The Transitional Experience of Family Caring for Their Child With a Tracheostomy

School adjustment experiences of ventilator-dependent children: A phenomenological study of mothers' perspectives

PURPOSE

This study aimed to describe the experiences of ventilator-dependent children (VDC) in adjusting to school life from the perspectives of their mothers.

DESIGN AND METHOD

This study employed a descriptive phenomenological approach. From July 2021 to September 2022, ten mothers of VDC were recruited via purposive sampling and underwent in-depth individual interviews. Data were analyzed using Colaizzi's phenomenological method. This study adheres to the COREQ guidelines for qualitative study.

FINDINGS

Four themes emerged: (1) the transition and burden of the mother's role; (2) positive adjustment and assessment of resources; (3) develop strategies to meet health and learning needs; (4) expectations for accessible school environments.

CONCLUSIONS

The mothers extensively assessed and adjusted their coping strategies on a rolling basis to ensure that their children received the resources that met their individual needs, promoted peer interactions, and helped adjustment to school life. The children's improvement and progress surpassed their mothers' expectations and demonstrated the benefits of a school education. Future educational settings should focus on building accessible school environments for special needs children.

PRACTICE IMPLICATIONS

These findings allow healthcare professionals to assess the needs of VDC at different educational levels and create care plans that meet their healthcare and educational needs. This study also provides a reference for amending policies and regulations on individualized educational programs for VDC and developing guidelines for realizing accessible school environments to help them adjust to school life.

Influence of caregiver-nurse communication on quality of life and clinical outcomes of children with long-term ventilator dependence

AIM

To determine the effects of communication behaviors observed during discussion of home management of hospitalized children with long-term ventilator dependence on post-discharge quality of life and clinical outcomes.

DESIGN

A descriptive, quantitative study of family caregiver and nurse communication.

METHODS

Conversations between 100 family caregivers and 48 nurses were recorded and transcribed. Transcripts were coded for key communication behaviors: ask, listen, explain, negotiate roles, verify understanding and advocate. Quality of life measures and clinical outcomes were collected one week and one month post-discharge. Analysis included descriptive statistics and linear mixed-effects models.

RESULTS

Each communication behavior was associated with quality of life outcomes. Family caregivers demonstrated more listening behaviors when there was poorer child quality of life (β = -1.52) and advocated more with increased child fatigue (β = 1.55). When family caregivers negotiated care roles with nurses, there was less child anxiety and more mobility (β = -2.15, β = -1.54). Less child fatigue and more mobility were evidenced when nurses advocated (β = -1.49, β = 0.92). Better child quality of life was predicted by nurses asking family caregivers more questions (β = 1.03), while poorer child quality of life was evident when nurses negotiated care roles (β = -2.22). Overall, when family caregivers demonstrated a need or willingness to negotiate care roles with nurses, more respiratory infections were found post-discharge at one week (β = 1.23) and one month (β = 1.59).

CONCLUSION

Family caregiver and nurse communication can impact outcomes for hospitalized children with long-term ventilator dependence. Family caregivers advocate and negotiate roles to ensure support and appropriate care for themselves and their child.

A Qualitative Descriptive Study Exploring the Systemic Challenges of Caring for Children With Medical Complexity at Home

INTRODUCTION

The purpose of this study is to explore challenges within the home care system encountered by parental caregivers of children with medical complexity in Massachusetts.

METHOD

A qualitative descriptive study was completed with 11 parental caregivers interviewed.

RESULTS

Using conventional content analysis of transcripts, three themes emerged: (1) lack of discharge preparedness causes emotional distress, (2) care becomes increasingly complex creating new unanticipated challenges, and (3) psychological toll of parents assuming provider role.

DISCUSSION

Navigating a variety of complex systemic challenges with minimal preparation or support contributes to an overall feeling of parental caregiver burnout. Additionally, mental health supports for parental caregivers are lacking, further exacerbating the negative impact of these challenges. Future work should focus on research, advocacy, and system reform that ensures parental caregivers receive necessary supports to care for children within a sustainable and supportive home care model. Nurses across the profession are in unique position to facilitate this change.

Exploration of trust between pediatric nurses and children with a medical diagnosis and their caregivers on inpatient care units: A scoping review

PROBLEM

Trust is central to the development of nurse-patient relationships. Pediatric nurses encounter difficulties developing trust with children and their caregivers. The purpose of this scoping review was to identify, examine, and summarize available evidence on the concept of trust among nurses and children/caregivers when admitted to hospital inpatient care units.

ELIGIBILITY CRITERIA

Using the Joanna Briggs Institute (JBI) methodology for conducing and reporting scoping reviews, CINAHL, MEDLINE, PsycINFO, Cochrane DSR, Cochrane Central, and JBI EBP were searched for qualitative, quantitative, mixed methods, and review studies with no time limits published in English. Included studies presented findings on the experiences of developing trust between pediatric nurses and children under 18 years of age and their caregivers within inpatient care units.

RESULTS

A total of 12,269 titles and abstracts were reviewed independently by two reviewers. 366 full-text articles were retrieved, a final of 81 studies were included in the review.

CONCLUSIONS

Trust was bi-directional between nurses and children/caregivers, developed over time during multiple interactions, and foundational to the development of relationships. Distinct facilitators and barriers to the development of trust between nurses and children/caregivers were identified. The development of trust was rewarding and enriching for both nurses and children/caregivers and was the fundamental to the provision of safe and high-quality nursing care.

IMPLICATIONS

Findings provide nurses with direction and strategies on how to develop and maintain trust with children/caregivers on inpatient care units. The development of training programs and interventions geared at equipping nurses with the skills to develop trust with children/caregivers is needed.

Parent perspectives on education to support hospital discharge for children with invasive mechanical ventilation

BACKGROUND

Children with invasive mechanical ventilation (IMV) often live at home, but for safety, parents must be prepared to assume primary responsibility for all aspects of their child's medically complex care. Prior studies have described discharge education programs, however often without perspectives of parents with lived experience transitioning home.

PURPOSE

To describe parent perspectives on hospital-based education for discharging home a child with IMV.

DESIGN AND METHODS

A secondary qualitative analysis of 23 parent interviews between February 2019 to January 2022 on topics related to caring for a child with IMV. Each interview was coded independently and discussed to consensus. Data from codes related to parent education and training were analyzed to identify themes and sub-themes.

RESULTS

Parents of 23 children with IMV participated in the primary interviews a month after hospital discharge. Four main themes in the secondary dataset were identified: (1) Training context: The hospital can be a stressful and difficult learning environment; (2) Training characteristics: Parents receive thorough training from interdisciplinary providers; (3) Learner characteristics: Parents are motivated learners who independently seek out knowledge; (4) Post-discharge education: Parents gain confidence in their expertise after navigating an emergency.

CONCLUSIONS

Parents who have transitioned from hospital-to-home describe sufficiently detailed hospital-based education; many felt trained as capably as nurses. However, parents experienced in-hospital training as inflexible and stressful.

PRACTICE IMPLICATIONS

Parents of children with IMV are eager learners but parent education is not always family-centered. Reforming the hospital learning environment to match parent needs will improve family experiences and training.

Caring for the child with a tracheostomy through the eyes of their caregiver: A photovoice study

PURPOSE

This qualitative descriptive study aimed to explore the daily experiences of caregivers of children with medical complexity with a tracheostomy at home.

