Balakrishnan, Karthik

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA2) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education.

ObjectivesIdentify predictors of high‐cost otolaryngology care.Study DesignCross‐sectional.SettingTertiary academic multispecialty hospital.Subjects/MethodsAll patients undergoing ≥1 otolaryngologic procedures from 2011 to 2015. Encounter costs were standardized using previously described methods approximating Medicare reimbursement. Patients were stratified by adult/pediatric and inpatient/outpatient. “Outliers” were defined as total encounter costs ≥95th percentile. Logistic regression measured predictors of outlier status.ResultsIn total, 2433 adult inpatient encounters (95th percentile $57,611), 10,031 adult outpatient encounters ($10,772), 346 pediatric inpatient encounters ($84,639), and 3027 pediatric outpatient encounters ($8978) were included. For adult inpatient and outpatient, isolated head and neck oncologic procedures were the reference group. Among adult inpatients, laryngology and facial plastics procedures predicted higher odds of outlier status (odds ratio [OR] = 4.1 and 7.2). Involvement of multiple otolaryngology subspecialties increased the odds (OR = 4.7). Neck dissection and reconstructive procedures were the most common primary operations for adult inpatient outliers. For adult outpatients, several subspecialties had lower odds than head and neck (OR ≤0.44). Increased comorbidities predicted outliers for adult inpatient care (OR = 1.5); sex, age, race, and ethnicity did not. Cochlear implant was the most common primary operation among adult and pediatric outpatient outliers. Greater subspecialty involvement and increasing age predicted pediatric outpatient outliers (OR = 8.0 and 1.1); younger age and female sex predicted pediatric inpatient outliers (OR = 0.8 and 3.5). Airway procedures dominated pediatric inpatient outliers.ConclusionThis is the first large‐scale study of high‐cost otolaryngology care across multiple subspecialties. Specific procedures and subspecialties and increased comorbidities predicted high‐cost care. Contrary to previous studies, patient sex, race, and ethnicity did not.

Objectives/HypothesisTo evaluate trends, outcomes, and healthcare utilization following medialization laryngoplasty (ML) with or without arytenoid adduction (AA) over 10 years.Study DesignRetrospective observational study.MethodsUsing OptumLabs Data Warehouse, trends, outcomes, and healthcare utilization from 2006 to 2015 were examined with a focus on discharge type (same day or not). Predictors of postoperative emergency department (ED) use and hospitalization were determined by multivariable logistic regression.ResultsOverall rate of ML was 1.09 per 100 thousand enrollees per year. Of these, 7.8% ML were combined with an AA. Outpatient same‐day discharge represented 62.0% (1,142 of 1,843) of total patients, steadily increasing over the 10‐year period (P < 0.01). There was a 5.9% revision ML rate and 1.0% rate of tracheotomy within 1 day of ML. A total of 5.6% visited an ED, and 5.4% were admitted to a hospital following initial discharge within 30 days. Same‐day discharge was found to be a predictor of hospitalization within 30 days after ML (odds ratio [OR] 1.74, P = 0.0452), along with Elixhauser comorbidity index of 4 + (OR 5.74, P = 0.0001). Pulmonary embolism, pulmonary hypertension, and weight loss were top predictors of ED visit or hospitalization.ConclusionTo our knowledge, this is the first search evaluating national claims data for ML with or without AA. Overall rate of ML is low, and same‐day discharge has become more common over a 10‐year period, with an associated higher 30‐day hospital admission risk. Correct patient selection criteria for disposition status cannot be fully determined based on current data, but a high Elixhauser comorbidity index clearly carries increased risk for hospitalization after initial discharge.Level of Evidence4 Laryngoscope, 129:952–960, 2019

