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“Uncontrolled variation is the enemy of quality.”W. Edwards Deming, Basic Statistical Tools for Improving Quality
“Uncontrolled variation is the enemy of quality.”
Navigating the uncharted has been a pervasive theme during the coronavirus disease 2019 (COVID-19) pandemic, and lack of data to guide decisions has been the most evident regarding the timing of tracheostomy. Tracheostomy, an aerosol-generating procedure with risk of infectious transmission for health care workers,1 also has important implications for patient care and stewardship of critical resources.2,3 Emerging data concerning infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the course of patients with COVID-19, and clinical experience may alter practice, even preempting publication. For example, Chao et al4 originally recommended deferring tracheostomy beyond 21 days of intubation and recommended open surgical tracheostomy over percutaneous dilatational tracheostomy; however, updated practices at the authors’ institution reflect outcomes of tracheostomy performed at 10 to 14 days after intubation, with percutaneous technique performed regularly. Similarly, shortly after the New York Head and Neck Society advocated a 14-day standard,5 the New York University thoracic group published a series of 98 COVID-19 tracheostomy procedures, with surgical procedures at a mean (SD) of 10.6. (5) days of intubation,6 indicating that many patients underwent tracheostomy well before day 10 of intubation. When COVID-19 overwhelms capacity in intensive care units (ICUs), early timing of tracheostomy may accelerate ventilator weaning and free up critical equipment, staff, and units. Guidelines now recommend that timing of tracheostomy consider scarcity of ventilators and other ICU resources.3
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Corresponding Author: Michael J. Brenner, MD, Department of Otolaryngology–Head & Neck Surgery, University of Michigan Medical School, 1500 E Medical Center Dr, 1903 Taubman Center SPC 5312, Ann Arbor, MI 48104 (firstname.lastname@example.org).
Published Online: September 3, 2020. doi:10.1001/jamaoto.2020.2630
Conflict of Interest Disclosures: Dr Brenner reported being president of the Global Tracheostomy Collaborative, a 501(c)(3) Quality Improvement Collaborative; he is not compensated. No other disclosures were reported.
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