METHODS

This study used photovoice, a participatory action research methodology. Adult English-speaking caregivers of children with a tracheostomy, living in Texas, with access to a smartphone were recruited. Photographs taken by participants and an interview guide were used to guide semi-structured interviews with caregivers.

RESULTS

Eight participants were recruited. After analyzing photographs and caregiver interviews, four main themes were identified: role transition, daily challenges, finding support, and thriving in the new normal.

CONCLUSIONS

Caregivers take on multiple roles, including providing medical care, advocating for their children, and educating others. While facing emotional challenges such as guilt, fear, and exhaustion, caregivers rely on external support systems, emphasizing the need for nurses and healthcare providers to provide comprehensive support and improve the accessibility of home nursing services.

PRACTICE IMPLICATIONS

The findings of this study can inform nurse-led interventions and advocacy efforts aimed at supporting marginalized children with medical complexity with a tracheostomy and their families. These efforts may include enhancing communication and collaboration between families, healthcare workers, and the public, providing comprehensive, proactive support for caregivers, and improving access to home nursing services.

Transitioning children using home invasive mechanical ventilation from hospital to home: Discharge criteria, disparities, and ethical considerations

Children using home invasive mechanical ventilation (HIMV), a valuable therapeutic option for chronic respiratory failure, constitute a growing population. Transitioning children using HIMV from hospital to home care is a complex process that requires a multidisciplinary approach involving healthcare professionals, caregivers, and community resources. Medical stability, caregiver competence, and home environment suitability are essential factors in determining discharge readiness. Caregiver education and training play a pivotal role in ensuring safe and effective home care. Simulation training and staged education progression are effective strategies for equipping caregivers with necessary skills. Resource limitations, inadequate home nursing support, and disparities in available community resources are common obstacles to successful HIMV discharge. International perspectives shed light on diverse healthcare systems and challenges faced by caregivers worldwide. While standardizing guidelines for HIMV discharge may be complex, collaboration among healthcare providers and the development of evidence-based regional guidelines can improve outcomes for children using HIMV and their caregivers. This review seeks to synthesize literature, provide expert guidance based on experience, and highlight components to safely discharge children using HIMV. It further assesses disparities and divergences within regional and international healthcare systems while addressing relevant ethical considerations.

Tracheostomy decision-making for children with medical complexity: What supports and resources do caregivers need?

OBJECTIVES

Caregivers of children with medical complexity (CMC) face decisions about life-sustaining interventions, such as tracheostomy. Our objective is to describe the support needs of caregivers of CMC and the resources they use surrounding tracheostomy decision-making (TDM) for their children.

METHODS

This qualitative study, conducted between 2013 and 2015, consisted of semi-structured interviews with 56 caregivers of 41 CMC who had tracheostomies, and 5 focus groups of 33 clinicians at a tertiary care children's hospital. Participants were asked about their perspectives on the TDM process. Qualitative data were transcribed, coded, and organized into themes.

RESULTS

Caregivers used five domains of resources surrounding TDM: (1) social network including extended family members, friends, and clergy; (2) healthcare providers including physicians and nurses; (3) other parents of children with tracheostomy; (4) tangible materials such as print materials, videos, tracheostomy tubes, mannequins, and simulation labs; and (5) internet including websites, social media, and online health communities. Caregivers used these resources for (1) decision-making, (2) becoming knowledgeable and skillful about child's diagnosis, tracheostomy, and home care, and (3) emotional and spiritual well-being. Caregivers agreed that they received enough support, but there were gaps. Clinicians were knowledgeable about these resources, discussed social network and internet less often than the other domains, and identified gaps in supporting caregivers.

SIGNIFICANCE OF RESULTS

Caregivers' need for support and use of resources surrounding tracheostomy placement for CMC extended beyond decision-making, and included becoming knowledgeable and getting emotional/spiritual support. Healthcare providers exploring these resources with caregivers could improve the quality of TDM communication.

Tracheostomy-related durable medical equipment: Insurance coverage, gaps, and barriers

PURPOSE

Tracheostomy care is supply- and resource-intensive, and airway-related adverse events in community settings have high rates of readmission and mortality. Devices are often implicated in harm, but little is known about insurance coverage, gaps, and barriers to obtaining tracheostomy-related medically necessary durable medical equipment. We aimed to identify barriers patients may encounter in procuring tracheostomy-related durable medical equipment through insurance plan coverage.

MATERIALS AND METHODS

Tracheostomy-related durable medical equipment provisions were evaluated across insurers, extracting data via structured telephone interviews and web-based searches. Each insurance company was contacted four times and queried iteratively regarding the range of coverage and co-pay policies. Outcome measures include call duration, consistency of explanation of benefits, and the number of transfers and disconnects. We also identified six qualitative themes from patient interviews.

RESULTS

Tracheostomy-related durable medical equipment coverage was offered in some form by 98.1 % (53/54) of plans across 11 insurers studied. Co-pays or deductibles were required in 42.6 % (23/54). There was significant variability in out-of-pocket expenditures. Fixed co-pays ranged from $0-30, and floating co-pays ranged from 0 to 40 %. During phone interviews, mean call duration was 19 ± 10 min, with an average of 2 ± 1 transfers between agents. Repeated calls revealed high information variability (mean score 2.4 ± 1.5). Insurance sites proved challenging to navigate, scoring poorly on usability, literacy, and information quality.

CONCLUSIONS

Several factors may limit access to potentially life-saving durable medical equipment for patients with tracheostomy. Barriers include out-of-pocket expenditures, lack of transparency on coverage, and low-quality information. Further research is necessary to evaluate patient outcomes.

"What choice do you have knowing your child can't breathe?!": Adaptation to Parenthood for Children Who Have Received a Tracheostomy

Introduction

A growing number of parents are navigating parenthood influenced by medical complexity and technological dependency as the group of children with long-term tracheostomy grows. However, little is known regarding the parental experiences of parenthood for this heterogeneous group of children now surviving through infancy and intensive care.

Objective

This study aimed to analyze how parents of children who have received a tracheostomy adapted to parenthood.

Methods

Interviews were conducted and analyzed following a constructivist grounded theory approach. Ten parents of seven children living with a tracheostomy in Sweden were recruited via the long-term intensive care unit (ICU).

Results

The core variable of parenthood "Stuck in survival" was explained by two categories and six subcategories. The category "Unaddressed previous history" describes the experiences from being in the ICU environment and how the parents are not able, due to insufficient time and resources, to address these stressful experiences. The category "Falling through the cracks of a rigid system" describes how the parents found themselves and their children to be continuously ill-fitted in a medical system impossible to adapt to their needs and situation. Parents placed the starting point of parenthood with the birth of the child, whilst the tracheotomy only constituted a turning point and would lead to the loss of any previously held expectations regarding parenthood.

Conclusion

This study identified a previously undescribed period prior to tracheostomy placement, which may have long-lasting effects on these families. The care provided in ICUs following the birth of a child who will require tracheostomy may not be tailored or adapted to accommodate the needs of these families leading to long-lasting effects on parenthood.

Delineating family needs in the transition from hospital to home for children with medical complexity: part 1, a meta-aggregation of qualitative studies

BACKGROUND

Advances in diagnostic and therapeutic interventions for rare diseases result in greater survival rates, with on the flipside an expanding group of children with medical complexity (CMC). When CMC leave the protective hospital environment to be cared for at home, their parents face many challenges as they take on a new role, that of caregiver rather than care-recipient. However, an overview of needs and experiences of parents of CMC during transition from hospital-to-home (H2H) is lacking, which hampers the creation of a tailored H2H care pathway. Here we address this unmet medical need by performing a literature review to systematically identify, assess and synthesize all existing qualitative evidence on H2H transition needs of CMC parents.

