Global Tracheostomy Collaborative
Perhaps the most ambitious registry is the Global Tracheostomy Collaborative (GTC), which was founded by David Roberson, MD, MBA, of Bayhealth Delaware in Dover. In 2011, when Dr. Roberson was a co-chair of the American Academy of Otolaryngology–Head and Neck Surgery (AAO–HNS) Patient Safety and Quality Improvement Committee, the committee conducted a survey of the academy members. “We asked, ‘Has something bad ever happened with a trach?’ and we collected a lot of reports of completely preventable terrible events,” he said. At the same time, the AAO–HNS Airway and Swallowing Committee was publishing a giant multi-institutional study of tracheostomies, likewise demonstrating major opportunities for improvement (Laryngoscope. 2012;122:38–45).
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November 2019At around the same time, Dr. Roberson read work from two institutions, St. Mary’s Hospital in the UK and Austin Health in Australia, that had independently developed tracheostomy programs that had reduced such important outcomes as length of stay and adverse events by 50% to 90% (Crit Care Resusc. 2009;11(1):14–19; Clin. Otolaryngol. 2011;36:482–488).
“In the world of quality improvement, one of the big challenges is disseminating information about improved treatments,” said Dr. Roberson. “One of the solutions is the idea of a quality improvement collaborative. Here are two hospitals that have published data with phenomenal improvements, but it’s not being widely adopted. It shouldn’t be that way.”
So, in July of 2012, Dr. Roberson invited tracheostomy experts from around the world to meet in Glasgow. “Twenty or so experts came, and we spent a day together and talked about tracheostomy care and agreed to form a collaborative. We had representatives from Australia, the UK, India, and America. Because tracheostomy care is multidisciplinary, we included representatives from nursing, respiratory care, speech pathology, otolaryngology, ICU, pulmonary care, [and] anesthesia, and a tracheostomy patient’s parent. We began enrolling hospitals in 2014 and currently have about 40 hospitals enrolled around the world,” he said.
Dr. Roberson acknowledged that there have been some barriers to enrollment. One is money. “We charge an annual fee of $7,500, which is extremely cheap for a QI collaborative,” he said. “However, in the UK and Australia, there is no discretionary funding, and GTC payment has to go through the national health service budget and approval process, which is slow, tedious, and sometimes not rational,” he said.
Another barrier to implementation has been getting different departments to work together. “To make this work, every department in the hospital has to get on board. For example, if the otolaryngology surgeons and general surgeons disagree about postoperative care and aren’t willing to work through that together, it can be a nonstarter,” he said. Often bedside caregivers—nursing, respiratory therapy, and speech—are well aware that care in a hospital is fragmented and confusing, but physicians may not realize it. “The otolaryngology and pulmonary departments often don’t understand how difficult and confusing it is for the patients and front line staff if every practitioner has a different set of postop orders. But if you can get all the disciplines in a room at the same time, and they listen to each other, then all of a sudden you can make decisions.”
A group of UK hospitals have published data demonstrating that GTC membership led to substantial and statistically significant reduction in adverse events, severity of events, and length of stay (BMJ Qual Improv Rep. 2017 May 23;6(1)). One AAO-HNS member, Joshua Bedwell, MD, a pediatric otolaryngologist at Children’s National Medical Center in Washington, D.C., has also published on the Center’s experience using the GTC database (Int J Pediatr Otorhinolaryngol. 2016;80:106–108).
Despite difficulty in enrolling hospitals, Dr. Roberson and colleagues have created the largest database of tracheostomy patients in existence—including more than 6,000 unique admissions. A manuscript describing outcomes across that entire dataset will be submitted in the next couple of months. “I can’t share this data in advance of peer review,” he said, “but I really look forward to seeing them in print.”