CAPÍTOL IX: CONCLUSIONS I CONSIDERACIONS FINALS
Taula 2. Definicions de referència
quality of the care provided?
!.#.a. Narrative: Why do we need to improve care?
Patients with tracheostomies often have complex underlying healthcare needs that cross traditional healthcare boundaries. Tracheostomy care has been under increasing scrutiny with successive reports from the United States, United Kingdom, and Australasia highlighting measurable harm in up to %&% of hospital admissions (Thomas and McGrath, !""#; McGrath and Thomas, !"#"; Martin et al., ,-./; Doherty and McGrath, +,-.).
One of the methodologies employed in understanding the problems in a particular field of healthcare is analysis of reported critical incidents. In the UK’s NHS hospitals, any local incident is reported and investigated locally. Reported incidents are then typically sent to the data-warehouses of the National Reporting and Learning Service (NRLS), formerly part of the National Patient Safety Agency (NPSA). Application to the NRLS to search the database is possible, with a relevant research question and the relevant approvals.
The basis for this paper was a keyword search that my co-author had previously tested in a smaller dataset. This keyword search was highly sensitive (retrieving all relevant airway incidents) but not specific (retrieving many irrelevant incidents). Over half of the ,,.,/ retrieved incidents were rejected, leaving 1,234 that could be analysed. These
incidents represented a snapshot of airway-related critical incidents reported in England and Wales over a !-year period from October +,,-. Both authors classified these incidents into pre-agreed categories described in Table ), using a bespoke Microsoft Access database that was developed in collaboration with a knowledgeable colleague from the Medical Physics department at Salford Royal Hospital. Thematic analysis and exploration of the data were undertaken using pivot tables in Access and statistical comparisons were made in IBM SPSS Statistics.
We reported that whilst attention had previously been focused on insertion of airway devices, over ./% of airway incidents occurred after insertion, and that these incidents could lead to significant harm. Recurrent themes around staffing, training, adequate infrastructure and appropriate equipment provision were made. A lack of monitoring equipment was identified and we made a recommendation that the same standards of care be applied to ICU airway management as to airway management in operating theatres. We highlighted the potential for improving the reporting of patient safety incidents and also made recommendations to improve the safety of airway devices in critical care.
This first paper presented in this section highlights the problems that airway devices and tracheostomies in particular can pose in critical care. These incidents described some of the worst harm, much of which appeared entirely preventable by prospective system-wide improvements. For the second paper in this series, the same two authors examined tracheostomy- specific reports. This time we examined reports originating outside of the ICU on hospital wards.
Despite ward patients being less sick than the critically ill, these patients were coming to more significant harm, often leading to subsequent ICU admission. Harm was likely due to staffing, educational, monitoring and equipment limitations in these ward areas (Hashimi et al., ./0.).
Importantly, we also identified that communication around the ‘ownership’ of patients with tracheostomies was poor and fragmented and that essential details around the nature of the patient’s airway could not be rapidly communicated to those responding to emergencies. This new knowledge was key to our development of tracheostomy bedhead signs and the strategies around creating designated ‘cohort’ wards to provide safe areas for patients with altered airways. It was also clear that comprehensive, accessible training resources were urgently needed. These findings catalysed the development of the National Tracheostomy Safety Project and the development of many guidelines and resources in response to the problems I had identified.
One of the significant limitations of analyses of this nature is that staff tend not to report incidents for a whole host of reasons. Estimates suggest only around #$% of incidents are reported (Sari et al., ,--.). However, this approach is still one of the best tools available for analyzing large datasets and offers a likely snapshot of problems related to airway management on a national scale, reported for the first time. The pattern of our findings was reproduced in later reports and these papers were cited by many authors in the UK and abroad when considering improvements in airway care in ICU (M. Jackson et al., 0123; McGrath and Wilkinson, 2345a; McGrath, Wilkinson, et al., ./01).
The use of reported patient safety incidents as a tool for assessing the impact of healthcare interventions is developed and discussed later in this thesis. See section ,.-.d.