METHODS

An extensive search in Medline, PsychINFO and CINAHL (up to September 2022); selection was performed to include all qualitative studies describing parental needs and experiences during H2H transition of CMC. All papers were assessed by two independent investigators for methodological quality before data (study findings) were extracted and pooled. A meta-aggregation method categorized the study findings into categories and formulated overarching synthesized findings, which were assigned a level of confidence, following the ConQual approach.

RESULTS

The search yielded 1880 papers of which 25 met eligible criteria. A total of 402 study findings were extracted from the included studies and subsequently aggregated into 50 categories and 9 synthesized findings: (1) parental empowerment: shifting from care recipient to caregiver (2) coordination of care (3) communication and information (4) training skills (5) preparation for discharge (6) access to resources and support system (7) emotional experiences: fatigue, fear, isolation and guilt (8) parent-professional relationship (9) changing perspective: finding new routines and practices. The overall ConQual Score was low for 7 synthesized findings and very low for 2 synthesized findings.

CONCLUSIONS

Despite the variability in CMC symptoms and underlying (rare disease) diagnoses, overarching themes in parental needs during H2H transition emerged. We will augment this new knowledge with an interview study in the Dutch setting to ultimately translate into an evidence-based tailored care pathway for implementation by our interdisciplinary team in the newly established 'Jeroen Pit Huis', an innovative care unit which aims for a safe and sustainable H2H transition for CMC and their families.

Parent Perspectives on the Child Experience of Pediatric Home Ventilation via Tracheostomy

BACKGROUND AND OBJECTIVE

Parents facing the decision of whether to initiate pediatric mechanical ventilation via tracheostomy ("home ventilation") report wanting information about what to expect for life at home for their child. The study objective is to explore parent descriptions of the child experience of home ventilation to increase awareness for clinicians in the inpatient setting caring for these children.

METHODS

Semistructured interviews were conducted using purposive sampling of parents with children who initiated home ventilation within the previous 5 years from 3 geographically diverse academic medical centers.

RESULTS

We interviewed 21 families from 3 geographic regions in the United States. About 75% of children had respiratory failure in the first year of life, 80% had medical complexity, and half had severe neurologic impairment. Five domains emerged regarding parent perceptions of their child's experience of home ventilation: (1) health and well-being; (2) development; (3) adaptation; (4) mobility and travel; and (5) relationships. Within each domain, several themes were identified. For each theme, there was a positive and negative subtheme to illustrate how the child's experience was modified by home ventilation. Parent descriptions were generally positive, however, in all domains and to varying degrees, parents expressed negative aspects of home ventilation.

CONCLUSIONS

By providing information about the realistic experiences of children using home ventilation, clinicians can support families in the inpatient setting as they face this complex decision. Balanced information about home ventilation is critical to enhancing clinician counseling so that families may benefit from the perspectives of experienced parents.

Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review

CONTEXT

Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking.

OBJECTIVE

To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC.

DATA SOURCES

PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched.

STUDY SELECTION

Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated.

DATA EXTRACTION

Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results.

RESULTS

Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies.

LIMITATIONS

No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review.

CONCLUSIONS

Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.

Hospital healthcare experiences of children and young people with life-threatening or life-shortening conditions, and their parents: scoping reviews and resultant conceptual frameworks

BACKGROUND

Patient experience is a core component of healthcare quality. Patient-reported experience measures (PREMs) are increasingly used to assess this, but there are few paediatric PREMs. This paper reports the first stage of developing two such measures, one for children and young people (0-18 years) (CYP) with a life-threatening or life-shortening condition (LT/LSC), and one for their parents. It comprised parallel scoping reviews of qualitative evidence on the elements of health service delivery and care that matter to, or impact on, CYP (Review 1) and parents (Review 2).

METHODS

Medline and PsychINFO (1/1/2010 - 11/8/2020) and CINAHL Complete (1/1/2010 - 4/7/2020) were searched and records identified screened against inclusion criteria. A thematic approach was used to manage and analyse relevant data, informed by existing understandings of patient/family experiences as comprising aspects of staff's attributes, their actions and behaviours, and organisational features. The objective was to identity the data discrete elements of health service delivery and care which matter to, or impact on, CYP or parents which, when organised under higher order conceptual domains, created separate conceptual frameworks.

RESULTS

18,531 records were identified. Sparsity of data on community-based services meant the reviews focused only on hospital-based (inpatient and outpatient) experiences. 53 studies were included in Review 1 and 64 in Review 2. For Review 1 (CYP), 36 discrete elements of healthcare experience were identified and organized under 8 higher order domains (e.g. staff's empathetic qualities; information-sharing/decision making; resources for socializing/play). In Review 2 (parents), 55 elements were identified and organized under 9 higher order domains. Some domains were similar to those identified in Review 1 (e.g. professionalism; information-sharing/decision-making), others were unique (e.g. supporting parenting; access to additional support).

CONCLUSIONS

Multiple and wide-ranging aspects of the way hospital healthcare is organized and delivered matters to and impacts on CYP with LT/LSCs, and their parents. The aspects that matter differ between CYP and parents, highlighting the importance of measuring and understanding CYP and parent experience seperately. These findings are key to the development of patient/parent experience measures for this patient population and the resultant conceptual frameworks have potential application in service development.

Can addressing family education improve outcomes of patients under home invasive mechanical ventilation? A randomized controlled clinical trial

The use of home mechanical ventilation is increasingly developing. The present study aimed to examine the effect of a family-centered training program on patients under home invasive mechanical ventilation. A total of 60 adult patients under invasive mechanical ventilation were selected and randomly allocated into two groups. The supportive home care program consisting of six training sessions using a teach-back technique and follow up training at home. The rate of hospital readmission and mortality in the intervention group was significantly lower than the control group(P = .02 and P = .03, respectively). Moreover, the home caregivers' level of knowledge in the intervention group was significantly higher than that of the control group(P = 0/000). In addition, implementing the intervention effectively increased home caregivers' ability of functional skills. Therefore, comprehensive preparation of the patient and family before discharge and coherent support and continuity of care after discharge with the effective presence of nurses.

Family-Reflections.com: Creating a parent-to-parent web-based tool regarding pediatric home ventilation

BACKGROUND

The decision to initiate pediatric mechanical ventilation via tracheostomy ("home ventilation") is complex and parents often desire information from other parents who have faced this decision. However, parent-to-parent communication is challenging as it is difficult to connect new families to experienced families in ways that optimize informed, balanced decision-making.

OBJECTIVE

Create a parent-to-parent web-based tool to support decision-making about pediatric home ventilation.

PATIENT INVOLVEMENT

The tool was created based on interviews and feedback from parents.

METHODS

We interviewed parents who previously chose for, or against, home ventilation for their child. Interview themes and family comments guided website development. Viewer feedback was solicited via an embedded survey in the tool.

RESULTS

We created 6 composite character families to communicate 6 themes about home ventilation: 1) Considering treatment options, 2) Talking with medical team, 3) Impact on life at home, 4) Impact on relationships, 5) Experience for the child, and 6) If the child's life is short. Nine families who reviewed the draft tool felt it would have helped with their decision about home ventilation. Specifically, it supported families in thinking through what was "most important about their child's breathing problems" (7 of 9 parents) and feeling "more at peace with the decision" (8 of 9 parents). Between 6/1/20-12/31/22, nearly 5500 viewers have accessed the tool and 56 viewers completed the survey (including 13 families and 39 clinicians). Feedback from experienced families and clinicians reported the tool taught them something new.

