Abstract
Assessing Patient Comfort with Tracheostomy Self-care
Andrew Tritter, MD (presenter); Trisha L. Thompson, MD; Rachel Mudge; Lori Lemonnier, MD
Objectives: Tracheostomy (trach) is a common surgical intervention in which a hole is created in the neck to allow direct passage of air to the lungs in cases where the normal pathway has been obstructed or impaired. Patients’ long-term health is related to how well they care for their trach, yet there is no standardized protocol for postoperative trach care education, and research regarding this topic is heavily lacking. The objective of this study was to provide evidence for the benefits of a standardized trach care education protocol.
Methods: In this clinical study, we evaluated 10 patients prior to undergoing trach care education for their knowledge and comfort level with providing their own trach care using a multiple-choice questionnaire and visual analog scale (VAS) developed specifically for this study. The patients were educated using a standardized protocol for trach care and subsequently retested with the same questionnaire.
Results: Our pre- and posteducation data demonstrate a variable degree of preeducation knowledge and comfort with trach care. Half of the patients surveyed showed varying degrees of improvement in their posteducation scores, while nearly all patients showed an improvement in their overall level of comfort as demonstrated on VAS evaluation.
Conclusions: These data demonstrate the potential utility of a standardized education protocol for patients having undergone a recent trach, and serve as a guide to help improve the current standard of care in postoperative trach management.
Calcium Monitoring/Supplementation and Thyroidectomy
Amrita Ray, DO (presenter); Alexandra Brown, MD; Lana Jackson, MD
Objectives: To describe how decreasing variation in calcium (Ca) monitoring after total thyroidectomy affects patient care. Apply strategies on establishing clinical best practices and reducing variation. Analyze the impact of effective test utilization on patient outcomes and hospital operational metrics.
Methods: We initiated a retrospective review of our clinical database to assess serum Ca and parathyroid hormone (PTH) ordering patterns for providers performing total laryngectomies from June 2012 to June 2016. Blinded baseline data on variation in ordering was presented at a faculty meeting. Physicians who perform total thyroidectomies in our department established a best practice guideline from literature review. This guideline was implemented in October 2016, and compliance is monitored prospectively. As a balance measure, we monitor the incidence of patients reporting symptoms of hypocalcemia, and any readmissions or emergency department (ED) visits after surgery secondary to hypocalcemia.
Results: There was significant variation in postthyroidectomy Ca and PTH ordering patterns between our physicians and for the same physician between different patients. Making our providers aware of this variation affected their engagement in standardizing this process. A best-practice goal of ordering 1 PTH within 1 hour of gland removal was established. This has resulted in considerable reduction in unnecessary test utilization and has not had any measurable negative impact on patient outcome (no patients reporting symptoms of hypocalcemia or hypocalcemia-related ED visits/readmissions). Protocol compliance = 91% for the first quarter it has been in effect (goal of 90%).
An Evaluation of ENT Clinical Instrument Disinfection
Pratyusha Yalamanchi (presenter); Jason L. Yu, MD; Natasha Mirza, MD
Objectives: While the effectiveness of high-level disinfection of flexible fiber-optic laryngoscopes has been established, the risk of bacterial contamination of other otorhinolaryngology clinic instruments during daily clinical practice has yet to be assessed. This is the first study to determine the effectiveness of standard high-level disinfection and storage of clinic instruments by measuring transmission of nonviral infectious microorganisms over the course of routine clinical practice.
Methods: To assess for cross-contamination and appropriate storage of clean instruments during routine clinical use, otorhinolaryngology clinic instruments subject to standard high-level disinfection and storage were assessed via surveillance cultures at the start and end of the outpatient clinical workday, to determine if microorganisms could be recovered. Control cultures were obtained by culturing contaminated instruments. The rate of microorganism recovery from the instruments was determined and compared with control specimens. The study was conducted in general and subspecialty otolaryngology clinics at an academic medical center in January 2017.
Results: Among a total of 30 cultures submitted from standard high-level disinfected and colocated clinic instruments, zero positive bacterial cultures occurred. Some 100% of control cultures were positive for bacterial species (P < .001). There was no difference between surveillance cultures obtained before and at the end of the clinic day, indicating that standard high-level disinfection and storage is statistically efficacious at preventing bacterial cross-contamination.
