ArticleCureus2025
Reducing the Morbidity Associated With Incorrect Pediatric Tracheostomy Tube Placement: A Quality Improvement Initiative.
Article in Cureus, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
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Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
introductionDespite an increase in pediatric patients being discharged with a tracheostomy tube (TT), morbidity and mortality rates remain considerable. The aim of this quality improvement (QI) project is to reduce the proportion of tracheostomy documentation errors per 1000 tracheostomy patients by 50% or more, and sustain this for six months.
methodsUsing the Model for Improvement and a Plan-Do-Study-Act (PDSA) cycle, a key driver diagram (KDD) identified challenges in accessing accurate TT information within the electronic medical record (EMR). EMR representatives created an alert for any patient with a TT diagnosis code to provide immediate access to tracheostomy information. Assessment of this intervention was conducted using descriptive statistics and QI control charts.
resultsPrior to intervention, an average of 56 different tracheostomy patients per year were evaluated, and 15 events were recorded. Upon implementation of the alert, there was one safety event in the 180-day pilot period. Since the initial PDSA cycle, there have been two TT documentation events, improving the average from one error in every 40 patients seen over a 28-month period to one error in every 137 patients seen over a 24-month period (and counting).
conclusionIncreased access to accurate TT information in the EMR demonstrated an increased interval between events. Future work includes routinely tracking events as a new metric to follow and implementing other interventions from the KDD for a multi-interventional approach to the global aim. We recommend that organizations implement this straightforward approach to dramatically reduce untoward outcomes with catastrophic potential.
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