DISCUSSION

This novel parent-to-parent tool shows promise for expanding access to balanced, family-centered information about pediatric home ventilation.

PRACTICAL VALUE

The diverse stories and decisions let parents access multiple family perspectives. The tool's focus is on family-centric information that parents reported was usually missing from clinician counseling.

FUNDING

This work was supported by the National Palliative Care Research Center.

Feeling stretched: Parents' narratives about challenges to resilience when their child has a tracheostomy

This study aimed to examine how parents develop personal resilience when facing the challenges of caring for a child with tracheostomy. This study employed a longitudinal qualitative design. Unstructured narrative interviews with 12 parents (from nine families) whose child had a new tracheostomy were undertaken at three time points over 12 months. Data were analysed using a socio-narratology method. Findings reveal the journey parents experienced, how their feelings changed and the processes involved in developing resilience over the first 12 months of their child having a tracheostomy. Stories told by parents early in their journey revealed emotional upheaval, negative emotions, stress and shock. Due to medical need, parents had little or no choice for their child to have a tracheostomy. Once their child's life was out of danger, parents started to reframe their experiences and beliefs. Resilience played a major part in how parents perceived and faced their situation, allowing them to deal with what came their way and to move forward with their lives. Different aspects of resilience such as self-awareness, grit, gratitude, internal locus of control and reframing came to the fore at different time points. Parents talked feeling stretched by the challenges they faced and how they reframed their perspectives about their child's tracheostomy. Parents' resilience and reframing is discussed in relation to the ABC-X model. This study identifies a theoretical model that explains this process of change, this results in transferable knowledge, useful for understanding and explaining the experience of other parents and families.

Providing care for children with tracheostomies: a qualitative interview study with parents and health professionals

OBJECTIVES

To explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers.

DESIGN

Qualitative semistructured interview study.

SETTING

One region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation.

PARTICIPANTS

A purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre.

INTERVENTION

Interviews undertaken by telephone or video link.

PRIMARY AND SECONDARY OUTCOME MEASURES

Qualitative reflexive thematic analysis with QSR Nvivo 12.

RESULTS

This paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies.

CONCLUSIONS

Understanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.

"What Would Give Her the Best Life?": Understanding Why Families Decline Pediatric Home Ventilation

Background: Families who must decide about pediatric home ventilation rely on the clinicians who counsel them for guidance. Most studies about pediatric home ventilation decisions focus on families who opt for this intervention, leaving much unknown about the families who decline. Objective: To describe the rationales of families who decline home ventilation. Design: Semi-structured interview study. Setting/Subjects: We interviewed 16 families in hospitals across 3 U.S. states, identified by their clinicians as previously deciding to not pursue home ventilation via tracheostomy within the past five years. Measurements: Targeted content and narrative analyses were used to understand family intentions and reasons for declining. Results: The clinical and social context varied among the 16 families in this study. Families' intentions in saying "no" fell into two categories: (1) definitive "No": Families who stood firm on in their decision and (2) contingent "No": Families who may consider this in the future. Families described four reasons why their child did not receive home ventilation: (1) concern about medical impacts, (2) concern about physical and/or communication restrictions, (3) concern that there would be no clear health benefit, and (4) concern about no clear meaningful life. Most families mentioned all four reasons, but concern about no clear meaningful life predominated. Conclusions: Though these families did not see home ventilation as an appropriate option, each reported a complex interplay of intentions behind and reasons for declining. Clinicians who counsel families about home ventilation could share the reasons that families commonly decline this intervention to facilitate a balanced discussion.

Parent education programs for children assisted by invasive mechanical ventilation: A scoping review

PROBLEM

The population of children assisted by invasive mechanical ventilation (IMV) and living at home is growing. Although parent education is essential for safe transitions from hospital-to-home, little is known about how this education is delivered. The aim of this review is to identify existing literature about parent education programs, synthesize the evidence, and identify gaps in the literature for future inquiry.

ELIGIBILITY CRITERIA

This scoping review was conducted in accordance with the Joanna Briggs Institute methodology. Full-text publications in the English language focused on describing parent education programs for children assisted by IMV, indexed in CINAHL, PubMed, OVID, and PsycINFO and published from 2010 to 2021 were included. Reference lists of relevant articles were reviewed, and a hand search was completed to locate any additional literature outside the original search.

SAMPLE

A total of 2472 citations were identified. After screening titles and abstracts, 37 full-text articles were retrieved and assessed for eligibility. Two independent reviewers completed the screening process. A hand search located one additional article. A final sample of 18 articles were included in the review.

RESULTS

The parent education programs described in the final sample included standardized discharge education programs, simulation training, resourcefulness training, patient-specific action plans, disaster preparedness, and symptom and technology management.

CONCLUSION

Although most parent education programs identified in this review focused on teaching caregiver skills, program characteristics and outcome measures varied widely.

IMPLICATIONS

This review recommends directions for future research to optimize parent education for children assisted by IMV.

A contextual needs assessment of families with home invasive mechanical ventilation patients: A qualitative study

OBJECTIVES

With the advancement of technology the number of patients surviving critical illness has increased. Home mechanical ventilation (HMV) is a growing option for patients requiring long-term mechanical ventilation. Caring for these patients is demanding and challenging. The aim of this study was to explore family caregivers'(carers) needs when providing care to adult patients under HMV from the perspective of nurses, home care attendants, and the caregivers themselves.

METHODS

Overall, 15 participants (nine carers, three home nurses, and three home care attendants) were selected by purposive sampling. Data were collected by in-depth semi-structured interviews and structured observation. Finally, data were analyzed through conventional content analysis with MAXQDA software.

RESULTS

Three categories of carers'needs were identified, including educational needs (basic and emergencies), psychological needs, and economic needs. In addition, since the needs, feelings, and views of caregivers change over time, the noted needs were divided into three periods: Pre-discharge preparation, initial transition from hospital to home, and appropriate long-term follow-up.

CONCLUSION

The study results showed that the families of patients under invasive HMV require a standard discharge plan based on their care needs, financial concerns, and psychological screening before discharge as well as a suitable long-term follow-up plan in collaboration with a multidisciplinary treatment team, insurance providers, and home care services.

Home mechanical ventilation for children with severe neurological impairment: Parents' perspectives on clinician counselling

AIM

To retrospectively explore the perspectives of parents of children with severe neurological impairment (SNI), such as those with severe cerebral palsy, epilepsy syndromes, and structural brain differences, on clinician counseling regarding home mechanical ventilation (HMV).

METHOD

Inductive thematic analysis was performed on data from telephone interviews with parents who chose for and against HMV for their child with SNI at three academic children's hospitals across the USA.

RESULTS

Twenty-six parents/legal guardians of 24 children were interviewed. Fourteen children had static encephalopathy, 11 received HMV, and 20 were alive at the time of parent interviews. Themes included how HMV related to the child's prognosis, risk of death, and integration with goals of care. Although clinicians voiced uncertainty about how HMV would impact their child, parents felt this was coupled with prescriptive/intimidating examples about the child's end of life and judgments about the child's quality of life.

INTERPRETATION

While prognositc uncertainty exists, this study suggests that parents of children with SNI seek clinician counseling about HMV that considers their goals of care and views on their child's quality of life.

