGU+PGFiYnItMT5DbGluaWNhbCBvdG9sYXJ5bmdv
bG9neSA6IG9mZmljaWFsIGpvdXJuYWwgb2YgRU5ULVVLIDsgb2ZmaWNpYWwgam91cm5hbCBvZiBO
ZXRoZXJsYW5kcyBTb2NpZXR5IGZvciBPdG8tUmhpbm8tTGFyeW5nb2xvZ3kgJmFtcDsgQ2Vydmlj
by1GYWNpYWwgU3VyZ2VyeTwvYWJici0xPjwvcGVyaW9kaWNhbD48YWx0LXBlcmlvZGljYWw+PGZ1
bGwtdGl0bGU+Q2xpbiBPdG9sYXJ5bmdvbDwvZnVsbC10aXRsZT48YWJici0xPkNsaW5pY2FsIG90
b2xhcnluZ29sb2d5IDogb2ZmaWNpYWwgam91cm5hbCBvZiBFTlQtVUsgOyBvZmZpY2lhbCBqb3Vy
bmFsIG9mIE5ldGhlcmxhbmRzIFNvY2lldHkgZm9yIE90by1SaGluby1MYXJ5bmdvbG9neSAmYW1w
OyBDZXJ2aWNvLUZhY2lhbCBTdXJnZXJ5PC9hYmJyLTE+PC9hbHQtcGVyaW9kaWNhbD48cGFnZXM+
NDgyLTg8L3BhZ2VzPjx2b2x1bWU+MzY8L3ZvbHVtZT48bnVtYmVyPjU8L251bWJlcj48ZWRpdGlv
bj4yMDExLzA4LzE2PC9lZGl0aW9uPjxrZXl3b3Jkcz48a2V5d29yZD5BcGFjaGU8L2tleXdvcmQ+
PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkhvc3BpdGFscywgVGVhY2hpbmc8L2tl
eXdvcmQ+PGtleXdvcmQ+SHVtYW5zPC9rZXl3b3JkPjxrZXl3b3JkPkludGVuc2l2ZSBDYXJlIFVu
aXRzPC9rZXl3b3JkPjxrZXl3b3JkPkludGVydmVudGlvbiBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3
b3JkPkxvbmRvbjwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPk1pZGRs
ZSBBZ2VkPC9rZXl3b3JkPjxrZXl3b3JkPlBhdGllbnQgQ2FyZS8qc3RhbmRhcmRzPC9rZXl3b3Jk
PjxrZXl3b3JkPlBhdGllbnQgQ2FyZSBUZWFtLypzdGFuZGFyZHM8L2tleXdvcmQ+PGtleXdvcmQ+
UHJvc3BlY3RpdmUgU3R1ZGllczwva2V5d29yZD48a2V5d29yZD5TdGF0aXN0aWNzLCBOb25wYXJh
bWV0cmljPC9rZXl3b3JkPjxrZXl3b3JkPipUcmFjaGVvc3RvbXk8L2tleXdvcmQ+PC9rZXl3b3Jk
cz48ZGF0ZXM+PHllYXI+MjAxMTwveWVhcj48cHViLWRhdGVzPjxkYXRlPk9jdDwvZGF0ZT48L3B1
Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjE3NDktNDQ4NiAoRWxlY3Ryb25pYykmI3hEOzE3NDktNDQ3
OCAoTGlua2luZyk8L2lzYm4+PGFjY2Vzc2lvbi1udW0+MjE4Mzg4MDc8L2FjY2Vzc2lvbi1udW0+
PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5ubG0ubmloLmdvdi9wdWJt
ZWQvMjE4Mzg4MDc8L3VybD48L3JlbGF0ZWQtdXJscz48L3VybHM+PGVsZWN0cm9uaWMtcmVzb3Vy
Y2UtbnVtPjEwLjExMTEvai4xNzQ5LTQ0ODYuMjAxMS4wMjM3OS54PC9lbGVjdHJvbmljLXJlc291
cmNlLW51bT48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DYW1lcm9uPC9BdXRob3I+PFll
YXI+MjAwOTwvWWVhcj48UmVjTnVtPjQ4NzwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NDg3
PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0idHZ0d3pmcGU4
OXRzZDZld3dydXB4ZXNiZXZ4dndwMGZhemRkIiB0aW1lc3RhbXA9IjE0NDQzMjAyNTAiPjQ4Nzwv
a2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9y
ZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q2FtZXJvbiwgVC4gUy48L2F1
dGhvcj48YXV0aG9yPk1jS2luc3RyeSwgQS48L2F1dGhvcj48YXV0aG9yPkJ1cnQsIFMuIEsuPC9h
dXRob3I+PGF1dGhvcj5Ib3dhcmQsIE0uIEUuPC9hdXRob3I+PGF1dGhvcj5CZWxsb21vLCBSLjwv
YXV0aG9yPjxhdXRob3I+QnJvd24sIEQuIEouPC9hdXRob3I+PGF1dGhvcj5Sb3NzLCBKLiBNLjwv
YXV0aG9yPjxhdXRob3I+U3dlZW5leSwgSi4gTS48L2F1dGhvcj48YXV0aG9yPk8mYXBvcztEb25v
Z2h1ZSwgRi4gSi48L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVz
cz5BdXN0aW4gSG9zcGl0YWwsIE1lbGJvdXJuZSwgVklDLiB0YW5pcy5jYW1lcm9uQGF1c3Rpbi5v
cmcuYXU8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5PdXRjb21lcyBvZiBwYXRpZW50cyB3
aXRoIHNwaW5hbCBjb3JkIGluanVyeSBiZWZvcmUgYW5kIGFmdGVyIGludHJvZHVjdGlvbiBvZiBh
biBpbnRlcmRpc2NpcGxpbmFyeSB0cmFjaGVvc3RvbXkgdGVhbTwvdGl0bGU+PHNlY29uZGFyeS10
aXRsZT5Dcml0IENhcmUgUmVzdXNjPC9zZWNvbmRhcnktdGl0bGU+PGFsdC10aXRsZT5Dcml0aWNh
bCBjYXJlIGFuZCByZXN1c2NpdGF0aW9uIDogam91cm5hbCBvZiB0aGUgQXVzdHJhbGFzaWFuIEFj
YWRlbXkgb2YgQ3JpdGljYWwgQ2FyZSBNZWRpY2luZTwvYWx0LXRpdGxlPjwvdGl0bGVzPjxwZXJp
b2RpY2FsPjxmdWxsLXRpdGxlPkNyaXQgQ2FyZSBSZXN1c2M8L2Z1bGwtdGl0bGU+PGFiYnItMT5D
cml0aWNhbCBjYXJlIGFuZCByZXN1c2NpdGF0aW9uIDogam91cm5hbCBvZiB0aGUgQXVzdHJhbGFz
aWFuIEFjYWRlbXkgb2YgQ3JpdGljYWwgQ2FyZSBNZWRpY2luZTwvYWJici0xPjwvcGVyaW9kaWNh
bD48YWx0LXBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Q3JpdCBDYXJlIFJlc3VzYzwvZnVsbC10aXRs
ZT48YWJici0xPkNyaXRpY2FsIGNhcmUgYW5kIHJlc3VzY2l0YXRpb24gOiBqb3VybmFsIG9mIHRo
ZSBBdXN0cmFsYXNpYW4gQWNhZGVteSBvZiBDcml0aWNhbCBDYXJlIE1lZGljaW5lPC9hYmJyLTE+
PC9hbHQtcGVyaW9kaWNhbD48cGFnZXM+MTQtOTwvcGFnZXM+PHZvbHVtZT4xMTwvdm9sdW1lPjxu
dW1iZXI+MTwvbnVtYmVyPjxlZGl0aW9uPjIwMDkvMDMvMTQ8L2VkaXRpb24+PGtleXdvcmRzPjxr
ZXl3b3JkPkFkdWx0PC9rZXl3b3JkPjxrZXl3b3JkPkNlcnZpY2FsIFZlcnRlYnJhZTwva2V5d29y
ZD48a2V5d29yZD5Db2hvcnQgU3R1ZGllczwva2V5d29yZD48a2V5d29yZD5Db3N0IFNhdmluZ3M8
L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29y
ZD48a2V5d29yZD5JbnRlbnNpdmUgQ2FyZS8qb3JnYW5pemF0aW9uICZhbXA7IGFkbWluaXN0cmF0
aW9uPC9rZXl3b3JkPjxrZXl3b3JkPipJbnR1YmF0aW9uLCBJbnRyYXRyYWNoZWFsPC9rZXl3b3Jk
PjxrZXl3b3JkPkxlbmd0aCBvZiBTdGF5PC9rZXl3b3JkPjxrZXl3b3JkPk1hbGU8L2tleXdvcmQ+
PGtleXdvcmQ+TWlkZGxlIEFnZWQ8L2tleXdvcmQ+PGtleXdvcmQ+UGF0aWVudCBDYXJlIFRlYW0v
Km9yZ2FuaXphdGlvbiAmYW1wOyBhZG1pbmlzdHJhdGlvbjwva2V5d29yZD48a2V5d29yZD5Qcm9n
cmFtIEV2YWx1YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+U3BpbmFsIENvcmQgSW5qdXJpZXMvKnRo
ZXJhcHk8L2tleXdvcmQ+PGtleXdvcmQ+VGhvcmFjaWMgVmVydGVicmFlPC9rZXl3b3JkPjxrZXl3
b3JkPipUcmFjaGVvc3RvbXk8L2tleXdvcmQ+PGtleXdvcmQ+VHJlYXRtZW50IE91dGNvbWU8L2tl
eXdvcmQ+PGtleXdvcmQ+WW91bmcgQWR1bHQ8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHll
YXI+MjAwOTwveWVhcj48cHViLWRhdGVzPjxkYXRlPk1hcjwvZGF0ZT48L3B1Yi1kYXRlcz48L2Rh
dGVzPjxpc2JuPjE0NDEtMjc3MiAoUHJpbnQpJiN4RDsxNDQxLTI3NzIgKExpbmtpbmcpPC9pc2Ju
PjxhY2Nlc3Npb24tbnVtPjE5MjgxNDM5PC9hY2Nlc3Npb24tbnVtPjx3b3JrLXR5cGU+RXZhbHVh
dGlvbiBTdHVkaWVzPC93b3JrLXR5cGU+PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93
d3cubmNiaS5ubG0ubmloLmdvdi9wdWJtZWQvMTkyODE0Mzk8L3VybD48L3JlbGF0ZWQtdXJscz48
L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+UGFuZGlhbjwvQXV0aG9yPjxZZWFy
PjIwMTI8L1llYXI+PFJlY051bT43Mjg8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjcyODwv
cmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9InR2dHd6ZnBlODl0
c2Q2ZXd3cnVweGVzYmV2eHZ3cDBmYXpkZCIgdGltZXN0YW1wPSIxNTI1NDAyMDYwIj43Mjg8L2tl
eT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVm
LXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlBhbmRpYW4sIFYuPC9hdXRob3I+
PGF1dGhvcj5NaWxsZXIsIEMuIFIuPC9hdXRob3I+PGF1dGhvcj5NaXJza2ksIE0uIEEuPC9hdXRo
b3I+PGF1dGhvcj5TY2hpYXZpLCBBLiBKLjwvYXV0aG9yPjxhdXRob3I+TW9yYWQsIEEuIEguPC9h
dXRob3I+PGF1dGhvcj5WYXN3YW5pLCBSLiBTLjwvYXV0aG9yPjxhdXRob3I+S2FsbWFyLCBDLiBM
LjwvYXV0aG9yPjxhdXRob3I+RmVsbGVyLUtvcG1hbiwgRC4gSi48L2F1dGhvcj48YXV0aG9yPkhh
dXQsIEUuIFIuPC9hdXRob3I+PGF1dGhvcj5ZYXJtdXMsIEwuIEIuPC9hdXRob3I+PGF1dGhvcj5C
aGF0dGksIE4uIEkuPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJl
c3M+UGVyY3V0YW5lb3VzIFRyYWNoZW9zdG9teSBTZXJ2aWNlLCBUaGUgSm9obnMgSG9wa2lucyBN
ZWRpY2FsIEluc3RpdHV0aW9ucywgQmFsdGltb3JlLCBNYXJ5bGFuZCAyMTI4NywgVVNBLiB2cGFu
ZGlhMUBqaG1pLmVkdTwvYXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPk11bHRpZGlzY2lwbGlu
YXJ5IHRlYW0gYXBwcm9hY2ggaW4gdGhlIG1hbmFnZW1lbnQgb2YgdHJhY2hlb3N0b215IHBhdGll
bnRzPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPk90b2xhcnluZ29sIEhlYWQgTmVjayBTdXJnPC9z
ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+T3RvbGFyeW5n
b2wgSGVhZCBOZWNrIFN1cmc8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz42ODQtOTE8
L3BhZ2VzPjx2b2x1bWU+MTQ3PC92b2x1bWU+PG51bWJlcj40PC9udW1iZXI+PGtleXdvcmRzPjxr
ZXl3b3JkPkNoaS1TcXVhcmUgRGlzdHJpYnV0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPkVmZmljaWVu
Y3ksIE9yZ2FuaXphdGlvbmFsPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29yZD48a2V5
d29yZD5Ib3NwaXRhbCBDb3N0czwva2V5d29yZD48a2V5d29yZD5IdW1hbnM8L2tleXdvcmQ+PGtl
eXdvcmQ+TGVuZ3RoIG9mIFN0YXkvc3RhdGlzdGljcyAmYW1wOyBudW1lcmljYWwgZGF0YTwva2V5
d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPk1pZGRsZSBBZ2VkPC9rZXl3b3Jk
PjxrZXl3b3JkPipPdXRjb21lIEFzc2Vzc21lbnQgKEhlYWx0aCBDYXJlKTwva2V5d29yZD48a2V5
d29yZD5QYXRpZW50IENhcmUgVGVhbS8qb3JnYW5pemF0aW9uICZhbXA7IGFkbWluaXN0cmF0aW9u
PC9rZXl3b3JkPjxrZXl3b3JkPlBvc3RvcGVyYXRpdmUgQ29tcGxpY2F0aW9ucy9lY29ub21pY3Mv
cHJldmVudGlvbiAmYW1wOyBjb250cm9sPC9rZXl3b3JkPjxrZXl3b3JkPlByb3NwZWN0aXZlIFN0
dWRpZXM8L2tleXdvcmQ+PGtleXdvcmQ+UmVncmVzc2lvbiBBbmFseXNpczwva2V5d29yZD48a2V5
d29yZD5SZXRyb3NwZWN0aXZlIFN0dWRpZXM8L2tleXdvcmQ+PGtleXdvcmQ+KlRyYWNoZW9zdG9t
eS9lY29ub21pY3M8L2tleXdvcmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAxMjwveWVhcj48
cHViLWRhdGVzPjxkYXRlPk9jdDwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjEwOTct
NjgxNyAoRWxlY3Ryb25pYykmI3hEOzAxOTQtNTk5OCAoTGlua2luZyk8L2lzYm4+PGFjY2Vzc2lv
bi1udW0+MjI2NzUwMDQ8L2FjY2Vzc2lvbi1udW0+PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0
dHBzOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvcHVibWVkLzIyNjc1MDA0PC91cmw+PC9yZWxhdGVk
LXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51bT4xMC4xMTc3LzAxOTQ1OTk4MTI0
NDk5OTU8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+
AG==