Conclusions: Using in vitro inoculation of otorhinolaryngology clinic instruments, this study demonstrates that standard high-level disinfection and storage is equally efficacious to more time-consuming and expensive individual instrument storage protocols with regard to bacterial contamination.
Familiarity of Neonatal Tracheostomy Care in the Neonatal Intensive Care Unit
Ryan M. Smith, MD (presenter); Courtney Miller, MS; Phillip LoSavio, MD, MS; Jill Jeffe, MD
Objectives: To assess the level of knowledge of neonatal intensive care unit (NICU) health care professionals in emergency stay suture usage during care of neonatal tracheostomy patients.
Methods: An online survey was completed by health care professionals in an NICU at a teaching hospital in Chicago, Illinois, USA. Participants were shown a photograph of a patient with a tracheostomy and emergency stay sutures and given a clinical vignette. A nine question anonymous survey was completed using an online survey website. The questions were designed to gauge familiarity with emergency stay suture usage and to assess job title, years of experience, and prior experience with accidental decannulation.
Results: Of 70 participants, 44 completed all questions. Of the 44, 9 (20%) had prior experience with accidental decannulation. Nineteen (43%) could correctly identify emergency stay sutures depicted in the photograph. Twenty-three participants (52%) correctly answered when stay sutures should be used. Nineteen (43%) knew their proper use. Subgroup analysis of job titles revealed 60% of attendings, 33% of residents, 29% of nurses, and 33% of respiratory therapists could correctly identify the stay sutures.
Conclusions: The level of knowledge of NICU health professionals regarding stay sutures in neonatal tracheostomy is poor. Less than half of respondents correctly identified stay sutures, and less than half knew how to use them in an emergency. Lack of experience with accidental decannulation was high. Quality improvement projects designed to increase the understanding of emergency stay suture use should be conducted to promote patient safety.
The Family Environment and Cochlear Implanted Children
Violeta I. Necula, MD, PhD (presenter); Alma Aurelia Maniu, MD, PhD; Magdalena Chirila, MD, PhD; Marcel Cosgarea, MD, PhD
Objectives: The role of cochlear implant in the development of deaf children is well known. However, the results are highly variable and depend on several factors, such as age of implantation, other diseases, and the quality of the rehabilitation process. The most important role in the rehabilitation process belongs to the family and family environment in which the child develops.
Methods: The questionnaire Family Environment Scale was sent to 98 families who had at least 1 cochlear implanted child who had more than 1 year of experience. One of the parents was asked to fill out the questionnaire, which also included general information about the child and the family.
Results: A total of 58 families responded to the questionnaire and accepted participation in the study. Mean values were higher compared with normal families in the areas of cohesion, expressiveness, intellectual-cultural orientation and organization, but the organization score mean value exceeded the normal values (between 40 and 60). The independence and the conflict areas had lower values than normal families but did not exceed the lower limit of normal (40).
Conclusions: The families included in the study are heavily involved in the rehabilitation process, which mean various educational, intellectual, and cultural activities. The rehabilitation process requires a huge effort from family, many sacrifices, hard work, and training for all members. The high determination, cohesion, and excessive organization may explain the low level of independence of these family members.
Head and Neck Cancer Readmission Reduction (HANCARRE)
Zachary C. Fridirici, MD (presenter); Jason Bell, MD; Eric Thorpe, MD; Carol Bier-Laning, MD, MBA
Objectives: (1) To understand the impact of reducing readmissions. (2) To learn about factors that contribute to readmissions in a busy tertiary care head and neck program. (3) To evaluate the benefit of using a multidisciplinary approach to decrease readmissions.
Methods: All otolaryngology admissions during the 1-year period between July 30, 2015, and June 1, 2016 (fiscal year [FY] 16), with the codes Medicare Severity–Diagnosis Related Group (MS-DRG) 146, 147, or 148, or International Classification of Diseases (ICD)−9 or −10, assigned to the head and neck oncology program with an unplanned 30-day readmission were evaluated. Patients with a qualifying MS-DRG or ICD-9 or -10 with a planned 30-day readmission were excluded. A multidisciplinary brainstorming session was performed to identify areas of quality improvement. Members of this multidisciplinary team included nurses, social workers, housestaff, attending physicians, and the neurosciences executive director.