Hospital training and preparedness of parents and carers in paediatric tracheostomy care: A mixed methods study

INTRODUCTION

Within the UK, the majority of paediatric tracheostomy care is delivered by parents and carers at home. To facilitate this, extensive in-hospital training is delivered by a variety of health care professionals. Our goal was to assess carer perceptions of this process and highlight areas in which we can further improve our service and the training for other hospital providers of paediatric tracheostomy care.

METHODS

A mixed method approach was adopted. In Phase I, qualitative data from five semi-structured interviews with carers of children with a tracheostomy were thematically analysed and subsequently used to develop a questionnaire. In Phase II, the piloted questionnaire was distributed via telephone, email or post to all eligible caregivers who had been tracheostomy trained at GOSH in the last three years (n = 92). Qualitative and quantitative data were analysed using thematic analysis and descriptive statistics respectively.

RESULTS

Thirty-five completed questionnaires were received (38% response rate). Overall participants were highly satisfied with the training provided (mean score 8.42 on a scale of 1 (lowest) to 10 (highest)). Carer identified areas requiring improvement were caregiver education pre-tracheostomy; emergency and complication training; supervision and training post hospital discharge; training schedule; emotional support; and support from community healthcare teams. These findings led to multiple subsequent interventions to further improve the carer training programme including training videos, psychology provision on request and increased community training.

CONCLUSION

Although the evaluation of the service revealed high participant satisfaction in home carer training overall, in-depth analysis of caregivers' experiences indicated common themes in the tracheostomy training service where further support would be beneficial. A carer-centred rather than health professional focus on training needs will allow future attention to be directed to areas of need identified by carers themselves as important to improve the tracheostomy training programme.

Impact of COVID-19 on carers of children with tracheostomies

OBJECTIVES

To explore the impact of the COVID-19 pandemic on the experiences of caregivers of children with tracheostomies.

DESIGN

Qualitative semistructured interviews.

SETTING

All participants were currently, or had previously cared for, a tracheostomised child who had attended a tertiary care centre in the North of England. Health professionals were purposively sampled to include accounts from a range of professions from primary, community, secondary and tertiary care.

PARTICIPANTS

Carers of children with tracheostomies (n=34), including health professionals (n=17) and parents (n=17).

INTERVENTIONS

Interviews were undertaken between July 2020 and February 2021 by telephone or video link.

MAIN OUTCOME MEASURE

Qualitative reflexive thematic analysis with QSR NVivo V.12.

RESULTS

The pandemic has presented an additional and, for some, substantial challenge when caring for tracheostomised children, but this was not always felt to be the most overriding concern. Interviews demonstrated rapid adaptation, normalisation and varying degrees of stoicism and citizenship around constantly changing pandemic-related requirements, rules and regulations. This paper focuses on four key themes: 'reconceptualising safe care and safe places'; 'disrupted support and isolation'; 'relationships, trust and communication'; and 'coping with uncertainty and shifting boundaries of responsibility'. These are described within the context of the impact on the child, the emotional and physical well-being of carers and the challenges to maintaining the values of family-centred care.

CONCLUSIONS

As we move to the next phase of the pandemic, we need to understand the impact on vulnerable groups so that their needs can be prioritised.

Finding a New Normal: Maternal Experiences Transitioning to Home From the Neonatal Intensive Care Unit Caring for Technology-Dependent Infants

BACKGROUND

Infants discharged from the neonatal intensive care unit (NICU) dependent on medical technology (eg, respiratory or nutritional support) are a growing vulnerable population. These infants are medically fragile, prone to emergency department visits and readmissions, and require increased caregiver demands at home. The experiences of their maternal caregiver's after NICU discharge however, are not well understood.

PURPOSE

This qualitative descriptive study addressed this knowledge gap by interviewing mothers of technology-dependent infants about their experience during their first 2 weeks transitioning to home from the NICU. This is a critical period in which mothers must first assume advanced caretaking responsibilities in the home.

METHODS

Eight mothers participated in semistructured audio-recorded interviews via the Web conferencing system Zoom and completed demographic questionnaires.

RESULTS

Five themes emerged from the data that described essential features of the mothers' transition to home: (a) needing coordinated discharge care; (b) establishing a routine; (c) being an advocate; (d) having a support system; and (e) finding normalcy. An additional important finding of this study was the presence of maternal posttraumatic stress and postpartum depression.

IMPLICATIONS FOR PRACTICE

Results highlight the importance of providing mothers hands-on practice opportunities and identifying social support and home healthcare options prior to discharge of technology-dependent infants.

IMPLICATIONS FOR RESEARCH

Future research should focus on multidisciplinary interventions targeted toward discharge preparation, transitional support, and understanding maternal psychiatric symptoms among mothers of technology-dependent infants.

Parent perspectives on facilitating decision-making around pediatric home ventilation

RATIONALE

Deciding about pediatric home ventilation is exceptionally challenging for parents. Understanding the decision-making needs of parents who made different choices for their children could inform clinician counseling that better supports parents' diverse values and goals.

OBJECTIVES

To determine how clinicians can meet the decisional needs of parents considering home ventilation using a balanced sample of families who chose for or against intervention.

METHODS

We conducted semi-structured interviews of parents who chose for or against home ventilation for their child within the previous 5 years. Parents were recruited from three academic centers across the United States. Interviews focused on parent-clinician communication during decision-making and how clinicians made the process easier or more difficult. Qualitative analysis was used to generate themes and identify key results.

RESULTS

Thirty-eight parents were interviewed; 20 chose for and 18 chose against home ventilation. Five themes described their perspectives on how clinicians can facilitate high-quality decision-making: demonstrating dedication to families, effectively managing the medical team, introducing the concept of home ventilation with intention, facilitating meaningful conversation about the treatment options, and supporting and respecting the family's decision.

CONCLUSIONS

High-quality decision-making around home ventilation depends on individual clinician actions and the complex operations of large academic settings. Strong working relationships with parents, collaborative alliances with colleagues, and appropriate delivery of key content can help meet the needs of parents considering invasive breathing supports for their children.

Experiences of Families with Adult Home Invasive Mechanical Ventilation Patients: A Meta-Synthesis

Adult home mechanical ventilation (HMV) represents a small but growing vulnerable population in the community. Caring for these patients exposes families to many positive and negative experiences. This study aimed to synthesize the existing qualitative research that examined family members' experiences of caring for adult patients using HMV. Medline, PubMed, CINAHL, Scopus, and Web of Science were searched for qualitative studies conducted with family caregivers of adult patients receiving HMV. Thematic synthesis was conducted to interpret the findings. The GRADE-CERQual approach was used to assess the level of confidence. After completion of the screening process, 11 studies were included. The main theme from the meta-synthesis was the Experience of changing as a person. Families' experiences were divided into three stages over time: (1) Mixed feelings, (2) Challenging, and (3) Continuity. Family experiences illustrate that teamwork with an interprofessional approach based on patient and family needs is required to deliver care, improve clinical outcomes, reduce adverse experiences, and increase family satisfaction.

Life with pediatric home ventilation: Expectations versus experience

OBJECTIVES

To explore the family experience of home ventilation through a comparison of anticipated home life changes with subsequent experiences.

STUDY DESIGN

Guided interviews with parents across three states who chose home ventilation for their child within the last 5 years.

PATIENT-SUBJECT SELECTION

Purposive sampling of parents who chose home ventilation for their child within the last 5 years.

