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Torrent-Vernetta A, Soriano MM, Iglesias Serrano I, Izquierdo AD, Rovira Amigo S, Messa IM, Gartner S, Moreno-Galdó A. Arrangement of residence before hospital discharge for children on home-invasive mechanical ventilation. Pediatr Pulmonol 2024; 59:2080-2088. [PMID: 37983751 DOI: 10.1002/ppul.26758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
Children on long-term home mechanical ventilation are a growing population due to clinical and technological advances and the benefit for the child's quality of life. Invasive home ventilation is one of the most complex therapies offered in the home setting, requiring adequate home environment and appropriate equipment and supplies before discharge. The transition from hospital to home represents a vulnerable period that can be facilitated with an established transition plan with multidisciplinary team involvement. Readiness for home care is achieved when the patient is stable and has been transitioned from a critical care ventilator to a home mechanical ventilator. In parallel, comprehensive competency-based training regarding the knowledge and skills needed to help families use the equipment confidently and safely. Before discharge, families should be counseled on an adequate home environment to ensure a safe transition. The residence arrangement may include physical space modifications, verifying electrical installation, or moving to another home. Durable medical equipment and supplies must be ordered, and community healthcare support arranged. Parents should receive practical advice on setting up the equipment at home and on preventive measures to minimize complications related to tracheostomy and ventilator dependence, including regular maintenance and replacement of necessary equipment. Given the overall impact of invasive ventilation on home life, a structured home care action package is essential to alleviate the burdens involved.
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Affiliation(s)
- Alba Torrent-Vernetta
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Growth and Development, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Majadahonda, Spain
| | - Maria Morillo Soriano
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ignacio Iglesias Serrano
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Growth and Development, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ana Díez Izquierdo
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Growth and Development, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Sandra Rovira Amigo
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Growth and Development, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Majadahonda, Spain
| | - Inés Mir Messa
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Growth and Development, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Silvia Gartner
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Growth and Development, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Antonio Moreno-Galdó
- Pediatric Allergy and Pulmonology Section, Department of Pediatrics, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Growth and Development, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Center for Biomedical Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Majadahonda, Spain
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2
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Zampoli M, Booth J, Gray DM, Vanker A. Home ventilation in low resource settings: Learning to do more, with less. Pediatr Pulmonol 2024; 59:2180-2189. [PMID: 38050799 DOI: 10.1002/ppul.26802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 12/06/2023]
Abstract
Long-term ventilation (LTV) in children at home, especially invasive ventilation, is not widely available nor practised in low-resource settings (LRS). Barriers to providing LTV include underdeveloped pediatric critical care services, limited expertise in pediatric LTV, limited capacity to screen for sleep-disordered breathing (SDB) and high cost of LTV equipment and consumables. Additional challenges encountered in LRS may be unreliable electricity supply and difficult socioeconomic conditions. Where LTV at home has been successfully implemented, caregivers and families in LRS must often take full responsibility for their child's care as professional home-based nursing care is scarce. Selecting suitable children and families to offer LTV in LRS may therefore face difficult ethical decisions when families are disempowered or incapable of providing 24-h care at home. Early caregiver participation and hands-on training in tracheostomy care and LTV equipment is key to success, irrespective of the caregiver's level of education. The use of overnight oximetry, mobile phone technology, spirometry, and clinical evaluation are simple tools that can aid recognition and monitoring of children needing LTV. As children survive longer supported by LTV, engaging with adult services at an early stage is important to ensure suitable pathways for transition to adult care are in place. Building capacity and expertise in pediatric LTV in LRS requires targeted training of health professionals in related disciplines and advocacy to policymakers and funders that LTV in appropriately selected circumstances is worthwhile, life-changing, and cost-saving.