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DZXR0bzwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl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ADDIN EN.CITE.DATA 5-7 Although early experience showing dramatic improvement were first published over a decade ago, widespread adoption of these practices has not been universal. This is not surprising as some of the practices (e.g. multidisciplinary synchronous ward rounds and joint decision making) represent cultural shifts and thus pose significant practical challenges.One strategy used to accelerate the spread of proven improvements strategies is the Quality Improvement Collaborative. First introduced by the Institute for Healthcare Improvement, Quality Improvement Collaboratives have been used to drive improvement for many different medical conditions. The endeavors range in size from a set of geographically co-located hospitals within one state to international projects. ADDIN EN.CITE <EndNote><Cite><Year>2003</Year><RecNum>731</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>731</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525402475">731</key></foreign-keys><ref-type name="Government Document">46</ref-type><contributors></contributors><titles><title>The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper</title></titles><dates><year>2003</year></dates><pub-location>Boston</pub-location><publisher>Institute for Healthcare Improvement</publisher><urls></urls></record></Cite></EndNote>8 In a QIC, member hospitals commit to appointing champions and taking specific, concrete steps to accelerate their progress towards the desired state. Participating sites use data to track both the consistency of process changes and the effect on the desired outcomes.Timeline of the Global Tracheostomy Collaborative (GTC)In 2012, a group of 21 tracheostomy and quality improvement experts met in Glasgow, Scotland to review the current state of tracheostomy care worldwide. At this initial meeting, the founding members decided to form The Global Tracheostomy Collaborative, which is now incorporated as a non-profit corporation in the USA. After the development of a defined improvement strategy and creation of an international, privacy-law compliant database, the GTC began holding kickoff meetings and enrolling hospital members in 2014. As of January 2018, the GTC has 45 member hospitals around the world, over 2000 healthcare professional members, over 1300 patient and family members, and almost 4000 admissions in its database. The GTC has co-hosted three International Tracheostomy Symposia, hosts tracheostomy education webinars eight times annually, and issues bi-annual data reports. These data allow hospitals to track their progress and to compare their outcomes to other GTC hospitals. Early data have demonstrated significant, meaningful reductions in serious adverse events coupled with improvements in surrogates for the quality and effectiveness of care, such as length of stay within 12 months. ADDIN EN.CITE <EndNote><Cite><Author>McGrath</Author><Year>2017</Year><RecNum>734</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>734</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525402505">734</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGrath, B. A.</author><author>Lynch, J.</author><author>Bonvento, B.</author><author>Wallace, S.</author><author>Poole, V.</author><author>Farrell, A.</author><author>Diaz, C.</author><author>Khwaja, S.</author><author>Roberson, D. W.</author></authors></contributors><auth-address>University Hospital South Manchester, UK.</auth-address><titles><title>Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals</title><secondary-title>BMJ Qual Improv Rep</secondary-title></titles><periodical><full-title>BMJ Qual Improv Rep</full-title></periodical><volume>6</volume><number>1</number><dates><year>2017</year></dates><isbn>2050-1315 (Print)
2050-1315 (Linking)</isbn><accession-num>28607676</accession-num><urls><related-urls><url> To understand how participation in the collaborative leads to these improvements, it is necessary to understand practical application of the five “key drivers” of tracheostomy care. Each of the five subsequent sections focuses on one driver, placing it in the context of the entire program. The key aspect of implementation and specific case examples drawing from different geographies and health care delivery systems. Thegrowing body of data in recent years demonstrates how the implementation of the five ‘key drivers’ of tracheostomy occurs and how it leads to substantial improvements in tracheostomy care across diverse healthcare systems.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0dyYXRoPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0dyYXRoPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48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ADDIN EN.CITE.DATA 5,6,9,10 Therefore, [maybe …the purpose of this study is to describe how change agents have implemented the five “key drivers” of tracheostomy care within their institution.article…. [see above]Coordinated Multidisciplinary Care Teams: A Perspective from Austin Health, AustraliaAustin Health is an academic tertiary health service serving 1.2 million people in Melbourne, Australia. The multidisciplinary Tracheostomy Review and Management Service (TRAMS) was established in 2001 in response to two deaths of in-patient tracheostomy patients. TRAMS is a consultative service of tracheostomy specialists including Speech-Language Pathologists, Respiratory Therapists and Intensivists, Nurse Consultants, and Physiotherapists. TRAMS coordinates twice-weekly ward rounds, multidisciplinary policy and procedures, and education across three separate hospital sites three campuses and into the community. The service demonstrated a significant increase in safety and quality of life outcomes along with substantial cost savings.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1lcm9uPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1lcm9uPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48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ADDIN EN.CITE.DATA 6 The TRAMS team have also reported improvements in patient-centered metrics such as a decrease in time to the first vocalization, faster times to decannulation and reductions in overall length of stay.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1lcm9uPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48
UmVjTnVtPjQ4NzwvUmVjTnVtPjxEaXNwbGF5VGV4dD48c3R5bGUgZmFjZT0ic3VwZXJzY3JpcHQi
PjY8L3N0eWxlPjwvRGlzcGxheVRleHQ+PHJlY29yZD48cmVjLW51bWJlcj40ODc8L3JlYy1udW1i
ZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ0dnR3emZwZTg5dHNkNmV3d3J1
cHhlc2Jldnh2d3AwZmF6ZGQiIHRpbWVzdGFtcD0iMTQ0NDMyMDI1MCI+NDg3PC9rZXk+PC9mb3Jl
aWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxj
b250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5DYW1lcm9uLCBULiBTLjwvYXV0aG9yPjxhdXRo
b3I+TWNLaW5zdHJ5LCBBLjwvYXV0aG9yPjxhdXRob3I+QnVydCwgUy4gSy48L2F1dGhvcj48YXV0
aG9yPkhvd2FyZCwgTS4gRS48L2F1dGhvcj48YXV0aG9yPkJlbGxvbW8sIFIuPC9hdXRob3I+PGF1
dGhvcj5Ccm93biwgRC4gSi48L2F1dGhvcj48YXV0aG9yPlJvc3MsIEouIE0uPC9hdXRob3I+PGF1
dGhvcj5Td2VlbmV5LCBKLiBNLjwvYXV0aG9yPjxhdXRob3I+TyZhcG9zO0Rvbm9naHVlLCBGLiBK
LjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkF1c3RpbiBI
b3NwaXRhbCwgTWVsYm91cm5lLCBWSUMuIHRhbmlzLmNhbWVyb25AYXVzdGluLm9yZy5hdTwvYXV0
aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPk91dGNvbWVzIG9mIHBhdGllbnRzIHdpdGggc3BpbmFs
IGNvcmQgaW5qdXJ5IGJlZm9yZSBhbmQgYWZ0ZXIgaW50cm9kdWN0aW9uIG9mIGFuIGludGVyZGlz
Y2lwbGluYXJ5IHRyYWNoZW9zdG9teSB0ZWFtPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkNyaXQg
Q2FyZSBSZXN1c2M8L3NlY29uZGFyeS10aXRsZT48YWx0LXRpdGxlPkNyaXRpY2FsIGNhcmUgYW5k
IHJlc3VzY2l0YXRpb24gOiBqb3VybmFsIG9mIHRoZSBBdXN0cmFsYXNpYW4gQWNhZGVteSBvZiBD
cml0aWNhbCBDYXJlIE1lZGljaW5lPC9hbHQtdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1
bGwtdGl0bGU+Q3JpdCBDYXJlIFJlc3VzYzwvZnVsbC10aXRsZT48YWJici0xPkNyaXRpY2FsIGNh
cmUgYW5kIHJlc3VzY2l0YXRpb24gOiBqb3VybmFsIG9mIHRoZSBBdXN0cmFsYXNpYW4gQWNhZGVt
eSBvZiBDcml0aWNhbCBDYXJlIE1lZGljaW5lPC9hYmJyLTE+PC9wZXJpb2RpY2FsPjxhbHQtcGVy
aW9kaWNhbD48ZnVsbC10aXRsZT5Dcml0IENhcmUgUmVzdXNjPC9mdWxsLXRpdGxlPjxhYmJyLTE+
Q3JpdGljYWwgY2FyZSBhbmQgcmVzdXNjaXRhdGlvbiA6IGpvdXJuYWwgb2YgdGhlIEF1c3RyYWxh
c2lhbiBBY2FkZW15IG9mIENyaXRpY2FsIENhcmUgTWVkaWNpbmU8L2FiYnItMT48L2FsdC1wZXJp
b2RpY2FsPjxwYWdlcz4xNC05PC9wYWdlcz48dm9sdW1lPjExPC92b2x1bWU+PG51bWJlcj4xPC9u
dW1iZXI+PGVkaXRpb24+MjAwOS8wMy8xNDwvZWRpdGlvbj48a2V5d29yZHM+PGtleXdvcmQ+QWR1
bHQ8L2tleXdvcmQ+PGtleXdvcmQ+Q2VydmljYWwgVmVydGVicmFlPC9rZXl3b3JkPjxrZXl3b3Jk
PkNvaG9ydCBTdHVkaWVzPC9rZXl3b3JkPjxrZXl3b3JkPkNvc3QgU2F2aW5nczwva2V5d29yZD48
a2V5d29yZD5GZW1hbGU8L2tleXdvcmQ+PGtleXdvcmQ+SHVtYW5zPC9rZXl3b3JkPjxrZXl3b3Jk
PkludGVuc2l2ZSBDYXJlLypvcmdhbml6YXRpb24gJmFtcDsgYWRtaW5pc3RyYXRpb248L2tleXdv
cmQ+PGtleXdvcmQ+KkludHViYXRpb24sIEludHJhdHJhY2hlYWw8L2tleXdvcmQ+PGtleXdvcmQ+
TGVuZ3RoIG9mIFN0YXk8L2tleXdvcmQ+PGtleXdvcmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5N
aWRkbGUgQWdlZDwva2V5d29yZD48a2V5d29yZD5QYXRpZW50IENhcmUgVGVhbS8qb3JnYW5pemF0
aW9uICZhbXA7IGFkbWluaXN0cmF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlByb2dyYW0gRXZhbHVh