METHODS

Interviews were transcribed for qualitative analysis and analyzed for thematic saturation and prevalence of codes.

RESULTS

Twenty families were interviewed. Families generally reported not considering potential home life changes when facing the decision about home ventilation; instead, they worried most about medical management. These concerns reversed in importance later. Families learned medical management quickly but felt largely unprepared for the extensive changes to their home life, including isolation, altered relationships with extended family and community, effects on siblings, financial strain, and need for physical changes to their house. Families had not anticipated how much they would be affected by home healthcare as a new part of their life.

CONCLUSIONS

The priorities that families consider during decisions about pediatric home ventilation may not be aligned with the actual home experience of this technology. Given that the success of home ventilation largely rests with the family's care, family expectations for home life adaptations must be augmented, as should postdischarge supports for families with complex home care experiences.

"This Is How Hard It Is". Family Experience of Hospital-to-Home Transition with a Tracheostomy

Rationale: Expansion of chronic ventilation options and shared decision-making have contributed to an increasing population of technology-dependent children. One particularly vulnerable group is children with tracheostomy who depend on technology for basic respiratory functions. Chronic critical care is now provided in the homecare setting with implications for family caregivers.Objectives: This study explores the experience of family caregivers of children and young adults with a tracheostomy during the transition from hospital to home care. We sought to identify the specific unmet needs of families to direct future interventions.Methods: We recruited a convenience sample of families from an established home ventilation program to participate in semistructured interviews. Sessions were conducted in person or via teleconference. A grounded-theory qualitative analysis was performed.Results: Between March 2017 and October 2018, we interviewed 13 individuals representing 12 families of children and/or young adults with tracheostomy. Patients ranged in age from 9 months to 28 years, had a tracheostomy for 8 months to 18 years, and represented a variety of underlying diagnoses. Five key themes emerged: 1) navigating home nursing; 2) care coordination and durable medical equipment (DME) impediments; 3) learning as a process; 4) managing emergencies; and 5) setting expectations.Conclusions: Our findings support the need for family-centered discharge processes including coordination of care and teaching focused on emergency preparedness.

Gaining Experience Over Time: The Family Caregivers' Perception of Patients with a Tracheostomy in Home Care

Background

The transition of tracheostomy patients to the home poses many challenges for both the patient and the family. Identifying and understanding the experiences of family caregivers pave the road for discovering and meeting care needs. This study has been aimed to explain the experiences of family caregivers of patients with a tracheostomy about patient care at home.

Materials and Methods

This qualitative study was conducted using a conventional content analysis approach from September 2018 to January 2019. Participants included nine family caregivers and one professional caregiver who were selected through purposive sampling method. The in-depth interviews were conducted at home or in health centers using field notes. Data were recorded manually and analyzed using the five-step method proposed by Granehim and Lundman.

Results

The data led to the emergence of 1591 initial codes, 23 subcategories, and 6 categories. Categories include the need for training, the need for receiving care support, care challenges, care burden, gaining experience, hope, and inner satisfaction.

Conclusions

In this study, the family caregivers faced with lots of challenges in caring patients with tracheostomy so that they were in needs of training and support from professionals. Although they got skillful in care and endure burden, they were so hopeful and satisfied with their attempts. Hence, there is a need for official nongovernmental organizations with the aim of maintaining care and protecting their families.

Family Experiences Deciding For and Against Pediatric Home Ventilation

OBJECTIVE

To understand what considerations drive family decisions for, and against, pediatric home ventilation.

STUDY DESIGN

Qualitative interviews with parents of children who faced a decision about home ventilation in the previous 5 years at 3 geographically dispersed institutions.

RESULTS

In total, 38 families (42 parents) were interviewed; 20 families opted for pediatric home ventilation, and 18 families opted against. Approximately one-quarter of children had isolated chronic lung disease; the remainder had medical complexity that was expected to remain static or decline. Parent perspectives about home ventilation generally reflected whether the child was early, or later, in their disease trajectory. Early on, parents often interpreted prognostic uncertainty as hope and saw home ventilation as a tool permitting time for improvement. For families of children later in their disease course, often already with home technology and home nursing, home ventilation held less possibility for meaningful improvement. Nearly all families experienced the decision as very emotionally distressing. Reflecting back, most families described feeling satisfied with whatever decision they made.

CONCLUSIONS

The 2 principal groups of families in our cohort-those with children whose respiratory insufficiency might improve, and those with children facing chronic decline-warrant targeted counseling approaches about initiating home ventilation. The distressing nature of this decision should be anticipated and family supports reinforced.

Identifying Caregiver Needs for Children With a Tracheostomy Living at Home

This study sought to understand caregiver needs of children with tracheostomies (CWT) living at home and inform development of standardized tracheostomy simulation training curricula. Long-term goals are decreasing hospital readmissions following tracheostomy placement and improving family experiences while implementing a medical home model. We recruited caregivers of CWT and conducted semistructured interviews, subsequently recorded, transcribed, and analyzed for emerging themes using NVivo. Demographic data were collected via quantitative surveys. Twenty-seven caregivers participated. Emerging themes included the following: (1) caregivers felt overwhelmed, sad, frightened when learning need for tracheostomy; (2) training described as adequate, but individualized training desired; (3) families felt prepared to go home, but transition was difficult; (4) home nursing care fraught with difficulty and yet essential for families of CWT. Families of CWT have specific needs related to discharge training, resources, support, and home nursing. Provider understanding of caregiver needs is essential for child well-being, patient-/family-centered care, and may improve health outcomes.

Parents' experiences of transition from hospital to home of a child with complex health needs: A systematic literature review

AIMS AND OBJECTIVES

To critically appraise primary research on the views and experiences of parents of children with complex health needs during the transition from hospital to home.

BACKGROUND

Children with complex health needs frequently transition across and within healthcare systems, due to their age, care needs and ongoing health conditions. Repeated and unplanned admissions are significantly higher for children with complex health needs. Yet parents, as the primary providers of care, report being unsupported and unprepared during the transition from hospital back to home due to poor communication, inadequate discharge planning and education, resulting in stress and anxiety within the home environment.

DESIGN

Systematic review following PRISMA guidelines.

METHODS

A systematic search was completed of the databases CINAHL, MEDLINE, PsycINFO, EMBASE and the Cochrane Library Review between January 2009 and September 2019. Data were extracted, categorised and analysed using a thematic analysis approach. An adapted CASP qualitative assessment tool was utilised for quality assessment. All included articles were marked for validity and relevance to current research with an overall score from 0-20.

RESULTS

A total of 13 studies of mixed quality were identified. CASP quality scores ranged from 13-18. Four themes emerged highlighting parents' experiences of the emotional processes, communication, coordination and support and resources when transitioning from hospital to home.

CONCLUSIONS

Hospital discharge and transition from hospital to home is a complicated and at times frustrating process for parents of children with complex health needs. Parents report being exhausted and stressed during this often-challenging period of adjustment which was perceived as a difficult and emotional process. There is a clear lack of support available for parents both from hospital and community services.

