Effect of Tracheostomy on Weaning Parameters in Difficult-to-Wean Mechanically Ventilated Patients: A Prospective Observational Study

<div><p>Background and Objective</p><p>Weaning parameters are commonly measured through an endotracheal tube in mechanically ventilated patients recovering from acute respiratory failure, however this practice has rarely been evaluated in tracheostomized patients. This study aimed to investigate changes in weaning parameters measured before and after tracheostomy, and to explore whether the data measured after tracheostomy were associated with weaning outcomes in difficult-to-wean patients.</p><p>Methods</p><p>In a two-year study period, we enrolled orotracheally intubated patients who were prepared for tracheostomy due to difficult weaning. Weaning parameters were measured before and after the conversion to tracheostomy and compared, and the post-tracheostomy data were tested for associations with weaning outcomes.</p><p>Results</p><p>A total of 86 patients were included. After tracheostomy, maximum inspiratory pressure (mean difference (Δ) = 4.4, 95% CI, 2.7 to 6.1, <i>P</i><0.001), maximum expiratory pressure (Δ = 5.4, 95% CI, 2.9 to 8.0, <i>P</i><0.001) and tidal volume (Δ = 33.7, 95% CI, 9.0 to 58.5, <i>P</i><0.008) significantly increased, and rapid shallow breathing index (Δ = -14.6, 95% CI, -25.4 to -3.7, <i>P</i><0.009) and airway resistance (Δ = -4.9, 95% CI, -5.8 to -4.0, <i>P</i><0.001) significantly decreased. The patients who were successfully weaned within 90 days of the initiation of mechanical ventilation had greater increments in maximum inspiratory pressure (5.9 vs. 2.4, <i>P</i> = 0.04) and maximum expiratory pressure (8.0 vs. 2.0, <i>P</i> = 0.02) after tracheostomy than those who were unsuccessfully weaned.</p><p>Conclusions</p><p>In conclusion, the conversion from endotracheal tube to tracheostomy significantly improved the measured values of weaning parameters in difficult-to-wean patients who subsequently weaned successfully from the mechanical ventilator. The change was significant only for airway resistance in patients who failed weaning.</p><p>Trial Registration</p><p>ClinicalTrials.gov <a href="https://clinicaltrials.gov/ct2/show/NCT01312142?id=NCT01312142&rank=1" target="_blank">NCT01312142</a></p></div

Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center

<div><p>Objective</p><p>There have been concerns about the workplace interpersonal conflict (WIC) among healthcare workers. As healthcare organizations have applied the incident reporting system (IRS) widely for safety-related incidents, we proposed that this system might provide a channel to explore the WICs.</p><p>Methods</p><p>We retrospectively reviewed the reports to the IRS from July 2010 to June 2013 in a medical center. We identified the WICs and typed these conflicts according to the two foci (task content/process and interpersonal relationship) and the three properties (disagreement, interference, and negative emotion), and analyzed relevant data.</p><p>Results</p><p>Of the 147 incidents with WIC, the most common related processes were patient transfer (20%), laboratory tests (17%), surgery (16%) and medical imaging (16%). All of the 147 incidents with WIC focused on task content or task process, but 41 (27.9%) also focused on the interpersonal relationship. We found disagreement, interference, and negative emotion in 91.2%, 88.4%, and 55.8% of the cases, respectively. Nurses (57%) were most often the reporting workers, while the most common encounter was the nurse-doctor interaction (33%), and the majority (67%) of the conflicts were experienced concurrently with the incidents. There was a significant difference in the distribution of worker job types between cases focused on the interpersonal relationship and those without (p = 0.0064). The doctors were more frequently as the reporter when the conflicts focused on the interpersonal relationship (34.1%) than not on it (17.0%). The distributions of worker job types were similar between those with and without negative emotion (p = 0.125).</p><p>Conclusions</p><p>The institutional IRS is a useful place to report the workplace interpersonal conflicts actively. The healthcare systems need to improve the channels to communicate, manage and resolve these conflicts.</p></div

Workplace interpersonal conflicts: Examples.

<p>Workplace interpersonal conflicts: Examples.</p

The flow chart of this study.

<p>The flow chart of this study.</p

Workplace interpersonal conflicts: Related processes and tasks (n = 147).

<p>Workplace interpersonal conflicts: Related processes and tasks (n = 147).</p

Comparison of weaning parameters between weaning success and weaning failure group.

<p>Before tracheostomy, the weaning parameters were no difference between the two groups. After tracheostomy, the MIP, MEP, Vt, Ve and RSBI showed significant improvement in the weaning success group.</p

Personnel involved and interpersonal relationship.

<p>Personnel involved and interpersonal relationship.</p

Weaning parameters measured before and after tracheostomy.

<p>MIP: maximum inspiratory pressure; MEP: maximum expiratory pressure; V_T: tidal volume; V_E: minute ventilation; RR; respiratory rate; RSBI: rapid shallow breathing index; C_RS: compliance; R_AW: airway resistance.</p><p>* Comparison of weaning parameters before and after tracheostomy, by paired t test or Wilcoxon signed-rank test, as appropriately.</p><p>^a By paired t test</p><p>Weaning parameters measured before and after tracheostomy.</p

Safety-related incidents during the study period.

<p>Safety-related incidents during the study period.</p

Workplace interpersonal conflicts: Types of the 147 incidents.

<p>Workplace interpersonal conflicts: Types of the 147 incidents.</p