dGlvbjwva2V5d29yZD48a2V5d29yZD5TcGluYWwgQ29yZCBJbmp1cmllcy8qdGhlcmFweTwva2V5
d29yZD48a2V5d29yZD5UaG9yYWNpYyBWZXJ0ZWJyYWU8L2tleXdvcmQ+PGtleXdvcmQ+KlRyYWNo
ZW9zdG9teTwva2V5d29yZD48a2V5d29yZD5UcmVhdG1lbnQgT3V0Y29tZTwva2V5d29yZD48a2V5
d29yZD5Zb3VuZyBBZHVsdDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDA5PC95
ZWFyPjxwdWItZGF0ZXM+PGRhdGU+TWFyPC9kYXRlPjwvcHViLWRhdGVzPjwvZGF0ZXM+PGlzYm4+
MTQ0MS0yNzcyIChQcmludCkmI3hEOzE0NDEtMjc3MiAoTGlua2luZyk8L2lzYm4+PGFjY2Vzc2lv
bi1udW0+MTkyODE0Mzk8L2FjY2Vzc2lvbi1udW0+PHdvcmstdHlwZT5FdmFsdWF0aW9uIFN0dWRp
ZXM8L3dvcmstdHlwZT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5s
bS5uaWguZ292L3B1Ym1lZC8xOTI4MTQzOTwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48L3Jl
Y29yZD48L0NpdGU+PC9FbmROb3RlPn==
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1lcm9uPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48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ADDIN EN.CITE.DATA 6Despite its impressive imprint on tracheostomy care in Australia and globally, TRAMS has a surprisingly small staff, operating with 2.6 full-time equivalent staff. Most TRAMS’ staff are part-time and also work within other related services. Patients at Austin Health are placed in specialty wards based on their primary diagnosis regardless of how frequently (or infrequently) the specialty ward cares for tracheostomy patients. Therefore, the migratory expertise of the TRAMS team goes to the patient. For instance, liver transplant patients with tracheostomy are placed in the liver transplant ward, and TRAMS provides consultation on site.A unique feature of TRAMS at Austin Health is continuity of care. The same clinicians who manage a patient in the inpatient setting during an acute admission follow long-term tracheostomy patients into the community. A review of 40 community-based tracheostomy patients in 2012-2013, revealed high long-term survival rates with no deaths directly attributed to tracheostomy-related complications (Reference In press). Numerous tracheostomy teams now exist in Australasia based on the TRAMS model, with thet body of literature on the effectiveness of such teamsgrowing rapidly.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYXJydWJiYTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+
PFJlY051bT40NjE8L1JlY051bT48RGlzcGxheVRleHQ+PHN0eWxlIGZhY2U9InN1cGVyc2NyaXB0
Ij41LDExLTE0PC9zdHlsZT48L0Rpc3BsYXlUZXh0PjxyZWNvcmQ+PHJlYy1udW1iZXI+NDYxPC9y
ZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0idHZ0d3pmcGU4OXRz
ZDZld3dydXB4ZXNiZXZ4dndwMGZhemRkIiB0aW1lc3RhbXA9IjE0NDEyMjc0NzciPjQ2MTwva2V5
PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYt
dHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+R2FycnViYmEsIE0uPC9hdXRob3I+
PGF1dGhvcj5UdXJuZXIsIFQuPC9hdXRob3I+PGF1dGhvcj5HcmlldmVzb24sIEMuPC9hdXRob3I+
PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+Q2VudHJlIGZvciBDbGluaWNh
bCBFZmZlY3RpdmVuZXNzLCBTb3V0aGVybiBIZWFsdGgsIENsYXl0b24sIFZpY3RvcmlhIDMxNjgs
IEF1c3RyYWxpYS4gbWFyaWUuZ2FycnViYmFAc291dGhlcm5oZWFsdGgub3JnLmF1PC9hdXRoLWFk
ZHJlc3M+PHRpdGxlcz48dGl0bGU+TXVsdGlkaXNjaXBsaW5hcnkgY2FyZSBmb3IgdHJhY2hlb3N0
b215IHBhdGllbnRzOiBhIHN5c3RlbWF0aWMgcmV2aWV3PC90aXRsZT48c2Vjb25kYXJ5LXRpdGxl
PkNyaXQgQ2FyZTwvc2Vjb25kYXJ5LXRpdGxlPjxhbHQtdGl0bGU+Q3JpdGljYWwgY2FyZTwvYWx0
LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkNyaXQgQ2FyZTwvZnVsbC10
aXRsZT48YWJici0xPkNyaXRpY2FsIGNhcmU8L2FiYnItMT48L3BlcmlvZGljYWw+PGFsdC1wZXJp
b2RpY2FsPjxmdWxsLXRpdGxlPkNyaXQgQ2FyZTwvZnVsbC10aXRsZT48YWJici0xPkNyaXRpY2Fs
IGNhcmU8L2FiYnItMT48L2FsdC1wZXJpb2RpY2FsPjxwYWdlcz5SMTc3PC9wYWdlcz48dm9sdW1l
PjEzPC92b2x1bWU+PG51bWJlcj42PC9udW1iZXI+PGVkaXRpb24+MjAwOS8xMS8xMDwvZWRpdGlv
bj48a2V5d29yZHM+PGtleXdvcmQ+QXVzdHJhbGlhPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwv
a2V5d29yZD48a2V5d29yZD4qSW50ZW5zaXZlIENhcmUgVW5pdHM8L2tleXdvcmQ+PGtleXdvcmQ+
TmV3IFplYWxhbmQ8L2tleXdvcmQ+PGtleXdvcmQ+KlBhdGllbnQgQ2FyZSBUZWFtPC9rZXl3b3Jk
PjxrZXl3b3JkPlBhdGllbnRzJmFwb3M7IFJvb21zPC9rZXl3b3JkPjxrZXl3b3JkPlRyYWNoZW9z
dG9teS9hZHZlcnNlIGVmZmVjdHMvbW9ydGFsaXR5LypzdGF0aXN0aWNzICZhbXA7IG51bWVyaWNh
bCBkYXRhPC9rZXl3b3JkPjwva2V5d29yZHM+PGRhdGVzPjx5ZWFyPjIwMDk8L3llYXI+PC9kYXRl
cz48aXNibj4xNDY2LTYwOVggKEVsZWN0cm9uaWMpJiN4RDsxMzY0LTg1MzUgKExpbmtpbmcpPC9p
c2JuPjxhY2Nlc3Npb24tbnVtPjE5ODk1NjkwPC9hY2Nlc3Npb24tbnVtPjx3b3JrLXR5cGU+UmV2
aWV3PC93b3JrLXR5cGU+PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93d3cubmNiaS5u
bG0ubmloLmdvdi9wdWJtZWQvMTk4OTU2OTA8L3VybD48L3JlbGF0ZWQtdXJscz48L3VybHM+PGN1
c3RvbTI+MjgxMTkyODwvY3VzdG9tMj48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+MTAuMTE4Ni9j
YzgxNTk8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0
aG9yPkNldHRvPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVjTnVtPjQ1NjwvUmVjTnVtPjxy
ZWNvcmQ+PHJlYy1udW1iZXI+NDU2PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9
IkVOIiBkYi1pZD0idHZ0d3pmcGU4OXRzZDZld3dydXB4ZXNiZXZ4dndwMGZhemRkIiB0aW1lc3Rh
bXA9IjE0NDEyMjcyODkiPjQ1Njwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJK
b3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRo
b3I+Q2V0dG8sIFIuPC9hdXRob3I+PGF1dGhvcj5Bcm9yYSwgQS48L2F1dGhvcj48YXV0aG9yPkhl
dHRpZ2UsIFIuPC9hdXRob3I+PGF1dGhvcj5OZWwsIE0uPC9hdXRob3I+PGF1dGhvcj5CZW5qYW1p
biwgTC48L2F1dGhvcj48YXV0aG9yPkdvbWV6LCBDLiBNLjwvYXV0aG9yPjxhdXRob3I+T2xkZmll
bGQsIFcuIEwuPC9hdXRob3I+PGF1dGhvcj5OYXJ1bGEsIEEuIEEuPC9hdXRob3I+PC9hdXRob3Jz
PjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RGVwYXJ0bWVudCBvZiBPdG9yaGlub2xhcnlu
Z29sb2d5LCBTdC4gTWFyeSZhcG9zO3MgSG9zcGl0YWwsIEltcGVyaWFsIENvbGxlZ2UgSGVhbHRo
Y2FyZSBOSFMgVHJ1c3QsIExvbmRvbiwgVUsuIHJhdWwuY2V0dG8xMEBpbXBlcmlhbC5hYy51azwv
YXV0aC1hZGRyZXNzPjx0aXRsZXM+PHRpdGxlPkltcHJvdmluZyB0cmFjaGVvc3RvbXkgY2FyZTog
YSBwcm9zcGVjdGl2ZSBzdHVkeSBvZiB0aGUgbXVsdGlkaXNjaXBsaW5hcnkgYXBwcm9hY2g8L3Rp
dGxlPjxzZWNvbmRhcnktdGl0bGU+Q2xpbiBPdG9sYXJ5bmdvbDwvc2Vjb25kYXJ5LXRpdGxlPjxh
bHQtdGl0bGU+Q2xpbmljYWwgb3RvbGFyeW5nb2xvZ3kgOiBvZmZpY2lhbCBqb3VybmFsIG9mIEVO
VC1VSyA7IG9mZmljaWFsIGpvdXJuYWwgb2YgTmV0aGVybGFuZHMgU29jaWV0eSBmb3IgT3RvLVJo
aW5vLUxhcnluZ29sb2d5ICZhbXA7IENlcnZpY28tRmFjaWFsIFN1cmdlcnk8L2FsdC10aXRsZT48
L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5DbGluIE90b2xhcnluZ29sPC9mdWxsLXRp
dGxlPjxhYmJyLTE+Q2xpbmljYWwgb3RvbGFyeW5nb2xvZ3kgOiBvZmZpY2lhbCBqb3VybmFsIG9m
IEVOVC1VSyA7IG9mZmljaWFsIGpvdXJuYWwgb2YgTmV0aGVybGFuZHMgU29jaWV0eSBmb3IgT3Rv
LVJoaW5vLUxhcnluZ29sb2d5ICZhbXA7IENlcnZpY28tRmFjaWFsIFN1cmdlcnk8L2FiYnItMT48
L3BlcmlvZGljYWw+PGFsdC1wZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkNsaW4gT3RvbGFyeW5nb2w8
L2Z1bGwtdGl0bGU+PGFiYnItMT5DbGluaWNhbCBvdG9sYXJ5bmdvbG9neSA6IG9mZmljaWFsIGpv
dXJuYWwgb2YgRU5ULVVLIDsgb2ZmaWNpYWwgam91cm5hbCBvZiBOZXRoZXJsYW5kcyBTb2NpZXR5
IGZvciBPdG8tUmhpbm8tTGFyeW5nb2xvZ3kgJmFtcDsgQ2Vydmljby1GYWNpYWwgU3VyZ2VyeTwv
YWJici0xPjwvYWx0LXBlcmlvZGljYWw+PHBhZ2VzPjQ4Mi04PC9wYWdlcz48dm9sdW1lPjM2PC92
b2x1bWU+PG51bWJlcj41PC9udW1iZXI+PGVkaXRpb24+MjAxMS8wOC8xNjwvZWRpdGlvbj48a2V5
d29yZHM+PGtleXdvcmQ+QXBhY2hlPC9rZXl3b3JkPjxrZXl3b3JkPkZlbWFsZTwva2V5d29yZD48
a2V5d29yZD5Ib3NwaXRhbHMsIFRlYWNoaW5nPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5
d29yZD48a2V5d29yZD5JbnRlbnNpdmUgQ2FyZSBVbml0czwva2V5d29yZD48a2V5d29yZD5JbnRl
cnZlbnRpb24gU3R1ZGllczwva2V5d29yZD48a2V5d29yZD5Mb25kb248L2tleXdvcmQ+PGtleXdv
cmQ+TWFsZTwva2V5d29yZD48a2V5d29yZD5NaWRkbGUgQWdlZDwva2V5d29yZD48a2V5d29yZD5Q
YXRpZW50IENhcmUvKnN0YW5kYXJkczwva2V5d29yZD48a2V5d29yZD5QYXRpZW50IENhcmUgVGVh
bS8qc3RhbmRhcmRzPC9rZXl3b3JkPjxrZXl3b3JkPlByb3NwZWN0aXZlIFN0dWRpZXM8L2tleXdv
cmQ+PGtleXdvcmQ+U3RhdGlzdGljcywgTm9ucGFyYW1ldHJpYzwva2V5d29yZD48a2V5d29yZD4q
VHJhY2hlb3N0b215PC9rZXl3b3JkPjwva2V5d29yZHM+PGRhdGVzPjx5ZWFyPjIwMTE8L3llYXI+
PHB1Yi1kYXRlcz48ZGF0ZT5PY3Q8L2RhdGU+PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4xNzQ5
LTQ0ODYgKEVsZWN0cm9uaWMpJiN4RDsxNzQ5LTQ0NzggKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Np
b24tbnVtPjIxODM4ODA3PC9hY2Nlc3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5o
dHRwOi8vd3d3Lm5jYmkubmxtLm5paC5nb3YvcHVibWVkLzIxODM4ODA3PC91cmw+PC9yZWxhdGVk
LXVybHM+PC91cmxzPjxlbGVjdHJvbmljLXJlc291cmNlLW51bT4xMC4xMTExL2ouMTc0OS00NDg2
LjIwMTEuMDIzNzkueDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PC9yZWNvcmQ+PC9DaXRlPjxD
aXRlPjxBdXRob3I+U3BlZWQ8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFyPjxSZWNOdW0+NDU5PC9S
ZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj40NTk8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48
a2V5IGFwcD0iRU4iIGRiLWlkPSJ0dnR3emZwZTg5dHNkNmV3d3J1cHhlc2Jldnh2d3AwZmF6ZGQi
IHRpbWVzdGFtcD0iMTQ0MTIyNzQ0MCI+NDU5PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBl
IG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhv
cnM+PGF1dGhvcj5TcGVlZCwgTC48L2F1dGhvcj48YXV0aG9yPkhhcmRpbmcsIEsuIEUuPC9hdXRo
b3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjxhdXRoLWFkZHJlc3M+RWFzdGVybiBIZWFsdGgs
IEJveCBIaWxsIFZJQywgQXVzdHJhbGlhLiBsYXVyZW4uc3BlZWRAZWFzdGVybmhlYWx0aC5vcmcu
