Improving Tracheostomy Care in Resource-Limited Settings.

OBJECTIVES: Tracheostomy care in leading pediatric hospitals is both multidisciplinary and comprehensive, including generalized care protocols and thorough family training programs. This level of care is more difficult in resource-limited settings lacking developed healthcare infrastructure and tracheostomy education among nursing and resident staff. The objective of this study was to improve pediatric tracheostomy care in resource-limited settings. METHODS: In collaboration with a team of otolaryngologists, respiratory therapists, tracheostomy nurses, medical illustrators, and global health educators, image-based tracheostomy education materials and low-cost tracheostomy care kits were developed for use in resource-limited settings. In addition, a pilot study was conducted, implementing the image-based tracheostomy pamphlet, manual suctioning device and low-cost ambulatory supply kit ("Go-Bags"), within a low-fidelity simulated training course for nurses and residents in Kigali, Rwanda. RESULTS: An image-based language and literacy-independent tracheostomy care manual was created and published on OPENPediatrics, an open-access online database of clinician-reviewed learning content. Participants of the training program pilot study reported the course to be of high educational and practical value, and described improved confidence in their ability to perform tracheostomy care procedures. CONCLUSIONS: Outpatient tracheostomy care may be improved upon by implementing image-based tracheostomy care manuals, locally-sourced tracheostomy care kits, and tailored educational material into a low-fidelity simulated tracheostomy care course. These materials were effective in improving technical skills and confidence among nurses and residents. These tools are expected to improve knowledge and skills with outpatient tracheostomy care, and ultimately, to reduce tracheostomy-related complications.

Association of a Multidisciplinary Care Approach With the Quality of Care After Pediatric Tracheostomy.

IMPORTANCE: Incidence of tracheostomy placement in children is increasing, and these children continue to have high incidences of morbidity and mortality. A multidisciplinary tracheostomy program may help improve the quality of care received by these patients. OBJECTIVE: To determine whether implementation of a multidisciplinary tracheostomy program can improve the care of children who received a tracheostomy through reduction in tracheostomy-related adverse events (TRAEs), improved tracheostomy education, and caregiver preparedness. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted from January 2015 to June 2018 at a pediatric tertiary referral center in Boston, Massachusetts. The participants included 700 children who had received a tracheostomy, most of whom were aged birth to 18 years, but some patients with congenital disorders were much older. EXPOSURES: Institution of a multidisciplinary tracheostomy team (MDT) whose activities included conducting staff meetings, organizing outpatient clinics, conducting inpatient tracheostomy ward rounds, and conducting inpatient tracheostomy rounds at a local rehabilitation hospital. Quality improvement initiatives included monitoring standardized TRAEs and distributing standardized tracheostomy "go-bags." MAIN OUTCOMES AND MEASURES: Reduction of TRAEs and improved caregiver preparedness through distribution of tracheostomy go-bags were assessed following the establishment of a multidisciplinary tracheostomy program. RESULTS: In total, 700 children who had received a tracheostomy during the study period were actively followed up by the MDT. Of these children, 378 (54.0%) were males and 322 (46.0%) were females; mean (SD) age was 4.1 (6.1) years. More than 60 new pediatric tracheostomies were performed annually at the referral center. Reported TRAEs were reduced by 43.0% from the first to the third year after the implementation of a standardized, closed-loop monitoring system (from a mean [SD] of 6.1 [5.2] TRAEs per 1000 inpatient tracheostomy-days in 2015 to a mean [SD] of 4.0 [2.5] in 2018). The most common TRAE was unplanned decannulation, which occurred 64 times during the study period. On average, 10 patients were seen in each monthly multidisciplinary tracheostomy clinic. Clinic interventions included continuing care (146 [52.5%]), communication enhancement (67 [23.6%]), plans for decannulation (52 [18.6%]), and referrals for comorbidities (13 [4.6%]). Approximately 19 inpatients were seen during biweekly rounds and 8 during monthly rounds at a local rehabilitation hospital. A total of 297 patients received standardized tracheostomy go-bags, and more than 70 positive bag checks were performed in the monthly MDT clinics. A positive bag check refers to the incidence when a family is given a go-bag and also uses it. In contrast, a negative bag check refers to when a family is given a go-bag but neither brings it to the clinic nor acknowledges that they use it. CONCLUSIONS AND RELEVANCE: This study's findings suggest that a multidisciplinary tracheostomy program may be a powerful tool for enhancing patient safety and quality improvement. Ongoing studies will develop measurable pediatric tracheostomy outcome metrics and assess long-term outcomes.

Standardization of pediatric tracheostomy care with "Go-bags".

