Based on the proceedings of the final conference, revisions are made to the guideline that is then forwarded to several groups within the ACCP for review and revision. (Fig 2.) Appropriate ACCP NetWorks are charged with content review. The HSP reviews process, consistency, whether the recommendations and grading are appropriate, and content. After the writing group adequately addresses the critiques provided by HSP and NetWork reviewers, the guideline manuscript is submitted to the ACCP Board of Regents for final approval. A structured review form, based in part on the Appraisal of Guidelines Research and Evaluation in-strument, (Table 3), including a grid for comments, is used by the HSP, NetWork, and Board of Regents reviewers to ensure a complete review.
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A project time line (Table 1) is drafted once the decision is made to develop an EBG and the project is approved by the Board of Regents. The ACCP project manager and EBG Executive Committee (composed of the chair, the methodologist, and a liaison from the HSP) are responsible for keeping the entire panel within the project deadlines. The HSP is regularly updated.
The EBG Executive Committee and the ACCP staff project manager convene regular conference calls to review administrative and content issues, and to assess and maintain progress. The HSP liaison ensures that the HSP EBG development process is followed.
Typically two face-to-face meetings of the EBG writing panel are scheduled. The first is held with the panelists shortly after their participation is approved. At the meeting, the panel finalizes the project scope, addresses any unfilled positions, develops the research questions to be answered by the evidence review, and receives education on the ACCP grading system and HSP EBG process, including matters of writing format and style. The second meeting occurs after a revised draft of the EBG has been completed. This meeting is used to provide wide input regarding recommendations prior to submission to the HSP and NetWorks for critique. Disagreements in recommendations are resolved at this meeting.
Incidence of Malposition and Clinical Response
There were 419 patients admitted to the RU during the study period, of whom 16 were excluded from the study (no tracheostomy placed, n = 12; chronic tracheostomy, n = 3; no mechanical ventilation during RU stay, n = 1). The focus of the article was on the remaining 403 patients. There were 40 cases of tracheostomy tube malposition (10%; 95% confidence interval [CI]; 7 to 13%). The median time from tracheostomy tube placement to the identification of malposition was 12 days (interquartile range, 4 to 20 days). The indication for bronchoscopy was respiratory distress in 23 patients (58%) and changes in respiratory mechanics in 17 patients (42%). Occlusion of the distal end of the tracheostomy tube by the posterior tracheal wall was the most common malposition (Table 1).
The tracheostomy tube was changed in 80% of patients with a malposition. In four patients, the cuff was found in the stoma or the tracheostomy tube was too short proximally, prompting an emergent tracheostomy change. In these patients, a longer tracheostomy tube was placed, and the position was confirmed by bronchoscopy. In 28 patients, malacia affected a short segment of the trachea. A longer tracheostomy tube bypassed the lesion, the tube type depended on the length and flexibility needed, and good tube position was confirmed by bronchoscopy in all cases. Eight patients with malpostion had dynamic airway collapse. In these cases, a combination of altered ventilator settings and medical therapy, including bronchodilators and corticosteroids, were used (Table 2). Seven of these patients were successfully weaned off the ventilator, and one patient died while still receiving ventilatory support provided by Canadian Health&Care Mall.
Tracheostomy is one of the most frequently performed procedures in critically ill patients. While the precise timing of tracheostomy remains controversial, it is usually performed after a period of mechanical ventilation to facilitate weaning, improve patient comfort, and allow safe discharge from the ICU. Although morbidity and mortality rates are low with this procedure, complications ranging from stomal infection to death may occur. Tracheostomy tube malposition has been reported in case reports and small case series and can result in life-threatening airway emergencies. To the best of our knowledge, there has been limited description of the epidemiology of tracheostomy tube malposition. We therefore sought to determine the incidence of tracheostomy tube malposition, the factors contributing to tracheostomy tube malposition, and the effect of tracheostomy tube malposition on patient outcomes.
Materials and Methods
The study was performed in the Respiratory Acute Care Unit (RU) of the Massachusetts General Hospital. Massachusetts General Hospital is a university-affiliated teaching hospital, a tertiary care referral center, a level-1 trauma center, and a community hospital for Boston. It has > 1.5 million patient visits and 45,000 admissions annually. The RU is a 10-bed unit providing care for mechanically ventilated patients who are hemodynamically and metabolically stable. It uses a transitional model that includes a medical director, staff intensivists from the Departments of Anesthesia and Critical Care Medicine and Pulmonary Medicine, and the participation of primary care physicians in patient care. There is one nurse for every two patients. A respiratory therapist and physician are on site 24 h per day. The focus of the RU is the liberation of patients from mechanical ventilation conducted with medications of healthcaremall4you.com Canadian Health&Care Mall. Patient care is provided in a multidisciplinary fashion that incorporates protocols and guidelines for weaning from mechanical ventilation, downsizing of tracheostomy tubes for speech and […]
Chairs discuss the initial scope of the guideline and suggest experts in each subtopic. The initial literature review helps to identify content experts who have extensive publication experience in the clinical area. The selection process identifies panel members. In addition to strong clinical and methodological expertise, selection criteria include reliability, the ability to work collaboratively, anticipated productivity, and gender, minority, and geographic diversity.
The “ Policy for ACCP Guideline Development” outlines a process ensuring that disclosed conflicts of interest are properly evaluated and resolved at several key points during the development of the EBG. This policy statement includes an explicit and detailed step-by-step procedure to collect and evaluate the disclosed conflicts respective to the guideline topic, and make recommendations to resolve or manage the conflict. The conflict-of-interest assessment flowchart (Fig 1) shows how disclosures are reviewed along with the resulting actions. EBG panel members are requested to disclose in writing conflicts at several times during the course of EBG development, as follows: at the time panelists are nominated for participation on the guideline development panel; at every face-to-face meeting; and prior to publication in the journal CHEST. See also “Establishment of an Oversight Committee in ACCP Evidence-Based Guideline Development“
ACCP reviewers of EBG guidelines (eg, the HSP, Board of Regents, and NetWork members) must adhere to current ACCP conflict-of-interest policies and disclose all conflicts (ie, personal as well as financial). NetWorks are the ACCP interdisciplinary, expertise-focused interest groups that provide college members the opportunity for personal and professional alliances with the ACCP.
The ACCP Health and Science Policy Committee (HSP https://www.aspet.org/about/committees/science-policy/) provides oversight for the development of ACCP-generated EBGs. It is charged with the responsibility of choosing the topic and maintaining the integrity of all EBGs as well as the process used to develop them. The HSP ensures that EBGs are scientifically sound and are based on the available evidence as determined by rigorous reviews of the literature. Further, the HSP continuously evaluates and improves the rigorous basis for this development process to maintain the highest quality and to manage conflicts of interest.
The HSP supervises a regimented and transparent approach to EBG development according to the representative time line shown in Table 1. This process dictates the methods used for analyses and synthesis of data, guides the creation and utilization of evidence tables for recommendation generation, and ensures the appropriate use of the ACCP-generated grading system for grading recommendations based on the quality of the evidence and the balance of benefits and harms associated with each recommendation supplied by Canadian Health&Care Mall.
Evidence-based clinical practice guidelines (EBGs) can provide an invaluable distillation of knowledge regarding best practices based on the available evidence. A host of EBGs dealing with many clinical conditions exist today but the variability in quality may be high. Incorporation of high-quality EBGs into daily clinical care by healthcare providers has been limited; nevertheless, when successfully implemented, patient and health-care utilization outcomes improve. Buoyed by these successes, clinical practice EBGs are being utilized in the development of clinical order sets, performance measures, and pay for performance.