YXU8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5UcmFjaGVvc3RvbXkgdGVhbXMgcmVkdWNl
IHRvdGFsIHRyYWNoZW9zdG9teSB0aW1lIGFuZCBpbmNyZWFzZSBzcGVha2luZyB2YWx2ZSB1c2U6
IGEgc3lzdGVtYXRpYyByZXZpZXcgYW5kIG1ldGEtYW5hbHlzaXM8L3RpdGxlPjxzZWNvbmRhcnkt
dGl0bGU+SiBDcml0IENhcmU8L3NlY29uZGFyeS10aXRsZT48YWx0LXRpdGxlPkpvdXJuYWwgb2Yg
Y3JpdGljYWwgY2FyZTwvYWx0LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxl
PkogQ3JpdCBDYXJlPC9mdWxsLXRpdGxlPjxhYmJyLTE+Sm91cm5hbCBvZiBjcml0aWNhbCBjYXJl
PC9hYmJyLTE+PC9wZXJpb2RpY2FsPjxhbHQtcGVyaW9kaWNhbD48ZnVsbC10aXRsZT5KIENyaXQg
Q2FyZTwvZnVsbC10aXRsZT48YWJici0xPkpvdXJuYWwgb2YgY3JpdGljYWwgY2FyZTwvYWJici0x
PjwvYWx0LXBlcmlvZGljYWw+PHBhZ2VzPjIxNiBlMS0xMDwvcGFnZXM+PHZvbHVtZT4yODwvdm9s
dW1lPjxudW1iZXI+MjwvbnVtYmVyPjxlZGl0aW9uPjIwMTIvMDkvMDc8L2VkaXRpb24+PGtleXdv
cmRzPjxrZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbnRlbnNpdmUgQ2FyZSBVbml0
cy9zdGF0aXN0aWNzICZhbXA7IG51bWVyaWNhbCBkYXRhPC9rZXl3b3JkPjxrZXl3b3JkPkxlbmd0
aCBvZiBTdGF5L3N0YXRpc3RpY3MgJmFtcDsgbnVtZXJpY2FsIGRhdGE8L2tleXdvcmQ+PGtleXdv
cmQ+UGF0aWVudCBDYXJlIFRlYW0vKnN0YXRpc3RpY3MgJmFtcDsgbnVtZXJpY2FsIGRhdGE8L2tl
eXdvcmQ+PGtleXdvcmQ+KlByb3N0aGVzZXMgYW5kIEltcGxhbnRzPC9rZXl3b3JkPjxrZXl3b3Jk
PipTcGVlY2g8L2tleXdvcmQ+PGtleXdvcmQ+VGltZSBGYWN0b3JzPC9rZXl3b3JkPjxrZXl3b3Jk
PlRyYWNoZW9zdG9teS9hZHZlcnNlIGVmZmVjdHMvKm1ldGhvZHMvKnN0YXRpc3RpY3MgJmFtcDsg
bnVtZXJpY2FsIGRhdGE8L2tleXdvcmQ+PGtleXdvcmQ+VHJlYXRtZW50IE91dGNvbWU8L2tleXdv
cmQ+PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAxMzwveWVhcj48cHViLWRhdGVzPjxkYXRlPkFw
cjwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjE1NTctODYxNSAoRWxlY3Ryb25pYykm
I3hEOzA4ODMtOTQ0MSAoTGlua2luZyk8L2lzYm4+PGFjY2Vzc2lvbi1udW0+MjI5NTEwMTc8L2Fj
Y2Vzc2lvbi1udW0+PHdvcmstdHlwZT5NZXRhLUFuYWx5c2lzJiN4RDtSZXZpZXc8L3dvcmstdHlw
ZT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L3B1
Ym1lZC8yMjk1MTAxNzwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNv
dXJjZS1udW0+MTAuMTAxNi9qLmpjcmMuMjAxMi4wNS4wMDU8L2VsZWN0cm9uaWMtcmVzb3VyY2Ut
bnVtPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPllhbmV6YTwvQXV0aG9yPjxZZWFyPjIw
MTU8L1llYXI+PFJlY051bT40NTc8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjQ1NzwvcmVj
LW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9InR2dHd6ZnBlODl0c2Q2
ZXd3cnVweGVzYmV2eHZ3cDBmYXpkZCIgdGltZXN0YW1wPSIxNDQxMjI3Mzk5Ij40NTc8L2tleT48
L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5
cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPllhbmV6YSwgTS4gTS48L2F1dGhvcj48
YXV0aG9yPkphbWVzLCBILiBQLjwvYXV0aG9yPjxhdXRob3I+RGF2aWVzLCBQLjwvYXV0aG9yPjxh
dXRob3I+SGFycmlzb24sIFMuPC9hdXRob3I+PGF1dGhvcj5NY0Fsb3J1bSwgTC48L2F1dGhvcj48
YXV0aG9yPkNsZW1lbnQsIFcuIEEuPC9hdXRob3I+PGF1dGhvcj5LdWJiYSwgSC48L2F1dGhvcj48
L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5EZXBhcnRtZW50IG9mIE90b2xh
cnluZ29sb2d5LFRoZSBSb3lhbCBIb3NwaXRhbCBmb3IgU2ljayBDaGlsZHJlbiAoWW9ya2hpbGwp
LEdsYXNnb3csVUsuJiN4RDtVbml2ZXJzaXR5IG9mIEdsYXNnb3cgTWVkaWNhbCBTY2hvb2wsIEds
YXNnb3cgVW5pdmVyc2l0eSxTY290bGFuZCxVSy4mI3hEO0RlcGFydG1lbnQgb2YgUGFlZGlhdHJp
YyBSZXNwaXJhdG9yeSBNZWRpY2luZSxUaGUgUm95YWwgSG9zcGl0YWwgZm9yIFNpY2sgQ2hpbGRy
ZW4gKFlvcmtoaWxsKSxHbGFzZ293LFVLLiYjeEQ7RGVwYXJ0bWVudCBvZiBTcGVlY2ggYW5kIExh
bmd1YWdlIFRoZXJhcHksVGhlIFJveWFsIEhvc3BpdGFsIGZvciBTaWNrIENoaWxkcmVuIChZb3Jr
aGlsbCksR2xhc2dvdyxVSy48L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5DaGFuZ2luZyBp
bmRpY2F0aW9ucyBmb3IgcGFlZGlhdHJpYyB0cmFjaGVvc3RvbXkgYW5kIHRoZSByb2xlIG9mIGEg
bXVsdGlkaXNjaXBsaW5hcnkgdHJhY2hlb3N0b215IGNsaW5pYzwvdGl0bGU+PHNlY29uZGFyeS10
aXRsZT5KIExhcnluZ29sIE90b2w8L3NlY29uZGFyeS10aXRsZT48YWx0LXRpdGxlPlRoZSBKb3Vy
bmFsIG9mIGxhcnluZ29sb2d5IGFuZCBvdG9sb2d5PC9hbHQtdGl0bGU+PC90aXRsZXM+PHBlcmlv
ZGljYWw+PGZ1bGwtdGl0bGU+SiBMYXJ5bmdvbCBPdG9sPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNh
bD48cGFnZXM+ODgyLTY8L3BhZ2VzPjx2b2x1bWU+MTI5PC92b2x1bWU+PG51bWJlcj45PC9udW1i
ZXI+PGVkaXRpb24+MjAxNS8wOS8wMTwvZWRpdGlvbj48a2V5d29yZHM+PGtleXdvcmQ+Q2xpbmlj
YWwgTnVyc2UgU3BlY2lhbGlzdDwva2V5d29yZD48a2V5d29yZD5PdG9sYXJ5bmdvbG9neTwva2V5
d29yZD48a2V5d29yZD5QZWRpYXRyaWNzPC9rZXl3b3JkPjxrZXl3b3JkPlB1bG1vbmFyeSBNZWRp
Y2luZTwva2V5d29yZD48a2V5d29yZD5TcGVlY2ggQW5kIExhbmd1YWdlIERpc29yZGVyIFJlaGFi
aWxpdGF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlRyYWNoZW9zdG9teTwva2V5d29yZD48L2tleXdv
cmRzPjxkYXRlcz48eWVhcj4yMDE1PC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+U2VwPC9kYXRlPjwv
cHViLWRhdGVzPjwvZGF0ZXM+PGlzYm4+MTc0OC01NDYwIChFbGVjdHJvbmljKSYjeEQ7MDAyMi0y
MTUxIChMaW5raW5nKTwvaXNibj48YWNjZXNzaW9uLW51bT4yNjMxNDMyMjwvYWNjZXNzaW9uLW51
bT48dXJscz48cmVsYXRlZC11cmxzPjx1cmw+aHR0cDovL3d3dy5uY2JpLm5sbS5uaWguZ292L3B1
Ym1lZC8yNjMxNDMyMjwvdXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNv
dXJjZS1udW0+MTAuMTAxNy9TMDAyMjIxNTExNTAwMTE0MDwvZWxlY3Ryb25pYy1yZXNvdXJjZS1u
dW0+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+QWJvZGU8L0F1dGhvcj48WWVhcj4yMDE2
PC9ZZWFyPjxSZWNOdW0+NTkzPC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj41OTM8L3JlYy1u
dW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ0dnR3emZwZTg5dHNkNmV3
d3J1cHhlc2Jldnh2d3AwZmF6ZGQiIHRpbWVzdGFtcD0iMTQ3NTQ0NzczMyI+NTkzPC9rZXk+PC9m
b3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBl
Pjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5BYm9kZSwgSy4gQS48L2F1dGhvcj48YXV0
aG9yPkRyYWtlLCBBLiBGLjwvYXV0aG9yPjxhdXRob3I+WmRhbnNraSwgQy4gSi48L2F1dGhvcj48
YXV0aG9yPlJldHNjaC1Cb2dhcnQsIEcuIFouPC9hdXRob3I+PGF1dGhvcj5HZWUsIEEuIEIuPC9h
dXRob3I+PGF1dGhvcj5Ob2FoLCBULiBMLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9y
cz48YXV0aC1hZGRyZXNzPlVuaXZlcnNpdHkgb2YgTm9ydGggQ2Fyb2xpbmEgSGVhbHRoIENhcmUg
U3lzdGVtLCBDaGFwZWwgSGlsbCwgTm9ydGggQ2Fyb2xpbmE7IGFuZCBEaXZpc2lvbiBvZiBQdWxt
b25vbG9neSwgRGVwYXJ0bWVudCBvZiBQZWRpYXRyaWNzLCBhbmQgamthQG1lZC51bmMuZWR1LiYj
eEQ7RGl2aXNpb24gb2YgUHVsbW9ub2xvZ3ksIERlcGFydG1lbnQgb2YgUGVkaWF0cmljcywgYW5k
IERpdmlzaW9uIG9mIFBlZGlhdHJpYyBPdG9sYXJ5bmdvbG9neSwgRGVwYXJ0bWVudCBvZiBPdG9s
YXJ5bmdvbG9neS9IZWFkIGFuZCBOZWNrIFN1cmdlcnksIFVuaXZlcnNpdHkgb2YgTm9ydGggQ2Fy
b2xpbmEgU2Nob29sIG9mIE1lZGljaW5lLCBDaGFwZWwgSGlsbCwgTm9ydGggQ2Fyb2xpbmEuJiN4
RDtEaXZpc2lvbiBvZiBQdWxtb25vbG9neSwgRGVwYXJ0bWVudCBvZiBQZWRpYXRyaWNzLCBhbmQu
PC9hdXRoLWFkZHJlc3M+PHRpdGxlcz48dGl0bGU+QSBNdWx0aWRpc2NpcGxpbmFyeSBDaGlsZHJl
biZhcG9zO3MgQWlyd2F5IENlbnRlcjogSW1wYWN0IG9uIHRoZSBDYXJlIG9mIFBhdGllbnRzIFdp
dGggVHJhY2hlb3N0b215PC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlBlZGlhdHJpY3M8L3NlY29u
ZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5QZWRpYXRyaWNzPC9m
dWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+ZTIwMTUwNDU1PC9wYWdlcz48dm9sdW1lPjEz
Nzwvdm9sdW1lPjxudW1iZXI+MjwvbnVtYmVyPjxrZXl3b3Jkcz48a2V5d29yZD5BZG9sZXNjZW50
PC9rZXl3b3JkPjxrZXl3b3JkPkNoaWxkPC9rZXl3b3JkPjxrZXl3b3JkPkNoaWxkLCBQcmVzY2hv
b2w8L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkhvc3BpdGFsIFVu
aXRzLypvcmdhbml6YXRpb24gJmFtcDsgYWRtaW5pc3RyYXRpb248L2tleXdvcmQ+PGtleXdvcmQ+
SHVtYW5zPC9rZXl3b3JkPjxrZXl3b3JkPkluZmFudDwva2V5d29yZD48a2V5d29yZD5JbmZhbnQs
IE5ld2Jvcm48L2tleXdvcmQ+PGtleXdvcmQ+KkludGVyZGlzY2lwbGluYXJ5IENvbW11bmljYXRp
b248L2tleXdvcmQ+PGtleXdvcmQ+TGVuZ3RoIG9mIFN0YXkvc3RhdGlzdGljcyAmYW1wOyBudW1l
cmljYWwgZGF0YTwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPk91dGNv
bWUgYW5kIFByb2Nlc3MgQXNzZXNzbWVudCAoSGVhbHRoIENhcmUpPC9rZXl3b3JkPjxrZXl3b3Jk
PlBhdGllbnQgQ2FyZSBUZWFtLypvcmdhbml6YXRpb24gJmFtcDsgYWRtaW5pc3RyYXRpb248L2tl
eXdvcmQ+PGtleXdvcmQ+UGF0aWVudCBEaXNjaGFyZ2Uvc3RhbmRhcmRzPC9rZXl3b3JkPjxrZXl3
b3JkPlBvc3RvcGVyYXRpdmUgQ29tcGxpY2F0aW9ucy9wcmV2ZW50aW9uICZhbXA7IGNvbnRyb2w8
L2tleXdvcmQ+PGtleXdvcmQ+UHJvZmVzc2lvbmFsLUZhbWlseSBSZWxhdGlvbnM8L2tleXdvcmQ+
PGtleXdvcmQ+UHJvZ3JhbSBFdmFsdWF0aW9uPC9rZXl3b3JkPjxrZXl3b3JkPlF1YWxpdHkgSW1w
cm92ZW1lbnQvKm9yZ2FuaXphdGlvbiAmYW1wOyBhZG1pbmlzdHJhdGlvbjwva2V5d29yZD48a2V5
d29yZD4qVHJhY2hlb3N0b215PC9rZXl3b3JkPjxrZXl3b3JkPllvdW5nIEFkdWx0PC9rZXl3b3Jk
Pjwva2V5d29yZHM+PGRhdGVzPjx5ZWFyPjIwMTY8L3llYXI+PHB1Yi1kYXRlcz48ZGF0ZT5GZWI8
L2RhdGU+PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4xMDk4LTQyNzUgKEVsZWN0cm9uaWMpJiN4
RDswMDMxLTQwMDUgKExpbmtpbmcpPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjI2NzU1Njk1PC9hY2Nl
c3Npb24tbnVtPjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vd3d3Lm5jYmkubmxtLm5p
aC5nb3YvcHVibWVkLzI2NzU1Njk1PC91cmw+PC9yZWxhdGVkLXVybHM+PC91cmxzPjxlbGVjdHJv
bmljLXJlc291cmNlLW51bT4xMC4xNTQyL3BlZHMuMjAxNS0wNDU1PC9lbGVjdHJvbmljLXJlc291
cmNlLW51bT48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPgB=