OBJECTIVES: To describe how pediatric tracheostomy emergency supplies and education are standardized with the use of "Go-bags" and to demonstrate how this has impacted tracheostomy-related adverse events. METHODS: A prospective study was completed at an urban pediatric tertiary care center. Standardized "Go-bags" of tracheostomy supplies were provided to pediatric patients with tracheostomy. All caregivers received standardized tracheostomy education. Check lists were used to monitor contents at return visits or admissions. Tracheostomy related adverse events were tracked on all patients with tracheostomy from July 2016 to May 2018, and rates were compared for patients who had received a "Go-bag" to those who had not. RESULTS: 292 "Go-bags" were distributed during the two-year study period. 35% were distributed by inpatient respiratory therapists, 23% by the home ventilation team, and 22% by a tracheostomy clinic nurse. Supply checks have led to more than 185 cases of emergency tracheostomy equipment replacement. 35% of tracheostomy-related adverse event (TRAE) occurred in patients who did not have a "Go-bag", while 22% of TRAEs occurred in patients who had "Go-bags". CONCLUSION: Standardized pediatric tracheostomy care is critical to patient safety, both in and out of the hospital. Standardized tracheostomy "Go-bags" are a simple and efficient method to educate caregivers, improve the quality of care for children with tracheostomy, and ultimately reduce tracheostomy related adverse events.

Standardized Tracheostomy Education Across the Enterprise.

PURPOSE: The purpose of this quality improvement project was to create a Tracheostomy Subject Matter Expert (Trach SME) Committee to standardize tracheostomy care, education, and the discharge process across Boston Children's Hospital. DESIGN AND METHODS: Boston Children's Hospital (BCH) is a free-standing urban tertiary pediatric hospital with 15 inpatient units. The newly formed Trach SME Committee evaluated the discharge process across the enterprise including hospital satellites and intra-hospital practice. Education materials were centralized, and policies were reviewed, revised and standardized to reflect current best practice. The Trach SME provided education to Trach Champions from each area that became resources for their respective units. The Trach SME also developed measurement outcomes to assess the effectiveness of the education process. RESULTS: In the implementation year of 2104, our 7-day unplanned readmission rate for tracheostomy patients was 18.18%. This rate decreased to 6.67% in 2015 and to 0% in 2016. In 2015, we began to monitor 30-day unplanned readmissions and the rate was 6.67% in 2015 and decreased to 0% in 2016. CONCLUSIONS AND PRACTICE IMPLICATIONS: Standardization of policies, procedures and caregiver educational materials for the management of patients with a tracheostomy tube improved tracheostomy care across the enterprise and reduced tracheostomy readmission rates.

A standardized, closed-loop system for monitoring pediatric tracheostomy-related adverse events.

OBJECTIVES/HYPOTHESIS: Advancement in neonatal and pediatric intensive care has increased the need for chronic-care interventions, including tracheostomy. It is well established that children with a tracheostomy are at a high risk for adverse events, many of which are preventable. Despite this, there is no standardized method of monitoring tracheostomy-related adverse events (TRAEs). Our objective was to describe and assess a standardized, closed-loop system for monitoring TRAEs. STUDY DESIGN: Prospective Study. METHODS: A specific tracheostomy-related category was established within the adverse event reporting system in January 2015. Monthly TRAE reports were supplied to the multidisciplinary tracheostomy team (MDT) with descriptions of event type, severity, and preventability. The MDT reviewed events and discussed necessary follow-up. The frequency of events was standardized by inpatient tracheostomy days (ITDs) using an automated monthly list. Adverse events were tracked using a control chart. Aggregated data were divided into biannual reports for analysis. RESULTS: Eighty-five TRAEs were reported between January 2015 and June 2017, averaging 5.75 per 1,000 ITDs. Most common events include unplanned decannulation (50%) and improper use of tracheostomy supplies (21%). The frequency of all preventable events has decreased by 76% since the second half of 2015. During this timeframe, minor events have decreased, moderate events have maintained a frequency of less than one per 1,000 ITDs, and only one severe event occurred. CONCLUSIONS: This standardized, closed-loop reporting method, modeled after other successful intensive care unit reporting systems, accurately tracks TRAEs. We have observed a decrease in preventable TRAEs without a negative impact on rates of severe events. Results suggest improved quality of care for patients with tracheostomy. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2419-2424, 2018.

A spontaneous breathing trial with pressure support overestimates readiness for extubation in children.

OBJECTIVE: To evaluate the performance of an extubation readiness test based on a spontaneous breathing trial using pressure support. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit. PATIENTS: All infants and children admitted to the pediatric intensive care unit requiring intubation from July 2007 to December 2008 were eligible for this study. INTERVENTIONS: Routine use of an extubation readiness test using pressure support set according to endotracheal tube size to determine completion of weaning and readiness for extubation. MEASUREMENTS AND MAIN RESULTS: A total of 755 extubation readiness tests were performed in 538 patients with a pass rate of 83%. Of 500 children who passed the extubation readiness test and were extubated without planned noninvasive ventilation use, the extubation failure rate was 11.2% (5.8% required reintubation). Extubation failure was defined as need for noninvasive ventilation or reintubation within 24 hrs of planned extubation. Logistic regression analysis revealed a significant association between duration of mechanical ventilation and extubation failure. Children ventilated for over 48 hrs had an 18.5% failure rate despite passing an extubation readiness test before extubation and the extubation readiness test was not a significant predictor of extubation success. Most extubation failures were the result of inadequate gas exchange attributable to lower respiratory tract dysfunction. CONCLUSIONS: A spontaneous breathing trial using pressure support set at higher levels for smaller endotracheal tubes overestimates readiness for extubation in children and contributes to a higher failed extubation rate. The objective data obtained during an extubation readiness test may help to identify patients who will benefit from extubation to noninvasive ventilation.