The technology-dependent child

Efficacy of standardized tracheostomy training with a simulation model for healthcare providers: A study by ISPAT team

INTRODUCTION

Tracheostomy care in children may be challenging, due to lack of knowledge of healthcare providers (HCPs). The aim of this study was to determine the level of knowledge of HCP who follow patients with tracheostomy and to increase this level with theoretical training and training in a simulation laboratory.

MATERIALS AND METHODS

ISPAT (IStanbul PAediatric Tracheostomy), a multidisciplinary team for tracheostomy care was established and a training program was prepared. Participants were subjected to theoretical and practical pretests which evaluated their knowledge levels and skills for care, follow-up, and treatment of a patient with tracheostomy. After the theoretical and practical training given to the participants with a simulation model, theoretical and practical posttests were applied.

RESULTS

Fifty-one HCP from nine tertiary pediatric clinics in Istanbul were enrolled in the training program. Only six (11.8%) of them had received standardized training programs previously. Regarding the theoretical tests, seven of the 33 questions were indicated as essential. The knowledge level of the participants based on the essential questions significantly increased after the training (p < 0.05 for all of the essential questions). The total number of correct answers and correct answers of three subheadings also significantly increased after the practical training (p < 0.001 for all). Ninety-five percent of the participants assessed the course as good or excellent in general.

CONCLUSION

Training in a simulation laboratory in combination with theoretical education can improve the knowledge and skills of the HCP enabling improved care of children with a tracheostomy.

Feasibility of long-term home noninvasive ventilation program in a general pediatric unit: 21 years' experience in Hong Kong

BACKGROUND

Long-term home noninvasive ventilation (NIV) is increasingly employed in children with sleep-disordered breathing and chronic respiratory failure. While studies suggest its successful implementation in tertiary care centers, little is known about the situation in a general care setting. Hence, we aim to evaluate the clinical profiles of these children in a general pediatric unit over the past two decades.

METHODS

Data collected retrospectively on patients younger than 18 years old receiving long-term home NIV from January 1, 1997 to December 31, 2017 in a Hong Kong regional general pediatric unit were reviewed.

RESULTS

The number of children on home NIV increased more than 10-fold over the past two decades. In total, 114 children were commenced on NIV during the 21-year period. Upper airway obstruction was the most common cause (77%), followed by neuromuscular diseases (16%), pulmonary disorders (4%), and abnormal ventilatory control (3%). Continuous positive airway pressure was the most common NIV type (59%). To date, 46% of the children remained in our NIV program, while 18% discontinued NIV support. NIV adherence increased significantly with follow-up (median of 78.6% and 82.5% at baseline and last follow-up, respectively). Sixty-five percent of the children used NIV for at least 4 h on 70% of the days monitored. Higher body mass index was associated with lower adherence.

CONCLUSION

Pediatric home NIV is feasible in the general care setting with good outcomes and adherence. As the demand for NIV service grows, input from local hospitals will be of increasing importance and should be considered upon healthcare planning.

Evaluating the Use of a Stability Guideline for Long-Term Ventilator-Dependent Children Discharging to Home: A Quality Improvement Project

INTRODUCTION

Defining stability before discharge for children with severe chronic lung disease requiring home ventilation has historically been dependent on an individual provider's opinion.

METHODS

An institutional guideline based on expert opinion was used for patients who were first discharged home on mechanical ventilation. A retrospective review determined if the guideline was used. Electronic medical record changes were initiated to improve compliance with the guideline.

RESULTS

The retrospective review showed that the guideline is documented in less than one third of patients, and 36% of patients met the requirements of the guideline before discharge. Following these results, electronic medical record documentation was changed.

DISCUSSION

Results showed a low utilization rate for the discharge home guideline for patients receiving long-term ventilation. Utilization of electronic medical record charting can improve the tracking of stability guidelines and provide the opportunity to further define stability in ventilator-dependent children.

Long-term ventilation in children: longitudinal trends and outcomes

BACKGROUND

Cross-sectional studies have suggested a rapid expansion in paediatric long-term ventilation (LTV) over the last 20 years but information on longitudinal trends is limited.

METHODS

Data were collected prospectively on all patients receiving LTV over a 15-year period (1.1.95-31.12.09) in a single regional referral centre.

RESULTS

144 children commenced LTV during the 15-year period. The incidence of LTV increased significantly over time, with an accompanying 10-fold increase in prevalence due to a significant increase in institution of non-invasive ventilation (NIV). There was no significant increase in invasive ventilation. 5-year survival was 94% overall and was significantly higher for patients on NIV (97%) than invasively ventilated patients (84%). 10-year survival was 91% overall. Although some children were able to discontinue respiratory support (21% at 5 years and 42% at 10 years), the number of patients transitioned to adult services increased significantly over time (26% of total cohort). Patients with neuromuscular disease were less likely to discontinue support than other patients.