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYXJydWJiYTwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+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ADDIN EN.CITE.DATA 5,11-14At the Austin, an Interdepartmental Tracheostomy Forum is held twice-yearly, where all heads of departments and senior staff from relevant disciplines meet to to review adverse events data, discuss challenging cases, update equipment, and provide cross-discipline education. The TRAMS at Austin Health collaborates with the GTC Patient & Family Committee to offer Tracheostomy Forums twice a year. Up to 75 tracheostomy patients, their families and professionals meet online to share stories, receive awards, and hear presentations on tracheostomy topics. TRAMS patients contribute to the GTC Patient & Family Newsletter and participate in the GTC Webinars. Even though different permutations of multidisciplinary tracheostomy teams exist with varying functional roles, having a Physician, a Nurse, a Respiratory Therapist, and a Speech-Language Pathologist as the basic composition of a team to improve clinical outcomes of tracheostomy patients (Cameron, Arora, Pandian).Institution-wide trach protocols: An Example from the Johns Hopkins ExperienceThe Johns Hopkins Hospital has championed the development of several institution-wide tracheostomy protocols to improve patient safety and clinical outcomes. One particularly impactful protocol was the “Standardized Tracheostomy Capping and Decannulation Protocol”, which developed in response to a root-cause analysis of a significant untoward outcome.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYW5kaWFuPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48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==
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYW5kaWFuPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48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==
ADDIN EN.CITE.DATA 15 The protocol not only embraces standardization but also embodies a multidisciplinary team culture in successfully weaning a patient from a tracheostomy. The Development ProcessThe development of the protocol required the formation of a multidisciplinary task force comprising experts from several pertinent disciplines – physicians, nursing, respiratory therapy, and speech-language pathology, as well as the hospital risk manager. Physicians with expertise in otolaryngology-head and neck surgery, interventional pulmonology, trauma surgery, and anesthesia collaborated. The multidisciplinary task force was led by a tracheostomy nurse practitioner and met bi-monthly to create components of the protocol (Figure 1). The team of experts debated and edited each component until consensus was reached. The protocol was then reviewed by the nursing standards of care committee, medical care evaluation committee, and the administrative committee of the medical board. Each committee provided suggestions and opportunities to improve content.Building Awareness Laying the groundwork for the protocol required attention to education and cultural factors. The process of building awareness about the protocol, creating a sense of urgency around the change, and obtaining buy-in from stakeholders caring for patients throughout the hospital was time-consuming and challenging. In common with many reports from change programs, experienced clinicians were often resistant to change. Certain surgeons did not want to change their approach because of fear of loss of control, while some respiratory therapists and nurses were reluctant to provide the extra monitoring or documentation. The multidisciplinary task force met with those resisting change in person or in groups to educate them about the importance of a standardized approach.Implementation of the protocolImplementation of the protocol occurred in two phases (Figure 2). In the first phase, the protocol was implemented for a six-month period in four medical/surgical wards after intensive education was provided. Just-in-time education was also provided by the tracheostomy nurse practitioner to strengthen the knowledge about the tracheostomy capping and decannulation protocol once an eligible patient was identified. Based on feedback from those who utilized the protocol in the first phase, the protocol was further refined. It was then implemented throughout the hospital for the next six months to ensure generalizability to other specialty wards and units. Upon successful implementation throughout the hospital, the protocol was once again reviewed by the stakeholers prior to adoption as an institutional policy into the interdisciplinary clinical practice manual. Experiences of protocol implementation may vary from one institution to another. Quality Control and Promotion of AdherenceAdherence to the protocol after the initial implementation phase by all specialties and disciplines is closely monitored by the multidisciplinary tracheostomy team. Adherence to the protocol was reviewed by the multidisciplinary tracheostomy team on a weekly basis during weekly tracheostomy rounds. In addition, spot checks were done by the Speech-Language Pathologists and the Tracheostomy Nurse Practitioner. The multidisciplinary tracheostomy team assists the clinicians in the wards with the identification of variations, modification of nursing/rehabilitative activities, and alteration of resource allocation to ensure successful implementation of the protocol.Multidisciplinary tracheostomy teams can facilitate the development and implementation of standardized protocols, which in turn enable provision of consistent patient care (Mitchell R Int J Nurs Stud 2013). The tracheostomy protocol created at the Johns Hopkins Hospital is being piloted in several other institutions including the University of Michigan.Coordinated Interdisciplinary Education: Texas Children’s HospitalChildren with tracheostomies are a uniquely complex and vulnerable population (Reference). Optimal carerequires knowledgeable and competent providers from numerous medical specialties, home care providers, equipment suppliers, and engagement withpatients and families themselves. Robust educational programsare an important component of any effort to improve quality of care and outcomes for tracheostomy patients.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaXRjaGVsbDwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+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 EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaXRjaGVsbDwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+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 EN.CITE.DATA 16 At Texas Children’s Hospital (TCH), a multidisciplinary team was formed to assess the current state of tracheostomy care at the institution, identify targets for improvement, and implement quality improvement initiatives. Here we describe some of the initiatives undertaken in the educational arena.Nursing EducationPrevious studies have described serious deficits in knowledge and comfort with tracheostomy care among health care providers. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb3J0b248L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS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 EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb3J0b248L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS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 EN.CITE.DATA 17-20 In response to a perceived deficit in knowledge and comfort among outpatient Pediatric Otolaryngology nurses at TCHCH, a tracheostomy education program was developed by a team of Otolaryngology faculty and advanced practice providers. The program consisted of a live lecture series, the practice of skills on a mannequin, and shadowing during inpatient multidisciplinary tracheostomy team rounds. The course was given over 3-4 days and included pre- and post-course self-efficacy and objective tracheostomy knowledge assessments. In line with other reports of staff education, there was a significant improvement in both self-efficacy and objective tracheostomy knowledge (Figures 3 and 4).PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BZ2Fyd2FsPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BZ2Fyd2FsPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48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ADDIN EN.CITE.DATA 18,20 Standardized Parent/Caregiver CurriculumSimilar to Austin Health, tracheostomy patients at TCH are cared for on a variety of inpatient units. In order to reduce variation in caregiver education prior to discharge, a tracheostomy education workgroup was formed to develop a standardized caregiver educational curriculum. Stakeholders included providers from numerous medical subspecialties (Otolaryngology, Pulmonology, Critical Care), nursing representatives from all inpatient wards caring for tracheostomy patients, Speech-Language Pathology, Respiratory Therapy, Social work, Case Management, and a group of families and caregivers. After an initial assessment of all currently used tracheostomy educational materials, the group worked collaboratively and iteratively