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Affiliation(s)
- Marco Zampoli
- Department of Pediatrics and Child Health, Division of Pediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Jane Booth
- Department of Pediatrics and Child Health, The Harry Crossley Children's Nursing Development Unit, University of Cape Town, Cape Town, South Africa
| | - Diane M Gray
- Department of Pediatrics and Child Health, Division of Pediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Aneesa Vanker
- Department of Pediatrics and Child Health, Division of Pediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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3
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Villarroel-Silva G, Jalil YF, Moya-Gallardo E, Oyarzún IJ, Moscoso GA, Astudillo Maggio C, Damiani LF. Effects of the First Spontaneous Breathing Trial in Children With Tracheostomy and Long-Term Mechanical Ventilation. Respir Care 2023; 68:1385-1392. [PMID: 37311627 PMCID: PMC10506639 DOI: 10.4187/respcare.10544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Weaning and liberation from mechanical ventilation in pediatric patients with tracheostomy and long-term mechanical ventilation constitute a challenging process due to diagnosis heterogeneity and significant variability in the clinical condition. We aimed to evaluate the physiological response during the first attempt of a spontaneous breathing trial (SBT) and to compare variables in subjects who failed or passed the SBT. METHODS This was a prospective observational study in tracheostomized children with long-term mechanical ventilation admitted to the Hospital Josefina Martinez, Santiago, Chile, between 2014-2020. Cardiorespiratory variables such as breathing pattern, use of accessory respiratory muscles, heart rate, breathing frequency, and oxygen saturation were registered at baseline and throughout a 2-h SBT with or without positive pressure depending on an SBT protocol. Comparison of demographic and ventilatory variables between groups (SBT failure and success) was performed. RESULTS A total of 48 subjects were analyzed (median [IQR] age of 20.5 [17.0-35.0] months, 60% male). Chronic lung disease was the primary diagnosis in 60% of subjects. Eleven (23%) total subjects failed the SBT (< 2 h), with an average failure time of 69 ± 29 min. Subjects who failed the SBT had a significantly higher breathing frequency, heart rate, and end-tidal CO2 than subjects who succeeded (P < .001). In addition, subjects who failed the SBT had significantly shorter duration of mechanical ventilation before the SBT, higher proportion unassisted SBT, and higher rate of deviation SBT protocol in comparison with subjects who succeeded. CONCLUSIONS Conducting an SBT to evaluate the tolerance and cardiorespiratory response in tracheostomized children with long-term mechanical ventilation is feasible. Time on mechanical ventilation before the first attempt and type of SBT (with or without positive pressure) could be associated with SBT failure.
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Affiliation(s)
- Gregory Villarroel-Silva
- Hospital Josefina Martínez, Santiago, Chile; and Programa de Doctorado Salud, Bienestar y Bioética, Blanquerna, Universidad Ramon Llull, Facultad de Ciencias de la Salud, Barcelona, España.
| | - Yorschua F Jalil
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; and Programa de Doctorado Ciencias Médicas, Pontificia Universidad Católica de Chile, Escuela de Medicina, Santiago, Chile
| | - Eduardo Moya-Gallardo
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ignacio J Oyarzún
- Hospital Josefina Martínez, Santiago, Chile; and Departamento de Cardiología y Enfermedades Respiratorias Pediátricas, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gonzalo A Moscoso
- Hospital Josefina Martínez, Santiago, Chile; and Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Astudillo Maggio
- Hospital Josefina Martínez, Santiago, Chile; and Departamento de Cardiología y Enfermedades Respiratorias Pediátricas, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - L Felipe Damiani
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; and Cardiorespiratory Research Laboratory, Departamento Ciencias de la Salud, Pontificia Universidad Católica de Chile, Santiago, Chile
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4
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McKinney RL, Agarwal A. Transition from intensive care unit to a portable ventilator in children with severe bronchopulmonary dysplasia. Pediatr Pulmonol 2023; 58:712-719. [PMID: 36510658 DOI: 10.1002/ppul.26274] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/09/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Abstract
As the population of ventilator-dependent children (VDC) with tracheostomies due to underlying severe bronchopulmonary dysplasia grows, there is an increasing need to shift the care of these children from hospital to home. Transitioning the ventilator-dependent child from the hospital to home is a complex process that requires coordination between the medical team and the family. One crucial step in the process is transitioning from an Intensive care unit (ICU) ventilator to a portable home ventilator (PHV). The Clinical team needs to understand the nuances in transitioning to PHV, including assessing readiness to transition and choosing the optimum settings on an available home ventilator. In recent years, various ventilator modes have been available in PHV that can help achieve synchronous breathing to allow for adequate gas exchange for the infant. This review details some approaches to asses readiness to transition and the process of Transition along with commonly used modes of support available in PHV, as well as the primary and secondary settings in which we should be mindful in supporting a child with chronic respiratory failure in the home setting.