CONCLUSIONS

The paediatric LTV population has expanded significantly over 15 years. Future planning of paediatric hospital and community services, as well as adult services, must take into account the needs of this growing population.

Saúde da família e cuidados paliativos infantis: ouvindo os familiares de crianças dependentes de tecnologia

O estudo discute um modelo de cuidados paliativos infantis baseado na Saúde da Família quando da assistência domiciliar, articulado com os demais níveis de atenção e nas demandas das famílias. Participaram do estudo dezoito membros de nove famílias de crianças do Instituto Fernandes Figueira (IFF), das quais quatro estão assistidas pelo Programa de Assistência Domiciliar Interdisciplinar (PADI), três internadas aguardando a inclusão no programa e duas internadas e já pertencentes ao PADI. O PADI foi estudado por ser o único que oferece cuidados paliativos infantis na rede pública de saúde. Os resultados demonstram-se positivos quanto ao vínculo estabelecido com a equipe, ao acolhimento, ao conhecimento pelos familiares acerca da doença e à dinâmica entre o PADI e o IFF. Como pontos negativos aparecem as dificuldades, que vão desde a implantação do programa até sua continuidade; quase todos os familiares referem agravos ou doenças. Concluiu-se, que apesar de o PADI se apresentar como a forma encontrada pelo IFF para a desospitalização, os cuidados domiciliares pela Saúde da Família, bem articulado com a rede, seriam o ideal por se tratar do nível de assistência adequado para tal.

Saúde da família e cuidados paliativos infantis: ouvindo os familiares de crianças dependentes de tecnologia

O estudo discute um modelo de cuidados paliativos infantis baseado na Saúde da Família quando da assistência domiciliar, articulado com os demais níveis de atenção e nas demandas das famílias. Participaram do estudo dezoito membros de nove famílias de crianças do Instituto Fernandes Figueira (IFF), das quais quatro estão assistidas pelo Programa de Assistência Domiciliar Interdisciplinar (PADI), três internadas aguardando a inclusão no programa e duas internadas e já pertencentes ao PADI. O PADI foi estudado por ser o único que oferece cuidados paliativos infantis na rede pública de saúde. Os resultados demonstram-se positivos quanto ao vínculo estabelecido com a equipe; o acolhimento; o conhecimento pelos familiares acerca da doença e a dinâmica entre o PADI e o IFF. Como pontos negativos, aparecem as dificuldades, que vão desde a implantação do programa até sua continuidade e que quase todos os familiares referem agravos ou doenças. Concluiu-se que, apesar do PADI se apresentar como a forma encontrada pelo IFF para a desospitalização, os cuidados domiciliares pela Saúde da Família, bem articulados com a rede, seria o ideal por ser o nível de assistência adequado para tal.

Weaning children from mechanical ventilation in a post-acute care setting

As medical and technological advances have made it possible to prolong the life of children with chronic respiratory failure, children are being referred to post-acute inpatient rehabilitation programmes. In these settings, children can be weaned from their ventilators and receive medical and rehabilitative care in a developmentally supportive environment at a lower financial cost than in an intensive care unit. There is strong evidence that weaning children from mechanical ventilation has beneficial effects on their functionality, ease of care and quality of life. There is, however, little scientific evidence describing how often successful weaning is achieved or the most effective methods. The purpose of this article is to present a consensus report detailing a structured approach to weaning children from mechanical ventilation in a post-acute care setting. This study proposes a Weaning Severity Index and a Weaning Algorithm for use in the assessment and implementation of the weaning process in post-acute rehabilitation. Future clinical studies are needed to validate the suggested approach to ventilator weaning and to determine whether or not the weaning algorithm results in beneficial patient outcomes.

The Integration of Children Dependent on Medical Technology Into Public Schools

Advances in medicine have increased the survival rates of children with complex medical conditions, including those who are dependent on technology such as ventilators and tracheostomies. The process of integrating children dependent on medical technology into public schools requires the collaboration of a multidisciplinary team to ensure that both their educational and health care needs are met. As coordinator of the school health program, the school nurse plays a vital role throughout the integration process and during the time the student is enrolled in the school. This article presents a case study that demonstrates the steps in the integration process, the roles of the team members, and implications for school nursing practice.

Home mechanical ventilation in children: retrospective survey of a pediatric population

BACKGROUND

Home care support is beneficial for children needing mechanical ventilation, when clinically stable.

METHODS

A retrospective analysis was carried out of the long-term home ventilation management of a pediatric population with chronic respiratory failure composed of 20 ventilator-dependent children categorized according to age, diagnosis and ventilation support. Age groups consisted of 10% under 1 year, 30% between 2 and 5 years, 30% between 6 and 12 years, and 30% older than 12 years. Diagnostic categories included myopathic disorder, n = 5; congenital central hypoventilation syndrome, n = 6; chest wall disorder, n = 5; cystic fibrosis, n = 1; pulmonary hypertension, n = 1; and diaphragmatic paralysis, n = 2.