ObjectiveTo assess the impact of implementing a dedicated Patient Safety and Quality Improvement (PSQI) curriculum for otolaryngology residents.MethodsResidents in two otolaryngology residency programs were recruited to participate in the study. Residents at institution A (intervention group) participated in a formal, newly developed, year‐long PSQI curriculum. Residents at institution B (control group) participated in traditional, morbidity, and mortality conference‐based PSQI education, with no formal curriculum in place. Curriculum participants completed anonymous surveys to assess learner satisfaction. Validated instruments were administered to assess for changes in resident confidence in the ability to develop PSQI projects, their attitudes toward patient safety, and PSQI‐related knowledge. The number and quality of PSQI‐related resident projects were also assessed.ResultsSurvey responses demonstrated excellent learner satisfaction with the curriculum. Based on validated instrument‐based responses, both programs demonstrated similar confidence scores (P = 0.05), safety attitudes (P = 0.82), and PSQI knowledge (P = 0.29) at the beginning of the year. The residents of institution A demonstrated significant improvement in confidence (P = 0.00009) and knowledge (P = 0.0006) after completing the curriculum, with no improvement noted for residents at institution B in either confidence (P = 0.06) or knowledge (P = 0.79). Neither program demonstrated improvement in attitudes toward patient safety at the end of the year‐long curriculum.ConclusionImplementing a formal curriculum dedicated to PSQI led to an improvement in PSQI‐related project development confidence and PSQI knowledge. Attitudes toward safety did not improve over the course of a year. Longer‐term studies involving multiple institutions and other interventions are needed to evaluate the impact and duration of changes that occur.Level of Evidence1b Laryngoscope, 129:1100–1106, 2019

Objectives/HypothesisOver the past decade, thoracic slide tracheoplasty (TST) has become the principal operation in the management of congenital tracheal stenosis. The purpose of this report was to describe our experience with revision TST following unsuccessful prior tracheal reconstruction.Study DesignRetrospective analysis at an academic children's hospital.MethodsPatients undergoing TST on cardiopulmonary bypass between January 2005 and May 2014 were reviewed. Patients with a history of prior airway surgery were extracted for further analysis. Preoperative patient variables and postoperative outcomes were evaluated and compared between patients undergoing revision slide tracheoplasty (RTST) and a control group of 26 matched patients undergoing primary surgery TST.ResultsTwenty‐six revision patients (25 referrals, one primary patient) of 162 patients reviewed over the study period met inclusion criteria. Twenty‐three patients had a history of complete tracheal rings, and three patients had cartilaginous deficiency. A total of 41 airway reconstruction procedures had been performed prior to RTST. When compared to primary TST, patients undergoing RTST required fewer cardiac procedures intraoperatively, and fewer mean ventilator hours (P = .01) postoperatively. There was no significant difference in the median length of stay, requirement of >48 hours ventilation, or postoperative complications between groups. There was one nonsurgical postoperative mortality following RTST.ConclusionsDespite some differences in the postoperative management when compared to nonrevision cases, revision TST can be successfully performed after prior tracheal reconstruction with good postoperative outcomes.Level of Evidence4. Laryngoscope, 128:2181–2186, 2018

ObjectiveThe objective is to describe variations in the otolaryngology morbidity and mortality (M&M) conference and to compare with other specialties.DesignCross‐sectional survey.SettingThe setting included otolaryngology departments across the United States and nonotolaryngology medical and surgical departments at 4 academic medical centers.Subjects and MethodsParticipants were members of a national otolaryngology quality/safety network and nonotolaryngology quality leaders at 4 large academic hospitals. Surveys were administered January 2017. Respondents described M&M conference practices, goals, and educational role.ResultsTwenty‐eight of 39 individuals representing 28 institutions completed the otolaryngology survey (72% response rate). Of 197 individuals, 60 (30% response rate) representing 11 surgical and 20 nonsurgical specialties completed the comparison survey. Twenty‐seven of 28 otolaryngologists (46 of 60 nonotolaryngologists) worked in academic settings. All otolaryngology programs conducted an M&M conference: 54% discussed all adverse events and errors; 32% used standard case selection processes; 70% used structured discussion, usually root cause analysis (64%); and 32% classified harm level. In comparison with other specialties, otolaryngology programs were more likely to discuss all adverse events and errors (P =. 01). Most conferences led to quality projects and intrainstitutional communication: 22% communicated to patients and families; 73% of respondents thought that M&M conferences should be standardized or use “best practices.” In both surveys, improving patient care was rated the conference’s most important function, followed by trainee education and culture change. Patient care and practice‐based learning were rated the most relevant Accreditation Council for Graduate Medical Education Core Competencies in both surveys.ConclusionsAcademic otolaryngology M&M practices generally align with other specialties, but specifics vary widely, making collaborative quality improvement challenging. Educational and administrative priorities cross specialties. Most respondents thought that standardization and best practices are worthwhile. Nonacademic practice data are needed.