to develop a caregiver handbook, to be used institution-wide for tracheostomy education. The handbook was designed as a resource for parents from initial pre-surgery discussions through discharge and outpatient care, including step-by-step instructions for basic tracheostomy care procedures, emergency algorithms, as well as commonly used state insurance forms and tracheostomy team contact information. Attempts to include all potential stakeholders at the outset was key in developing the most comprehensive resource possible, as well as obtaining buy-in from units accustomed to their own unique policies and procedures. Including families was indispensable in ensuring the handbook focused on high-yield topics and explained concepts and procedures in language understandable to non-medically-trained readers. Simulation in Parent/Caregiver EducationAfter a child receives a tracheostomy, it is imperative to ensure that the child’s primary caregivers are competent to independently care for the child at home. At TCH, families undergo a training in a number of settings, including classroom instruction, bedside training with nurses, and a “rooming-in” period in which they assume all care for their child while in the inpatient setting. Similar training programs are fairly standard across pediatric hospitals, and yet parents report a lack of knowledge and confidence in caring for their child with a tracheostomy upon discharge from the hospital.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy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ADDIN EN.CITE.DATA 21The use of simulation in medical education has exploded in popularity in recent years, and yet reports of its use in educating patients and caregivers are limited.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2xlbWFuPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2xlbWFuPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48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ADDIN EN.CITE.DATA 22,23 At TCH, a simulation-based educational program (the “Parent Emergency Preparedness for Tracheostomy Assisted Living and Care,” or PEPTALC program) was created using feedback from recently discharged families to develop high-yield simulation scenarios. ADDIN EN.CITE <EndNote><Cite><Author>Arnold</Author><Year>2016</Year><RecNum>717</RecNum><DisplayText><style face="superscript">24</style></DisplayText><record><rec-number>717</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1524852463">717</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Arnold, J.</author><author>Diaz, M. C.</author></authors></contributors><auth-address>Division of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Electronic address: mcdiaz@.</auth-address><titles><title>Simulation training for primary caregivers in the neonatal intensive care unit</title><secondary-title>Semin Perinatol</secondary-title></titles><periodical><full-title>Semin Perinatol</full-title></periodical><pages>466-472</pages><volume>40</volume><number>7</number><keywords><keyword>Adaptation, Psychological</keyword><keyword>Cardiopulmonary Resuscitation</keyword><keyword>Caregivers/*education/psychology</keyword><keyword>Curriculum</keyword><keyword>Health Knowledge, Attitudes, Practice</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>*Intensive Care Units, Neonatal</keyword><keyword>Interdisciplinary Communication</keyword><keyword>*Patient Discharge</keyword><keyword>*Patient Simulation</keyword><keyword>*Simulation Training/methods</keyword></keywords><dates><year>2016</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1558-075X (Electronic)
0146-0005 (Linking)</isbn><accession-num>27810116</accession-num><urls><related-urls><url> Prior to discharge to home, all caregivers of new tracheostomy patients complete the 4-hour course, which includes four scenarios: blocked tracheostomy tube, dislodged tube, water in the ventilator tubing, and cardiac arrest. Debriefing is done with trained simulation educators, and learners have the ability to repeat scenarios until competency is obtained. Caregiver-reported self-efficacy is measured before and after completing the course. The effects of simulation on caregiver knowledge and confidence are under study, with planned publication of findings in the near future (Reference). Simulation-based training can bridge the gap in tracheostomy education by intensifying training not only for clinicians but also for family members, who can then translate their knowledge and skills into improving patient safety. Simulation-based tracheostomy training of clinicians and family members is being attempted at the Johns Hopkins Hospital. Certainly, more tracheostomy-based simulation devices need to be developed to make this a reality.Patient and Family-centered care: University of Michigan, United Kingdom, and BeyondIncluding patients as bona fide members of a multidisciplinary tracheostomy team allows the team to identify problems early and work toward a patient-centered solution. The patient advocacy credo, “Nothing about us without us,” emphasizes the deep desire of patients and their caregivers to be engaged in decision making. High-quality care is fostered by seeking patient perspectives, inviting feedback, and developing patient-centered performance measures. ADDIN EN.CITE <EndNote><Cite><Author>Ward</Author><Year>2018</Year><RecNum>740</RecNum><DisplayText><style face="superscript">25</style></DisplayText><record><rec-number>740</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525402869">740</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ward, E.</author><author>Pandian, V.</author><author>Brenner, M. J.</author></authors></contributors><auth-address>Boston Children's Hospital Tracheostomy Team, Institute for Professionalism and Ethical Practice, Boston Children's Hospital, 4 Oakhill Drive, Methuen, MA, 01844, USA.
Acute and Chronic Care, Johns Hopkins School of Nursing, 525 N Wolfe St, Rm 442, Baltimore, MD, 21205, USA.
Department of Otolaryngology - Head and Neck Surgery, University of Michigan School of Medicine, 1500 East Medical Center Drive SPC 5312, 1904 Taubman Center, Ann Arbor, MI, 48109-5312, USA. mbren@med.umich.edu.</auth-address><titles><title>The Primacy of Patient-Centered Outcomes in Tracheostomy Care</title><secondary-title>Patient</secondary-title></titles><periodical><full-title>Patient</full-title></periodical><pages>143-145</pages><volume>11</volume><number>2</number><dates><year>2018</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1178-1661 (Electronic)
1178-1653 (Linking)</isbn><accession-num>29071525</accession-num><urls><related-urls><url> As the Agency for Healthcare Research and Quality notes, patient engagement promotes measurable improvements in safety and quality. ADDIN EN.CITE <EndNote><Cite><Year>2013</Year><RecNum>588</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>588</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1462986912">588</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Agency for Healthcare Research and Quality. Guide to Patient and Family Engagement in Hospital Quality and Safety</title></titles><dates><year>2013</year></dates><pub-location>Rockville, MD</pub-location><urls><related-urls><url> Patient and caregivers are an integral part of GTC, and the collaborative prioritizes clinical outcomes based on such input.For example, while reducing adverse events is a key objective of quality improvement efforts, patients and families frequently also emphasize factors that influence the quality of life. While improving the safety healthcare is essential, patients rightly demand more of their healthcare providers.simply Patients and their families frequently note not only the risks associated with tracheostomy but also the frustrations in areas such as communication or in securing necessary medical supplies. Increasingly, patients and caregivers are challenging the healthcare community to frame goals in positive, aspirational terms that will improve day-to-day experiences of patients with a tracheostomy, which is at the heart of patient-centered care. Involving patients in these efforts along with physicians in training will have a lasting impact on culture and quality improvement efforts. ADDIN EN.CITE <EndNote><Cite><Author>Morrison</Author><Year>2017</Year><RecNum>742</RecNum><DisplayText><style face="superscript">27</style></DisplayText><record><rec-number>742</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525403083">742</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Morrison, R. J.</author><author>Bowe, S. N.</author><author>Brenner, M. J.</author></authors></contributors><auth-address>Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee.
Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston.
Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor.</auth-address><titles><title>Teaching Quality Improvement and Patient Safety in Residency Education: Strategies for Meaningful Resident Quality and Safety Initiatives</title><secondary-title>JAMA Otolaryngol Head Neck Surg</secondary-title></titles><periodical><full-title>JAMA Otolaryngol Head Neck Surg</full-title><abbr-1>JAMA otolaryngology-- head & neck surgery</abbr-1></periodical><pages>1069-1070</pages><volume>143</volume><number>11</number><dates><year>2017</year><pub-dates><date>Nov 1</date></pub-dates></dates><isbn>2168-619X (Electronic)
2168-6181 (Linking)</isbn><accession-num>28796866</accession-num><urls><related-urls><url> At the University of Michigan, patients and caregivers are deliberately integrated into a “Tracheostomy Trail” that provides a detailed framework for orchestrating care from before the tracheostomy through discharge with an iterative assessment of patient needs and training.Patients and caregivers describe how impaired speech and communication after tracheostomy can lead to social withdrawal and compromised emotional well-being. ADDIN EN.CITE <EndNote><Cite><Author>Nakarada-Kordic</Author><Year>2018</Year><RecNum>744</RecNum><DisplayText><style face="superscript">28</style></DisplayText><record><rec-number>744</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525403158">744</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nakarada-Kordic, I.</author><author>Patterson, N.</author><author>Wrapson, J.</author><author>Reay, S. D.</author></authors></contributors><auth-address>Design for Health and Wellbeing (DHW) Lab, Auckland City Hospital, Auckland University of Technology, Level 5, Building 32, Park Rd., Auckland, 1023, New Zealand. ivana@.
Design for Health and Wellbeing (DHW) Lab, Auckland City Hospital, Auckland University of Technology, Level 5, Building 32, Park Rd., Auckland, 1023, New Zealand.</auth-address><titles><title>A Systematic Review of Patient and Caregiver Experiences with a Tracheostomy</title><secondary-title>Patient</secondary-title></titles><periodical><full-title>Patient</full-title></periodical><pages>175-191</pages><volume>11</volume><number>2</number><dates><year>2018</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1178-1661 (Electronic)
1178-1653 (Linking)</isbn><accession-num>28914429</accession-num><urls><related-urls><url> Multidisciplinary teams can play a critical role in patient-centered care outcomes such as restoring speech. Timely speech rehabilitation after tracheostomy may seem less pressing than other medical procedures, such as placing intravenous lines, fluid resuscitation, or medication administration, an aphonic patient is vulnerable and in significant psychological distress. In one study, a majority of floor nurses with less than 5 years’ experience were uncomfortable with tracheostomy emergencies.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qcml0Y2hldHQ8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFy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==
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qcml0Y2hldHQ8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFy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==
ADDIN EN.CITE.DATA 29 Fear is pervasive for these patients. Patients may not be able to call for help during a medical emergency. A team-based approach led to improved use of one-way speaking valves, which in turn resulted in decreased adverse events, decreased length of stay, and shorter duration of cannulation.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1lcm9uPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW1lcm9uPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48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ADDIN EN.CITE.DATA 30Social media platforms incorporating patients and family promote ideas for improvement opportunities. One survey of patients and family with tracheostomy found that only around half of respondents had the opportunity to meet with a patient with a tracheostomy prior to surgery or felt prepared to care for the tracheostomy at time of discharge.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy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ADDIN EN.CITE.DATA 21 Fragmented care and lack of teamwork were noted by a third of respondents. Eleven percent of respondents reported that no emergency preparedness training was provided, and 14% required emergency care within a week of discharge.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy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ADDIN EN.CITE.DATA 21 Patients and family also noted the difficulty in securing products and services relating to the tracheostomy care. Such difficulties are more than inconveniences, resulting in considerable distress and risking the loss of life in the event of tracheostomy occlusion or malfunction. ADDIN EN.CITE <EndNote><Cite><Author>Das</Author><Year>2012</Year><RecNum>465</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>465</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1441228373">465</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Das, P.</author><author>Zhu, H.</author><author>Shah, R. K.</author><author>Roberson, D. W.</author><author>Berry, J.</author><author>Skinner, M. L.</author></authors></contributors><auth-address>School of Clinical Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge, UK.</auth-address><titles><title>Tracheotomy-related catastrophic events: results of a national survey</title><secondary-title>Laryngoscope</secondary-title><alt-title>The Laryngoscope</alt-title></titles><periodical><full-title>Laryngoscope</full-title></periodical><pages>30-7</pages><volume>122</volume><number>1</number><edition>2011/12/21</edition><keywords><keyword>Catastrophic Illness</keyword><keyword>Data Collection</keyword><keyword>Humans</keyword><keyword>Postoperative Complications/epidemiology/etiology</keyword><keyword>*Quality Improvement</keyword><keyword>Tracheotomy/*adverse effects/*standards</keyword><keyword>United States</keyword></keywords><dates><year>2012</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1531-4995 (Electronic)
0023-852X (Linking)</isbn><accession-num>22183626</accession-num><urls><related-urls><url> A great strength of the collaborative approach isto provide a forum for patients to share experiences among themselves and with the medical community. The National Tracheostomy Safety Project (NSTP) in the UK affords a perspective on the impressive reach of social media-based strategies. This NTSP developed a marketing campaign to target key staff groups with easily digestible tracheostomy safety resources. The strategy was built around understanding the audience (what they wanted and how they wanted to consume resources), developing high quality, professional content to convey key messages, and then targeting frontline staff through a mixture of native and promoted social media activity. This resulted in significant interaction – much more interaction than occurs from publishing a paper in a journal. At the time of writing this report, the Multidisciplinary Emergency Tracheostomy Guidelines paper that underpinned this project had been cited in the medical literature a total of 89 times since its publication in September 2012. ADDIN EN.CITE <EndNote><Cite><Author>McGrath</Author><Year>2012</Year><RecNum>748</RecNum><DisplayText><style face="superscript">31</style></DisplayText><record><rec-number>748</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525990888">748</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGrath, B. A.</author><author>Bates, L.</author><author>Atkinson, D.</author><author>Moore, J. A.</author><author>National Tracheostomy Safety, Project</author></authors></contributors><auth-address>University Hospital of South Manchester NHS Foundation Trust, Manchester, UK. brendan.mcgrath@</auth-address><titles><title>Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies</title><secondary-title>Anaesthesia</secondary-title></titles><periodical><full-title>Anaesthesia</full-title><abbr-1>Anaesthesia</abbr-1></periodical><pages>1025-41</pages><volume>67</volume><number>9</number><keywords><keyword>Adult</keyword><keyword>Airway Management/*standards</keyword><keyword>Algorithms</keyword><keyword>Child</keyword><keyword>Device Removal</keyword><keyword>Emergency Medical Services/*standards</keyword><keyword>Equipment Design</keyword><keyword>Humans</keyword><keyword>Laryngectomy/instrumentation/*standards</keyword><keyword>Oxygen Inhalation Therapy</keyword><keyword>Patient Safety</keyword><keyword>Respiration</keyword><keyword>Societies, Medical</keyword><keyword>Suction</keyword><keyword>Tracheostomy/instrumentation/*standards</keyword><keyword>United Kingdom</keyword></keywords><dates><year>2012</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1365-2044 (Electronic)
0003-2409 (Linking)</isbn><accession-num>22731935</accession-num><urls><related-urls><url> These figures are dwarfed by the metrics from the 2018 social media project, totaling 629,270 social media impressions of the newly created video and infographic resources. Management of tracheostomy extends beyond the boundaries of clinicians. Involving family members in education and decision-making at every step possible can help address patient and family expectations of clinical outcomes and prepare them effectively for discharge.Data Collection and Tracking Outcomes: Multi-Hospital initiatives in the United Kingdom (UK)Accurate and meaningful data is essential in determining the impact of quality improvement interventions. The ideal tracheostomy-related data collection tools will track patient-level metrics that can inform medical institutions about progress and performance at ward-level (reductions in harm or provision of essential equipment), at a system level (reductions in length of stay or readmission rates), or metrics that reflect quality of care (early vocalization or oral intake). As alluded to in the prior section, patients and their families often describe very different performance metrics to those that would appear important to healthcare providers. ADDIN EN.CITE <EndNote><Cite><Author>McGrath</Author><Year>2018</Year><RecNum>746</RecNum><DisplayText><style face="superscript">32</style></DisplayText><record><rec-number>746</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525403477">746</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGrath, B.; Lynch, J.; Coe, B.; Wallace, S.; Bonvento, B.; Eusuf, D.; Firn, M.</author></authors></contributors><titles><title>Improving tracheostomy care: collaborative national consensus and prioritisation of quality improvements in the United Kingdom</title><secondary-title>Medical Research Archives</secondary-title></titles><periodical><full-title>Medical Research Archives</full-title></periodical><pages>1-10</pages><volume>6</volume><number>1</number><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>32 The GTC Database Committee created a robust, HIPAA-compliant database for prospectively following tracheostomy outcomes. The database was created by expert volunteers from nine disciplines and has been in use for over a period of 5 years and now has about 4,000 entries (Figure 5). Biannual reports are provided to member institutions with their own data and aggregate data of all sites. An important element of data collection is establishing who collects the data, where and when. In the UK, the GTC has worked with over 25 hospitals in establishing the most effective methods of data collection. Member institutions have attempted a variety of methods, from dedicated data clerks to senior medical staff. Whilst it may only take a few minutes to physically enter the data, identifying and tracking a patient through their hospital stay can be a challenge for busy clinical teams.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYXZpbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYXZpbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl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ADDIN EN.CITE.DATA 10 It is often the case that a degree of topic-specific medical knowledge is required for meaningful data collection. The relative importance of a specific metric must be balanced against the accuracy and ease of its collection. In a detailed analysis of the data collection of four UK sites participating in the GTC, data quality was found to be high, with 918 of 934 (98.3%) of new cases completing a minimum, defined a mandatory dataset. ADDIN EN.CITE <EndNote><Cite><Author>McGrath</Author><Year>2017</Year><RecNum>734</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>734</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525402505">734</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGrath, B. A.</author><author>Lynch, J.</author><author>Bonvento, B.</author><author>Wallace, S.</author><author>Poole, V.</author><author>Farrell, A.</author><author>Diaz, C.</author><author>Khwaja, S.</author><author>Roberson, D. W.</author></authors></contributors><auth-address>University Hospital South Manchester, UK.</auth-address><titles><title>Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals</title><secondary-title>BMJ Qual Improv Rep</secondary-title></titles><periodical><full-title>BMJ Qual Improv Rep</full-title></periodical><volume>6</volume><number>1</number><dates><year>2017</year></dates><isbn>2050-1315 (Print)