Results: A total of 224 patients were admitted to our tertiary care medical center and identified as head and neck oncology patients during FY16. Thirteen patients met the criteria for unplanned readmission for an incidence of 5.8%. Areas identified by our multidisciplinary team to target reduction of readmissions included improved patient education, utilization of skilled nursing facilities for training in the care of head and neck cancer patients, and appropriate utilization of observation status.
Conclusions: Head and neck oncology patients have unique risk factors for readmission. This study identified high-impact areas for improvement. Implementation of the tactics identified will be reported to determine the effectiveness of this multidisciplinary strategy aimed at reducing readmissions.
Implementation of Hearing Screening Protocol in Honduras
Samantha Cummins (presenter); Sivakumar Chinnadurai, MD, MPH
Objectives: To identify barriers to hearing health and assess the feasibility of implementing a sustainable community hearing screening protocol in rural Honduras. To obtain initial epidemiologic data on the demographic and clinical predictors of hearing impairment in this population.
Methods: This is a prospective epidemiological study conducted at a rural hospital in Olancho, Honduras, during November 2016. A convenience sample (ages 3 years and older) was enrolled. Participant historical and demographic data were collected with a translated, scripted survey. Audiometry was performed using a low-cost, clinically validated, mobile tablet audiometer. Post hoc descriptive statistics correlated historical and demographic data with risk factors for hearing impairment to identify cohorts for future targeted interventions.
Results: Identified barriers to hearing health included geographic distance to a major hospital, concern for cost, unfamiliarity with hearing screening testing (ie, pain), and a need for greater promotion for hearing testing by Honduran physicians. Seventy-four participants were enrolled. The largest cohort was 35- to 64-year-old women, primarily homemakers and caregivers; 32% (11/34) of the women presented to the hospital for the care of a family member (children or elders). Risk factors for hearing impairment included ear infections (31.1%), head trauma (16.9%), prior ear surgery (6.9%), hearing aid use (12.2%), and tympanic membrane perforation (8.1%).
Conclusions: This project represents the initiation of a formalized, inexpensive, sustainable hearing screening program in rural Honduras and characterizes the initial data regarding the epidemiology of hearing loss in this region. The high proportion of women presenting in caregiver roles represents a cohort for future hearing health intervention.
Improving Needlestick Reporting among ENT Residents
James M. Hamilton, MD (presenter); Patrick Tassone, MD; Akshay Sanan, MD; Candace Mitchell, MD; Kiley Trott, MD; Edmund Pribitkin, MD, MBA; Maurits Boon, MD
Objectives: At the conclusion of this session, participants should be able to (1) identify that needlestick injuries among surgical trainees often go unreported and (2) recognize that an educational intervention increased awareness of reporting policies among residents but did not decrease unreported injuries.
Methods: A lecture-based educational intervention was designed to detail the importance of self-reporting needlestick injuries when they occur in otolaryngology trainees. Surveys were distributed before this intervention to assess patterns of behavior in self-reporting needlestick injuries among residents. One year later, surveys were distributed again, and results were compared with the preintervention behaviors.
Results: Prior to an educational intervention, 70% of otolaryngology residents were aware of departmental policies on self-reporting of needlestick injuries. On postintervention survey, 93% were aware of the policy. Six of 12 (50%) most recent injuries were reported before the intervention, and 8 of 12 (75%) were reported following the educational intervention. Needlestick injuries were unlikely to be reported if no one other than the injured resident knew of the injury.
Conclusions: A lecture-based educational intervention increased awareness of reporting policy regarding needlestick injuries among otolaryngology trainees, but the number of unreported needlestick injuries did not decrease by this intervention alone.
Interactive Communication Application for the Operating Room
Joshua R. Zeiger (presenter); Satish Govindaraj, MD; Alfred Marc Calo Iloreta, MD
Objectives: To introduce a new communication application for the operating room (OR). To use the application to gather intraoperative time data and train new OR team members.
Methods: A communication application called ExplORer was introduced to rhinology ORs at an academic medical center in 2016. This application can be accessed on web-enabled devices. OR staff members access a unique workflow associated with their assigned roles: surgeon, surgical technologist, or circulating nurse. The interactive workflows are custom-built for the particular procedure and surgeon. Users “check off” tasks as they are completed. Safety notifications are integrated into the workflow at key surgical steps. In this study, a functional endoscopic sinus surgery was built for 2 attending rhinology surgeons. The OR team members used tablets to interact with the application. It has been used in 15 cases thus far.