AbstractAimPersistent or recurrent wheezing is a common indication for flexible bronchoscopy, as anatomic and infectious or inflammatory changes are highly prevalent. We sought to evaluate the prevalence of anatomic, infectious, and inflammatory disease in a cohort of children undergoing flexible bronchoscopy for wheezing or poorly controlled asthma.MethodsWe retrospectively reviewed all children <18 years old who underwent flexible bronchoscopy at our center from October 29, 2012‐December 31, 2016 for the primary or secondary indication of wheezing (persistent, frequently recurring, or atypical) or poorly controlled asthma.ResultsA total of 101 procedures were identified in 94 patients, aged 3 months to 18 years. Potential anatomic causes for wheezing identified in 45.7% of patients and inflammatory changes in 49.5% of procedures. This included the identification of a laryngeal cleft in 17% for which half required medical or surgical management. Tracheobronchomalacia was the most commonly identified anatomic lesion. Thirty children from this cohort had poorly controlled asthma. Among this subgroup, 54% had increased neutrophils on BAL and 30% had an anatomic contributor to wheezing, including one with a laryngeal cleft. Based on findings from flexible bronchoscopy, management changes made in 63.8% of patients. This included medication changes in 54 and surgical intervention in 9.DiscussionWe conclude that transnasal flexible bronchoscopy has high yield in children with recurrent, persistent, or atypical wheezing and those with poorly controlled asthma. Laryngeal cleft has a reasonably high prevalence that warrants specific evaluation in this population.

Objectives/HypothesisChildren with bilateral true vocal fold immobility (BTVFI) may present with significant airway distress necessitating tracheostomy. The objective of this study was to review our preliminary experience with the anterior–posterior cricoid split (APCS), an endoscopic intervention used as an alternative to tracheostomy in children with BTVFI.Study DesignMulticenter review.MethodsA review of patients undergoing endoscopic APCS for BTVFI at four institutions was performed. Patients were evaluated for the ability to ventilate without the requirement for tracheostomy or reintubation. Additional data extracted included the duration of intubation following APCS, the requirement for additional procedures, and demographics. Surgical success was defined as the ability to avoid tracheostomy and to cap or decannulate without respiratory symptoms if a tracheostomy was present prior to APCS.ResultsNineteen APCS procedures were performed between October 2010 and June 2016. There were 12 male patients, the mean age at APCS was 4.7 months. BTVFI was primarily idiopathic (58%) and associated with other comorbidities (74%). All patients were candidates for tracheostomy prior to APCS. Fourteen patients (74%) were considered surgical successes. Of the unsuccessful patients, three (66%) required tracheostomy following APCS, and one was treated with a posterior cartilage graft. There was one nonsurgical mortality greater than 2 months after APCS and thought to be unrelated to the airway.ConclusionsEndoscopic APCS appears to be a safe and effective intervention for pediatric BTVFI. Under the correct circumstances, this can be performed as a single procedure, obviating tracheostomy. Further study is warranted.Level of Evidence4. Laryngoscope, 128:257–263, 2018