Holding Their Own and Being Resilient: Narratives of Parents over the First 12 Months of Their Child Having Tracheostomy

Caring for a child with a tracheostomy can be challenging for parents and learning to safely manage their child's airway can be frightening due to their child's breathing issues, complex diagnosis and the difficult decisions they have to make. The aim of this longitudinal narrative study was to tell the stories of parents whose child had a new tracheostomy. Twenty three narrative interviews were conducted with twelve parents from nine families at three time points over a 12 month period. Data were analyzed using a socio-narratological approach. The stories told how parents were able to 'hold their own' despite experiencing shock, emotional upheaval and uncertainty during the period of their child's surgery. 'Holding their own' was possible for parents because resilience played an important part of their journey. Parents continued to be resilient as they adapted to being at home and dealt with ongoing challenging and stressful circumstances. All of the parents told stories reflecting on and recognizing that there were times when they exhibited higher levels of resilience and times when their resilience was lower. Looking back on their experiences parents appreciated that they reframed their initial often negative views about their child's need for a tracheostomy into more positive understandings and a future orientated perspective.

Nurse Practitioner-Led Telehealth to Improve Outpatient Pediatric Tracheostomy Management in South Texas

INTRODUCTION

Pediatric tracheostomy patients are a medically complex population with increased incidence of emergency room use, hospital readmission, tracheostomy-associated complications, and caregiver anxiety, especially within 30 days after discharge.

METHOD

The specific aims of this quality improvement initiative include using a nurse-led, interprofessional care team to improve access to care with creation and implementation of a hospital-based discharge protocol and adoption of telehealth follow-up care for newly placed tracheostomy tubes.

RESULTS

Telehealth was accessible for patients living more than 150 miles from the primary clinical site. Caregiver knowledge, satisfaction, self-efficacy, and competence in tracheostomy skills increased after protocol implementation. Outcomes included no tracheostomy-associated complications, emergency room visits, or unnecessary hospitalizations.

DISCUSSION

Evaluation of this initiative showed promise telehealth was effective in supporting caregivers and refining proficiency caring for tracheostomy-dependent children. This facility's experience with nurse-led telehealth found it to be an accessible, affordable, and valuable health-care service .

Pediatric tracheostomies in patients less than 2 years of age: Analysis of complications and long-term follow-up

PURPOSE

Identify variables that are predictive of morbidity and mortality in children under the age of two undergoing tracheostomy and to provide longitudinal data on this patient population.

METHODS

Patients were retrospectively identified using Current Procedural Terminology codes 31600, 31601, 31610 from 2009 to 2016.

RESULTS

Median age at time of tracheostomy was 0.43 years (interquartile range, 0.27-0.61). Patients were followed for a median of 1.39 years (range 0.03-4.25). Overall mortality rate in this cohort was 23.5% with the majority (81.3%) of deaths occurring >30 days following tracheostomy. The most frequently encountered major complication was cardiopulmonary arrest (10.29%) in the short-term follow up period (<30 days) and accidental decannulation (32.81%) during long-term follow up (>30 days). Peristomal skin breakdown was less likely to develop in patients who did not receive paralytics following tracheostomy. Most patients (54.4%) were discharged to home following initial admission and experienced a mean of 2.10 readmissions for any reason during the follow-up period. 64.4% of patients underwent surveillance direct laryngoscopy and bronchoscopy during the follow-up period and suprastomal granuloma formation was detected in 31.2% of these patients. 9 patients underwent decannulation at a median of 2 years from original tracheostomy placement.

CONCLUSION

Pediatric patients under the age of 2 undergoing tracheostomy exhibit high morbidity during both the initial hospital admission and the subsequent months following discharge. However, major complications were low and mortality was not directly related to tracheostomy status in any case.

Evaluation of a Multimodal Resuscitation Program and Comparison of Mouth-to-Mouth and Bag-Mask Ventilation by Relatives of Children With Chronic Diseases

OBJECTIVES

Children with chronic critical illness are at higher risk for cardiopulmonary arrests. Before chronically ill children are discharged from hospital, family members receive training in basic life support at many institutions. We evaluated whether a multimodal training program is able to teach adherence to current resuscitation guidelines and whether laypersons can be trained to perform both bag-mask ventilation and mouth-to-mouth ventilation equally effective in infants.

DESIGN

Prospective observational study.

SETTING

Pediatric critical care unit of a tertiary referral center.

SUBJECTS

Relatives of children with chronic illness prior to discharge from hospital.

INTERVENTIONS

Multimodal emergency and cardiopulmonary resuscitation training program.

MEASUREMENTS AND MAIN RESULTS

Following participation in our cardiopulmonary resuscitation training program 56 participants performed 112 simulated cardiopulmonary resuscitations (56 with mouth-to-mouth ventilation, 56 with bag-mask ventilation). Nearly all participants checked for consciousness and breathing. Shouting for help and activation of the emergency response system was only performed in half of the cases. There was almost full adherence to the resuscitation guidelines regarding number of chest compressions, chest compression rate, compression depth, full chest recoil, and duration of interruption of chest compression for rescue breaths. The comparison of mouth-to-mouth ventilation and bag-mask ventilation revealed no significant differences regarding the rate of successful ventilation (mouth-to-mouth ventilation: 77.1% ± 39.6%, bag-mask ventilation: 80.4% ± 38.0%; p = 0.39) and the cardiopulmonary resuscitation performance.

CONCLUSIONS

A standardized multimodal cardiopulmonary resuscitation training program for family members of chronically ill children is effective to teach good cardiopulmonary resuscitation performance and adherence to resuscitation guidelines. Laypersons could be successfully trained to equally perform mouth-to-mouth and bag-mask ventilation technique.

Disparities and ethical considerations for children with tracheostomies during the COVID-19 pandemic

The COVID-19 pandemic is exacerbating longstanding challenges facing children with tracheostomies and their families. Myriad ethical concerns arising in the long-term care of children with tracheostomies during the COVID-19 pandemic revolve around inadequate access to care, healthcare resources, and rehabilitation services. Marginalized communities such as those from Black and Hispanic origins face disproportionate chronic illness because of racial and other underlying disparities. In this paper, we describe how these disparities also present challenges to children who are technology-dependent, such as those with tracheostomies and discuss the emerging ethical discourse regarding healthcare and resource access for this population during the pandemic.

Children's and adolescents' experiences of living with respiratory assistance: A systematic review of qualitative studies

OBJECTIVES

To date, no review has focused exclusively on the child's reported experience of living with respiratory assistance. The objective of this study was to review empirical studies exploring children's experiences and perceptions of living with respiratory assistance.

METHODS

Literature searches (1980-2017) of databases (PubMed, Web of Science, PsycINFO and CINAHL) resulted in 1,750 references. Studies were included if they used qualitative methods to explore children's (under 18 years) experiences of living with respiratory assistance, such as tracheostomies and/or those who were ventilator dependent. Studies that focused only on parents, carers or other family member's perspectives, included only adults, used only quantitative methods or were not published in the English language were excluded. Reference lists of relevant studies were reviewed. Each study meeting criteria was reviewed and assessed and key themes were extracted and grouped.

RESULTS

Seven studies were included in this review. Synthesis of the data identified four main themes: children's understanding of respiratory assistance, identity, social experiences and service delivery. Most children recognised the important function of respiratory assistance on their physical health. They spoke of positive social experiences and some of the challenges they had experienced. Children discussed their experiences of healthcare providers in terms of what was helpful to them and provided suggestions, based on their experience, for future service provision.

CONCLUSION

This review identified the valuable contribution children's perspectives make to the growing evidence-base in this area. Further in-depth explorations are needed to provide greater understanding about children's experiences of living with respiratory assistance. Research exploring the journey of a young person with respiratory assistance is important in developing knowledge and service provision in this field.