RESULTS

Sixty-five percent were ventilated using non-invasive mode (NIMV): eight with nasal mask, five with full-face mask, and two children in NIMV also used negative pressure mode; 35% were ventilated using tracheostomy, one of them also used a diaphragmatic pacer. Seventy percent needed nocturnal ventilatory support, (20% 12-18 h, 10% full-day). A total of 18 children were included in the home care and follow-up program. Two children died: one because of worsening of his chronic disease and one because of septic shock.

CONCLUSION

Although home care ventilation is not yet widely diffused, it represents a valid alternative to long hospitalization for children with stable chronic respiratory failure.

A família da Criança Dependente de Tecnologia: aspectos fundamentais para a prática de enfermagem no ambiente hospitalar

O objetivo deste artigo é discutir as mudanças significativas que ocorrem no interior da organização das famílias em função do cuidado da criança dependente de tecnologia (CDT). Realizamos um estudo com abordagem qualitativa, utilizando, como instrumento para coleta de dados, a entrevista semi-estruturada. Os sujeitos da pesquisa foram quatro famílias de CDTs. Delineamos quatro dimensões da mudança familiar: emocional, social, financeira e impacto nas atividades rotineiras. Verificamos que acontecem mudanças no interior das famílias que cuidam de uma CDT. Estas mudanças se apresentam de forma multidimensional. A complexidade do estado de saúde-doença associado à dependência tecnológica é um desafio para as organizações dos serviços e para a abordagem dos profissionais da área hospitalar. Torna-se necessário repensar o modo de atender centrado na doença e incluir a família no processo terapêutico. O estudo aponta a relevância de desenvolvermos modelos de cuidado centrado nas famílias aplicáveis ao cotidiano hospitalar.

Home care of the high-risk infant

Increasingly, infants are discharged from the neonatal intensive care unit (NICU) with unresolved healthcare issues and ongoing technology needs. A well-planned discharge of a medically stable infant is important to assure safe and effective care in the home and to minimize avoidable hospital readmissions. This article addresses the discharge of and home care options for 3 groups of infants who have traditionally been cared for in the hospital. These include infants requiring palliative care, infants who are technology dependent, and those stable premature infants requiring intensive home support. Intermittent and continuous home nursing care options are defined, and the goals of home care nursing are outlined. The importance of objective discharge criteria and medical stability is discussed along with practical tips and strategies to assure success. A teaching tool to assist parents in choosing a home care provider is included.

Economic and psychologic costs for maternal caregivers of gastrostomy-dependent children

OBJECTIVE

To examine the economic and psychologic costs of care provided by maternal caregivers to children with gastrostomy tube (GT) feedings.

STUDY DESIGN

We conducted a 3-site study of primary maternal caregivers of 101 chronically ill children, with (n = 50) and without (n = 51) enteral nutrition support by GT to determine the time spent providing technical care, nontechnical care, and health care management and to assess depressive mood and quality of life. Associated costs were determined.

RESULTS

Caregivers spent 339.7 +/- 34.1 (SEM) min/d to provide all care. Children with a GT required more than twice as much care time as children without a GT: 484.5 +/- 54.6 versus 197.8 +/- 30.6 min/d ( P < .0001). The mean annual total value of home care by the primary caregiver for a child with a GT was 37,232 dollars, compared with 15,004 dollars for the child without a GT. Caregivers of children with GT were no more depressed or less satisfied with their lives than caregivers of children without GT.

CONCLUSIONS

Use of a GT for enteral nutrition support is associated with significant increased care time by the primary caregiver but not at additional psychologic cost compared with caring for chronically ill children.

Nurse-parent dialogue: illuminating the evolving pattern of families with children who are medically fragile

Guided by Newman's theory of health as expanding consciousness, this study explored the pattern of nurse-parent interaction in families with children who were medically fragile by applying the hermeneutic, dialectic method of interviewing and analysis. Living with children who are medically fragile was manifested by continual uncertainity. Families changed from trying to gain control of their uncertainty to learning to live in the uncertainty, as they evolved through an initial p[eriod of disruption and disorganization to organization at another level. This required new ways of relating to friends, family, healthcare providers, and the community, expanding the consciousness of the family.

Creating a context of safety and achievement at school for children who are medically fragile/technology dependent

Parents, nurses, and educators collaborate closely to create school environments that are safe and productive for children who are medically fragile/technology dependent. This article reports the results of a field study conducted in schools and family homes with the significant adults who care for and facilitate school participation for children who are medically fragile/technology dependent. Key steps in this process included learning about rights and responsibilities, planning for children's individual needs, being persistent in the face of systemic barriers, and taking actions to protect both children and professionals from perceived threats.