2050-1315 (Linking)</isbn><accession-num>28607676</accession-num><urls><related-urls><url> The UK group also met and worked through a consensus exercise to agree the priority and order that interventions would be attempted in, and which metrics would be collected to track their progress. As a result, member institutions reported a degree of ownership and ‘buy-in’ to the project and did not feel that they were collecting irrelevant data or undertaking interventions that were not considered useful at their site. ADDIN EN.CITE <EndNote><Cite><Author>McGrath</Author><Year>2018</Year><RecNum>746</RecNum><DisplayText><style face="superscript">32</style></DisplayText><record><rec-number>746</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1525403477">746</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McGrath, B.; Lynch, J.; Coe, B.; Wallace, S.; Bonvento, B.; Eusuf, D.; Firn, M.</author></authors></contributors><titles><title>Improving tracheostomy care: collaborative national consensus and prioritisation of quality improvements in the United Kingdom</title><secondary-title>Medical Research Archives</secondary-title></titles><periodical><full-title>Medical Research Archives</full-title></periodical><pages>1-10</pages><volume>6</volume><number>1</number><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>32 Detailed analyses to date of the GTC projects in the National Health System of the UK have demonstrated improvements across domains, including safer care, reduced length of stay and shorter times to vocalization and established oral intake following tracheostomy. The ability to benchmark these metrics over time and then to compare them with other similar sites will be a welcome addition to this, and to any project, with comparisons becoming increasingly valid and meaningful as the database grows. Future targets are likely to arise from the current 3-year Improving Tracheostomy Care project in the UK, where a target of 1,200 healthcare staff, patients, and their families will be asked about the difficulties faced providing and experiencing high quality and safe care. As an example of how the improvement collaboratives can be responsive to the needs of participating sites and their patients, future metrics can be defined and refined through an active social media community, involving both care providers and patients themselves. Synthesis and conclusionsThe examples of institutions implementing the key drivers of GTC exemplify change agents who have not only made an impact within their institution but also disseminated to other institutions. Collaboratives are learning communities that drive positive change through effective communication, dissemination, and implementation of proven strategies. In the case of the GTC, this learning occurs through sharing of ideas between institutions via discussion boards, live webinars, and the International Tracheostomy Symposia. Standardized hospital protocols, policies, and procedures are easily shared online with other member hospitals. Patients and caregivers access these same platforms to share their perspectives with each other and the medical professionals involved in their care. Patients share insights into the lived-experience and priorities of tracheostomy patient, and the direct and ongoing interaction afforded by the GTC ensures a continued focus on patient-centered outcomes.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaWxraW5zb248L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFy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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaWxraW5zb248L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFy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ADDIN EN.CITE.DATA 21,33 Communicating data is also critical. The GTC database has been refined to reflect the needs of its users, affording institutions an easy way to track their own outcomes, and pooling data can help in identifying trends that may not be apparent on a small scale. Members are able to easily recognize targets for improvement when they can see how their own outcomes are situated in the context of other member hospitals. Such benchmarking may also prove useful in building the case for requesting additional funding or other resources for a tracheostomy program. Future efforts to widely distribute data and best practices surrounding tracheostomy care will likely involve engaging with social media. This future is already becoming reality with initiatives emerging in the United Kingdom.In summary, adopting the five key drivers of the GTC has proven highly effective for a wide range of international institutions for improving the care of patients with tracheostomies. These drivers serve as a framework for assessing the current quality of care and for designing targeted interventions. A universal theme in all examples is the importance of the multidisciplinary team. While the benefits of coordinated multidisciplinary tracheostomy teams appeared in the literature prior to the formation of the GTC, ADDIN EN.CITE <EndNote><Cite><Author>Garrubba</Author><Year>2009</Year><RecNum>461</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>461</rec-number><foreign-keys><key app="EN" db-id="tvtwzfpe89tsd6ewwrupxesbevxvwp0fazdd" timestamp="1441227477">461</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Garrubba, M.</author><author>Turner, T.</author><author>Grieveson, C.</author></authors></contributors><auth-address>Centre for Clinical Effectiveness, Southern Health, Clayton, Victoria 3168, Australia. marie.garrubba@.au</auth-address><titles><title>Multidisciplinary care for tracheostomy patients: a systematic review</title><secondary-title>Crit Care</secondary-title><alt-title>Critical care</alt-title></titles><periodical><full-title>Crit Care</full-title><abbr-1>Critical care</abbr-1></periodical><alt-periodical><full-title>Crit Care</full-title><abbr-1>Critical care</abbr-1></alt-periodical><pages>R177</pages><volume>13</volume><number>6</number><edition>2009/11/10</edition><keywords><keyword>Australia</keyword><keyword>Humans</keyword><keyword>*Intensive Care Units</keyword><keyword>New Zealand</keyword><keyword>*Patient Care Team</keyword><keyword>Patients' Rooms</keyword><keyword>Tracheostomy/adverse effects/mortality/*statistics & numerical data</keyword></keywords><dates><year>2009</year></dates><isbn>1466-609X (Electronic)
1364-8535 (Linking)</isbn><accession-num>19895690</accession-num><work-type>Review</work-type><urls><related-urls><url> these reports did not result in broad adoption. The creation and growth of the Quality Improvement Collaborative created a community of like-minded members, who now have a platform for sharing and a track record of measurable, lasting improvements in outcomes being tracked on a large-scale basis. References ADDIN EN.REFLIST 1.Agency for Healthcare Research and Quality. Statistics on hospital stays. 2014; ;. Accessed October 6, 2014.2.Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. Respir Care. 2014;59(6):895-915; discussion 916-899.3.Shah RK, Lander L, Berry JG, Nussenbaum B, Merati A, Roberson DW. Tracheotomy outcomes and complications: a national perspective. Laryngoscope. 2012;122(1):25-29.4.Das P, Zhu H, Shah RK, Roberson DW, Berry J, Skinner ML. Tracheotomy-related catastrophic events: results of a national survey. Laryngoscope. 2012;122(1):30-37.5.Cetto R, Arora A, Hettige R, et al. Improving tracheostomy care: a prospective study of the multidisciplinary approach. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 2011;36(5):482-488.6.Cameron TS, McKinstry A, Burt SK, et al. Outcomes of patients with spinal cord injury before and after introduction of an interdisciplinary tracheostomy team. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 2009;11(1):14-19.7.Pandian V, Miller CR, Mirski MA, et al. Multidisciplinary team approach in the management of tracheostomy patients. Otolaryngol Head Neck Surg. 2012;147(4):684-691.8.The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003.9.McGrath BA, Lynch J, Bonvento B, et al. Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ Qual Improv Rep. 2017;6(1).10.Lavin J, Shah R, Greenlick H, Gaudreau P, Bedwell J. The Global Tracheostomy Collaborative: one institution's experience with a new quality improvement initiative. Int J Pediatr Otorhinolaryngol. 2016;80:106-108.11.Garrubba M, Turner T, Grieveson C. Multidisciplinary care for tracheostomy patients: a systematic review. Critical care. 2009;13(6):R177.12.Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. Journal of critical care. 2013;28(2):216 e211-210.13.Yaneza MM, James HP, Davies P, et al. Changing indications for paediatric tracheostomy and the role of a multidisciplinary tracheostomy clinic. J Laryngol Otol. 2015;129(9):882-886.14.Abode KA, Drake AF, Zdanski CJ, Retsch-Bogart GZ, Gee AB, Noah TL. A Multidisciplinary Children's Airway Center: Impact on the Care of Patients With Tracheostomy. Pediatrics. 2016;137(2):e20150455.15.Pandian V, Miller CR, Schiavi AJ, et al. Utilization of a standardized tracheostomy capping and decannulation protocol to improve patient safety. Laryngoscope. 2014;124(8):1794-1800.16.Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20.17.Dorton LH, Lintzenich CR, Evans AK. Simulation model for tracheotomy education for primary health-care providers. Ann Otol Rhinol Laryngol. 2014;123(1):11-18.18.Yelverton JC, Nguyen JH, Wan W, Kenerson MC, Schuman TA. Effectiveness of a standardized education process for tracheostomy care. Laryngoscope. 2015;125(2):342-347.19.McGrath B, Wilkinson K, Shah RK. Notes from a Small Island: Lessons from the UK NCEPOD Tracheotomy Report. Otolaryngol Head Neck Surg. 2015;153(2):167-169.20.Agarwal A, Marks N, Wessel V, et al. Improving knowledge, technical skills, and confidence among pediatric health care providers in the management of chronic tracheostomy using a simulation model. Pediatric pulmonology. 2015.21.McCormick ME, Ward E, Roberson DW, Shah RK, Stachler RJ, Brenner MJ. Life after Tracheostomy: Patient and Family Perspectives on Teaching, Transitions, and Multidisciplinary Teams. Otolaryngol Head Neck Surg. 2015.22.Coleman EA. Extending simulation learning experiences to patients with chronic health conditions. JAMA : the journal of the American Medical Association. 2014;311(3):243-244.23.Sigalet E, Cheng A, Donnon T, et al. A simulation-based intervention teaching seizure management to caregivers: A randomized controlled pilot study. Paediatr Child Health. 2014;19(7):373-378.24.Arnold J, Diaz MC. Simulation training for primary caregivers in the neonatal intensive care unit. Semin Perinatol. 2016;40(7):466-472.25.Ward E, Pandian V, Brenner MJ. The Primacy of Patient-Centered Outcomes in Tracheostomy Care. Patient. 2018;11(2):143-145.26.Agency for Healthcare Research and Quality. Guide to Patient and Family Engagement in Hospital Quality and Safety. 2013; RJ, Bowe SN, Brenner MJ. Teaching Quality Improvement and Patient Safety in Residency Education: Strategies for Meaningful Resident Quality and Safety Initiatives. JAMA otolaryngology-- head & neck surgery. 2017;143(11):1069-1070.28.Nakarada-Kordic I, Patterson N, Wrapson J, Reay SD. A Systematic Review of Patient and Caregiver Experiences with a Tracheostomy. Patient. 2018;11(2):175-191.29.Pritchett CV, Foster Rietz M, Ray A, Brenner MJ, Brown D. Inpatient Nursing and Parental Comfort in Managing Pediatric Tracheostomy Care and Emergencies. JAMA otolaryngology-- head & neck surgery. 2016;142(2):132-137.30.Cameron M, Corner A, Diba A, Hankins M. Development of a tracheostomy scoring system to guide airway management after major head and neck surgery. International journal of oral and maxillofacial surgery. 2009;38(8):846-849.31.McGrath BA, Bates L, Atkinson D, Moore JA, National Tracheostomy Safety P. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-1041.32.McGrath BL, J.; Coe, B.; Wallace, S.; Bonvento, B.; Eusuf, D.; Firn, M. Improving tracheostomy care: collaborative national consensus and prioritisation of quality improvements in the United Kingdom. Medical Research Archives. 2018;6(1):1-10.33.Wilkinson KAM, I.C.; Freeth, H.; Kelly, K.; Mason, M. NCEPOD: On the right trach? In: Death NCEiPOa, ed. London, UK2014. ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- university of minnesota college of education
- university of minnesota school of social work
- wharton school of the university of pennsylvania
- cost of university of scranton
- university of minnesota school of education
- university of scranton cost of attendance
- university of south florida college of medicine
- university of minnesota masters of social work
- ecampus of university of phoenix
- university of minnesota college of continuing education
- university of illinois college of nursing
- university of north texas college of nursing