Results: Implementation presented challenges. Handling the tablets in the OR and maintaining sterility required training and experience. Senior personnel felt that it would be useful for training staff members who are naive to a particular procedure or surgeon. Staff members also felt that it would be useful as preparatory review prior to the procedure. The “check off” feature allows for intraoperative time tracking of particular surgical steps. This data are being gathered to analyze ways to improve efficiency. It is also being used to track resident surgeon efficiency. Further, the application is being used to track supply utilization to understand surgical costs.
Conclusions: This new technology has the potential to improve communication, training, and efficiency in the OR.
Interest Groups in Undergraduate Medical Education
Ryan Tabtabai (presenter); Michael Canfarotta; James Naples, MD; Kourosh Parham, MD, PhD; Todd Falcone, MD
Objectives: (1) To determine the influence of otolaryngology interest groups on medical student awareness of the specialty. (2) To analyze the impact of otolaryngology interest groups on a resident’s decision to apply to an otolaryngology residency program.
Methods: Two web-based surveys were distributed by the Division of Otolaryngology—Head and Neck Surgery at UConn Health: one to current medical students at the University of Connecticut School of Medicine and the other to Accreditation Council for Graduate Medical Education approved otolaryngology training programs.
Results: Fifty medical students (21%) and 89 residents (5.6%) completed the surveys. Medical students who attended otolaryngology interest group meetings had improved levels of understanding and awareness of otolaryngology as a specialty compared with those who did not attend (P < .001). Medical students ranked interest groups as an influential factor in specialty selection more frequently than residents did (56% vs 20%, P < .001). Among students and residents, respectively, faculty/resident interactions (73% vs 80%), clinical rotations (54% vs 82%, P = .001), and anatomy/physiology (63% vs 74%) were identified as the most influential elements in raising interest in otolaryngology.
Conclusions: Otolaryngology interest groups appear to play a role in increasing specialty awareness and understanding among medical students, but the decision to pursue otolaryngology residency is shaped by other factors, such as interactions with faculty, experience on clinical rotations, and anatomy/physiology. Further research is necessary to understand the complete role of interest groups in otolaryngology undergraduate medical education.
Opioid Prescribing Patterns among Otolaryngologists
Marissa A. Schwartz, MD (presenter); James Naples, MD; Todd Falcone, MD
Objectives: Opioid dependence is a nationwide epidemic with significant public health ramifications. An increase in opioid prescribing by medical providers has been cited as a contributing factor to this trend. While many surgeons prescribe opioid medications, there has been little investigation into optimal postoperative pain control regimens. Recent studies have demonstrated that patients may not take up to half of the opioid pills prescribed to them after discharge. This study aims to evaluate opioid prescribing patterns by otolaryngologists.
Methods: A survey study was designed and distributed to all practicing otolaryngologists in Connecticut to determine opioid prescribing patterns for the treatment of postoperative pain following common otolaryngologic procedures.
Results: The most common opioid prescribed postoperatively by otolaryngologists was hydrocodone-acetaminophen, and the most common nonopioid medication suggested was nonsteroidal anti-inflammatory medication. The largest amount of opioid medication was prescribed for tonsillectomy, while the least amount was prescribed for direct laryngoscopy.
Conclusions: This study identifies variations in opioid prescribing patterns among otolaryngologists in Connecticut. Future studies are needed to evaluate prescription patterns nationwide. In addition, patient usage patterns should be evaluated with goals to propose more standardized prescribing patterns for postoperative opioid medication in the field of otolaryngology.
Simulation-Based Assessment of Emergency Department Advanced Airway Cart
Malika Atmakuri, MD (presenter); Kim Reid, MD; Jennifer Stone, MD; Sanjay Parikh, MD; Andy Inglis, MD; Kaalan Johnson, MD
Objectives: (1) To describe the evaluation of a process improvement question using in situ simulation based assessments. (2) To evaluate the perceived utility of introducing advanced airway equipment to a tertiary care emergency department (ED).