Boot Camp for Caregivers of Children With Medically Complex Conditions

BACKGROUND

The safe transition of children with complex medical conditions who are dependent on technology from hospital to home requires that caregivers receive specialized training from qualified health care professionals. Inadequate caregiver training can lead to discharge delays and hospital readmissions, often resulting in caregiver distress.

OBJECTIVE

To determine the effectiveness of a structured boot camp-style predischarge training program for caregivers of pediatric patients with complex medical conditions.

METHODS

We conducted a quasi-experimental interventional study to compare outcomes before and after implementation of the training program, which involved 34 caregivers. Pre-boot camp data were collected retrospectively from the medical records of 34 control patients.

RESULTS

After program implementation, statistically significant decreases were found in mean unit length of stay (92 vs 60 days; P = .02), mean discharge training days (60 vs 16 days; P < .001), and median total parental stress score, expressed as a percentile (49 vs 45; P < .001). More than 90% of caregiver participants were very satisfied with the program. On the basis of minimal length of stay limits, cost savings were estimated at between $53 300 and $69 900 per patient.

CONCLUSION

The results of this study indicate that the training program is a valuable tool to track and verify caregiver education, reduce hospital length of stay, increase caregiver satisfaction, decrease caregiver stress, and reduce medical costs.

Mothers' Voices Related to Caregiving: The Transition of a Technology-Dependent Infant from the NICU to Home

PURPOSE

The transition from the NICU to home is a complicated, challenging process for mothers of infants dependent on lifesaving medical technology, such as feeding tubes, supplemental oxygen, tracheostomies, and mechanical ventilation. The study purpose was to explore how these mothers perceive their transition experiences just prior to and during the first three months after initial NICU discharge.

DESIGN

A qualitative, descriptive, longitudinal design was employed.

SAMPLE

Nineteen mothers of infants dependent on lifesaving technology were recruited from a large Midwest NICU.

MAIN OUTCOME VARIABLE

Description of mothers' transition experience.

RESULTS

Three themes were identified pretransition: negative emotions, positive cognitive-behavioral efforts, and preparation for life at home. Two posttransition themes were negative and positive transition experiences. Throughout the transition, the mothers expressed heightened anxiety, fear, and stress about life-threatening situations that did not abate over time despite the discharge education received.

A Descriptive Qualitative Study of Home Care Experiences in Parents of Children with Tracheostomies

PURPOSE

The number of pediatric patients who require a long-term tracheal tube at home is gradually increasing. Studies have demonstrated that the parents of these children report high levels of stress, anxiety and other negative emotions as early as shortly after discharge from the hospital. The purpose of this study is to describe the home care experiences of parents of children with tracheostomies during the transition from hospital to home in China to more effectively address their needs.

DESIGN AND METHODS

This study used a qualitative descriptive design and face-to-face interviews with semi-structured questions to learn about the home care experiences of parents whose children had undergone a tracheostomy.

RESULTS

Thirteen parents were recruited from the otorhinolaryngology outpatient ward of Xinhua Hospital in Shanghai, China. These parents described three categories of home care experiences: "direct care overload," "psychological overload," and "personal growth." Subcategories included parental "role change," "from helplessness to skillfulness," "lack of professional support," "anxiety and depression," and "social isolation." They also reported personal growth, which was mainly reflected by "changing their perspectives" and "developing potential."

CONCLUSION

Although the findings of this study indicate that the physical and psychological overload reported by parents of children with tracheostomies during home care is inevitable, a better understanding of parents' caring experiences among professionals may facilitate clinical practice and promote continued community nursing care in China.

PRACTICE IMPLICATIONS

Parents hope to receive systematic education during hospitalization, including web-based video education for skills training after discharge. In addition, parents desire public recognition so that they can participate in normal family and community activities.

Identifying Opportunities to Provide Family-centered Care for Families With Children With Type 1 Spinal Muscular Atrophy

STUDY PURPOSE

The purpose of this qualitative study was to understand, from the parent perspective, the experience of the family whose child has Type 1 spinal muscular atrophy (Type 1 SMA), in the emergency center, hospital, and clinical care settings to identify opportunities for improved family-centered care (FCC).

DESIGN AND METHODS

This study used a qualitative descriptive design with individual or small group interviews guided by a semi-structured questionnaire. Reviewers used framework analysis to identify gaps in the provision of FCC and opportunities for improvement with respect to services health professionals may provide families of children with Type 1 SMA.

RESULTS

Nineteen families with 22 children with Type 1 SMA participated. Results are organized according to eight basic tenets of FCC. Family-to-family interactions strongly impacted participants' decision-making and perceived level of support. Participants valued strong family/provider partnerships, feeling heard and respected by their providers, and receiving complete education regarding disease trajectory.

CONCLUSIONS

Our analyses revealed both successful application of FCC and gaps in care where FCC could have been used to benefit families who have children with Type 1 SMA. As a pediatric chronic illness affects the whole family, FCC is important in maintaining the providers' focus on the family during the child's care.

PRACTICE IMPLICATIONS

There are opportunities for nursing, social work, care managers and others to engage as care coordinators to explain the family's goals and values to the medical team. Care coordinators help ensure understanding between families and providers, empowering the family to articulate their hopes and concerns.

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 quality study of family-centered care coordination to improve care for children undergoing tracheostomy and the quality of life for their caregivers

IMPORTANCE

Approximately 4000 U.S. children undergo tracheostomy yearly [1], and these surgeries often result in hospital re-admissions that have definite cost and caregiver burdens due to complications that are avoidable with proper training and support.

OBJECTIVE

To assess the impact of a Family-Centered Care Coordination (FCCC) program on the quality of care received by children undergoing tracheostomy and their caregivers.

DESIGN

Caregivers of children undergoing tracheostomies from January 2012 to January 2013 and then a different set of caregivers of children undergoing tracheostomies from January 2015 to January 2016 completed both the Pediatric Tracheostomy Health Status Instrument (PTHSI) 1 month after discharge and the Medical Complications Associated with Pediatric Tracheostomy (MCAT) questionnaire 6 months after initial tracheostomy. To assess complication rates, these same sets of caregivers were asked to complete the MCAT and only those who provided complete medical data for all 6 months were included for comparative analysis.

SETTING

The PTHSI and MCAT were administered at Massachusetts Eye and Ear in a hospital setting.

PARTICIPANTS

Ten caregivers of children undergoing tracheostomies completed the PTHSI before FCCC program implementation and12 caregivers then completed the PTHSI after FCCC implementation. For each of the 2 groups, 5 caregivers provided complete data on the MCAT questionnaires.

EXPOSURES

FCCC is a collection of programs, policies, and tools designed to ensure safe transition home for children undergoing tracheostomies, reduce re-admission rates, and minimize "caregiver burden".

MAIN OUTCOMES AND MEASURES

The PTHSI is a validated caregiver quality of life instrument that was supplemented by the MCAT which records post-discharge medical issues following tracheostomy that relate specifically to the tracheotomy placement.

RESULTS

The time to first follow-up appointment decreased from 6.4 weeks (SD = 1.52) to 6 days (SD = 0.18) with FCCC implementation. The total MCAT scores decreased from 15.2 (SD = 1.1) to 1.3 (SD = 1.3) (Wilcoxon sum rank test: P < 0.016) whereas neither PTHSI scores (P = 0.32) nor the specific caregiver burden domain (P = 0.18) demonstrated a significant change.

CONCLUSIONS

and Relevance: By reducing the time to first follow-up after tracheostomy and by optimizing caregiver tracheostomy tube care and teaching, children's quality of care and caregiver burden can be significantly improved.