Utility of telemedicine in tracheostomy-dependent children

Low-Resource Hospital Days for Children Following New Tracheostomy

BACKGROUND AND OBJECTIVES

Children with new tracheostomy and invasive mechanical ventilation (IMV) require transitional care involving caregiver education and nursing support. To better understand hospital resource use during this transition, our study aimed to: (1) define and characterize low-resource days (LRDs) for this population and (2) identify factors associated with LRD occurrence.

METHODS

This retrospective cohort analysis included children ≤21 years with new tracheostomy and IMV dependence admitted to an ICU from 2017 to 2022 using the Pediatric Health Information System database. A LRD was defined as a post tracheostomy day that accrued nonroom charges <10% of each patient's accrued nonroom charges on postoperative day 1. Factors associated with LRDs were analyzed using negative binomial regression.

RESULTS

Among 4048 children, median post tracheostomy stay was 69 days (interquartile range 34-127.5). LRDs were common: 38.6% and 16.4% experienced ≥1 and ≥7 LRDs, respectively. Younger age at tracheostomy (0-7 days rate ratio [RR] 2.42 [1.67-3.51]; 8-28 days RR 1.8 (1.2-2.69) versus 29-365 days; Asian race (RR 1.5 [1.04-2.16]); early tracheostomy (0-7 days RR 1.56 [1.2-2.04]), and longer post tracheostomy hospitalizations (31-60 days RR 1.85 [1.44-2.36]; 61-90 days RR 2.14 [1.58-2.91]; >90 days RR 2.21 [1.71-2.86]) were associated with more LRDs.

CONCLUSIONS

Approximately 1 in 6 children experienced ≥7 LRDs. Younger age, early tracheostomy, Asian race, and longer hospital stays were associated with increased risk of LRDs. Understanding the postacute phase, including bed utilization, serves as an archetype to explore care models for children with IMV dependence.

Equitable Care for Children With a Tracheostomy: Addressing Challenges and Seeking Systemic Solutions

BACKGROUND

Children with medical complexity (CMC) often face significant barriers to accessing care, obtaining appropriate insurance coverage for medical devices, technology, supplies, home nursing and social services. These challenges, when viewed through the lens of social determinants of health, highlight concerns about healthcare inequity. These inequities can impact CMC by limiting access to follow-up appointments, leading to disproportionate use of emergency department services, restricting support services, reducing the quality of medical products and increasing the likelihood of adverse events. Addressing these concerns requires comprehensive policy changes at both state and federal levels. Achieving successful collaborations between states and federal agencies is particularly challenging and may take months or even years to accomplish.

OBJECTIVES

Through an exploratory qualitative approach, this study facilitates a nuanced inquiry into the experiences and systemic challenges encountered by medical professionals and primary caregivers managing CMC who require a paediatric tracheostomy.

METHODS

Qualitative interviews were conducted with 17 health professionals and primary caregivers residing in the United States. A thematic analysis was used to analyse the transcribed interview data.

RESULTS

Using exploratory thematic analysis, we identified challenges and opportunities for improvement regarding (a) access to health insurance, (b) procurement of essential medical supplies, (c) logistical constraints and (d) identifying interim solutions.

CONCLUSION

Building on our findings, we discuss how socioecological factors impact health and quality of life of CMC and families. Additionally, we address the growing gap in quality of care through a comprehensive approach that considers patient needs, regulatory frameworks and affordability.

PATIENT OR PUBLIC CONTRIBUTION

Medical practitioners and healthcare professionals were actively involved in the development, production and implementation of the research project. These individuals were given the opportunity to review their statements and review the manuscript before publishing. While caregivers did not engage in member checking, each provided their consent before data collection.

Comparing Telemedicine and In-Person Clinical Evaluations for Pediatric Urology Concerns

INTRODUCTION

Telemedicine may promote equitable health care delivery, particularly in rural and underserved regions. While patient and provider satisfaction with telemedicine appear to be high, it remains unclear if telemedicine accomplishes the same clinical goals as in-person clinic visits. We undertook this study to compare the differences in history-taking, physical examination, and recommended follow-up in new pediatric urology patients seen via telemedicine and in-person.

METHODS

This cross-sectional study was performed by retrospectively reviewing the charts of all new patients visiting the general pediatric urology clinic at a single freestanding children's hospital in January and April of three consecutive years (2019, 2020, 2021). Data were abstracted on patient demographics, comprehensiveness of history of present illness, completeness of physical examination, and recommended follow-up. Patients seen by telemedicine and in-person were compared.

RESULTS

Of 1354 patients, 1244 (91.9%) had in-person and 110 (8.1%) telemedicine visits. Telemedicine patients had a median of 4 history of present illness components recorded; in-person patients had 3 (P < 0.0001). Patients seen in-person had a more comprehensive physical examination recorded compared with telemedicine patients (median 12 vs 2 systems, P < 0.0001). Significantly fewer telemedicine patients were discharged from clinic after the initial visit (2.7% vs 16.5%), and significantly more were asked to return for additional evaluation (39.1% vs 23.2, P < 0.0001).

CONCLUSIONS

Initial pediatric urology telemedicine consultations gathered more historical and fewer physical examination components and were more likely to require an additional clinic visit for evaluation. Goals of care should be considered when selecting a visit modality.