Methods: A retrospective review of prospectively gathered in situ simulation data. In the first iteration, participants performed the scenario with the existing system of care and then with the proposed rigid bronchoscopy airway cart in the ED. In the second iteration, the scenario order was reversed. The scenario involved foreign-body (FB) aspiration in a child resulting in progressive airway obstruction in the ED. Objective outcomes included time to airway stabilization (FB removal or successful right mainstem intubation). Subjective outcomes included agreement to introduce advanced airway cart to the ED and effectiveness of simulation.
Results: In the existing system, the average time to airway stabilization was 14 minutes. With the proposed advanced airway equipment, time to stabilization was 12.5 minutes. Subjective outcomes demonstrated that 62% of participants agreed or strongly agreed that advanced airway cart placement in the ED would be beneficial, and when asked in reverse, 12.5% preferred the current system. Ninety-two percent of participants agreed that simulation was an effective method for learning and process improvement, and 75% of participants felt this scenario helped to better inform their clinical decision making.
Conclusions: Simulation-based assessments are an effective means to evaluate potential implementation of advanced airway equipment in a tertiary care children’s hospital ED. Based on objective and subjective outcomes, consensus supported introduction of an advanced airway cart at our institution.
Treatment Outcomes of Sudden Sensorineural Hearing Loss
Meghan E. McCoy, MS, PA-C (presenter); Victoria A. Jordan, MD; Rick Odland, MD, PhD
Objectives: Evaluate the efficacy of oral steroids, intratympanic steroid injections, and hyperbaric oxygen (HBO) for idiopathic sudden sensorineural hearing loss (ISSNHL) in combination and individually. Analyze outcomes of accepted treatment options for ISSNHL to determine if one combination is more efficient than another. Develop a standardized protocol for treatment in patients diagnosed with ISSNHL.
Methods: A retrospective chart review of 23 patients diagnosed with ISSNHL who underwent treatment at a tertiary care center from August 2013 to January 2017. Age, sex, comorbid conditions, associated symptoms, magnetic resonance imaging results, time to treatment, treatment regimen, and pre- and posttreatment audiograms were collected. Patients were given oral steroids, a series of intratympanic steroid injections, and/or HBO therapy, in combination or alone. The main outcome measure was improvement in the posttreatment audiogram defined as greater than a 15-dB increase in pure-tone average.
Results: Of the 23 patients studied, 7 demonstrated improvement on posttreatment audiogram. Four of the 7 who showed improvement above 15-dB hearing level were given all 3 therapies. Only 3 patients showed complete recovery based on pure-tone audiometry, all of which were given triple modality therapy. In addition, treatment time of within 2 weeks was associated with improvement (6 in 13 compared with 1 in 10).
Conclusions: Triple-modality therapy with oral steroids, intratympanic steroid injections, and HBO may be more efficient than other combinations of treatment with either dual or individual therapy. Prospective studies are planned to examine this issue.
Update on Tracheotomy Timing and Outcomes
Mingyang Gray, MD (presenter); Caitlin W. Pacheco; Charles Tong, MD; Isaac Wasserman; Anmol Gupta; Mike Yao, MD
Tracheotomies are commonly performed for critically ill patients requiring prolonged mechanical ventilation, allowing for improved pulmonary toilet, decreased long-term damage to the upper airway, improved mobility, and return of activities of daily living. In 2012, a study from Mount Sinai Hospital was published on the outcomes of critically ill patients who required tracheotomy from 2005 to 2010.The results of the study showed that early tracheotomy resulted in lower intensive care unit (ICU) and overall hospital lengths of stay. Since the previous study, several initiatives have been implemented to improve patient outcomes in the ICU, including a multidisciplinary respiratory care pathway. Hospital leadership also encouraged early rehabilitation to shorten ICU length of stay. To the best of our knowledge, this is the first follow-up study to investigate potential changes in the management and outcome of patients requiring tracheotomies at a major tertiary care center. This study was designed to compare the rates of early and late tracheotomies performed on patients in the medical ICU and analyze differences in outcomes as measured by length of stay in the ICU and hospital. This study confirms that early tracheotomy leads to shorter ICU and overall hospital stays. However, there has been no change in practice in the timing of tracheotomies for critically ill patients in the medical ICU over the past 10 years. Future analysis will include identifying disparities that affect outcomes. These data are also important for quality improvement initiatives to increase the number of early tracheotomies for these patients.