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Affiliation(s)
- Robin L McKinney
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Amit Agarwal
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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5
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Caldarelli V, Porcaro F, Filippo PD, Attanasi M, Fainardi V, Gallucci M, Mazza A, Ullmann N, La Grutta S. Long-Term Ventilation in Children with Medical Complexity: A Challenging Issue. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1700. [PMID: 36360427 PMCID: PMC9688784 DOI: 10.3390/children9111700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/11/2022] [Accepted: 10/28/2022] [Indexed: 12/09/2023]
Abstract
Children with medical complexity (CMCs) represent a subgroup of children who may have congenital or acquired multisystemic disease. CMCs are frequently predisposed to respiratory problems and often require long-term mechanical ventilation (LTMV). The indications for LTMV in CMCs are increasing, but gathering evidence about indications, titration, and monitoring is currently the most difficult challenge due to the absence of validated data. The aim of this review was to examine the clinical indications and ethical considerations for the initiation, continuation, or withdrawal of LTMV among CMCs. The decision to initiate long-term ventilation should always be based on clinical and ethical considerations and should be shared with the parents.
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Affiliation(s)
- Valeria Caldarelli
- Department of Mother and Child, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Paola Di Filippo
- Department of Pediatrics, SS Annunziata Hospital, University of Chieti, 66100 Chieti, Italy
| | - Marina Attanasi
- Department of Pediatrics, SS Annunziata Hospital, University of Chieti, 66100 Chieti, Italy
| | - Valentina Fainardi
- Cystic Fibrosis Unit, Department of Paediatrics, Parma University Hospital, 43126 Parma, Italy
| | - Marcella Gallucci
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy
| | - Angelo Mazza
- Department of Pediatrics, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Nicola Ullmann
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Stefania La Grutta
- Institute of Traslational Pharmacology IFT, National Research Council, 90146 Palermo, Italy
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6
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Baker CD. Chronic respiratory failure in bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56:3490-3498. [PMID: 33666365 DOI: 10.1002/ppul.25360] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 11/09/2022]
Abstract
Although survival has improved dramatically for extremely preterm infants, those with the most severe forms of bronchopulmonary dysplasia (BPD) fail to improve in the neonatal period and go on to develop chronic respiratory failure. When careful weaning of respiratory support is not tolerated, the difficult decision of whether or not to pursue chronic ventilation via tracheostomy must be made. This requires shared decision-making with an interdisciplinary medical team and the child's family. Although they suffer from increased morbidity and mortality, the majority of these children will survive to tolerate ventilator liberation and tracheostomy decannulation. Care coordination for the technology-dependent preterm infant is complex, but there is a growing consensus that chronic ventilation can best support neurodevelopmental progress and improve long-term outcomes.
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Affiliation(s)
- Christopher D Baker
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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7
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Chiang J, Karim A, Hoffman A, Dryden-Palmer K, Keilty K, Syed F, Janevski J, Dutta T, Fellin M, Lindsay S, Beaune L, Amin R. Tough transitions: Family caregiver experiences with a pediatric long-term ventilation discharge pathway. Pediatr Pulmonol 2021; 56:3380-3388. [PMID: 34320689 DOI: 10.1002/ppul.25588] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/10/2021] [Accepted: 07/02/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Discharging a child home on long-term ventilation (LTV) via tracheostomy is complex and involves multiple healthcare providers across healthcare sectors. To date, there has been a paucity of data with respect to the experiences of families transitioning a child home on LTV. Our objective was to explore the perceptions of family caregivers (FCs) who have completed a newly developed LTV discharge pathway as they transitioned home. METHODS We conducted 11 semi-structured interviews with FCs. Interviews focused on FC's experience with the training process, perception of competency from a knowledge and skill perspective, and opportunities for improvement. Interviews were audiotaped, transcribed verbatim, coded, and analyzed using an inductive thematic analysis approach. RESULTS Eight mothers and three fathers of ten children participated. Six primary themes were identified: (1) making an informed decision, (2) transitioning to rehabilitation, (3) building capacity for self-care, (4) coordinating case management, (5) readying for discharge home, and (6) experiencing home care. CONCLUSION Overall, FCs felt that the preparation and transition support obtained through the application of a standardized LTV discharge pathway allowed successful attainment of new knowledge and skills necessary to care for their child with LTV at home.
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Affiliation(s)
- Jackie Chiang
- Hospital for Sick Children, Toronto, Ontario, Canada.,Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Allia Karim
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrea Hoffman
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Karen Dryden-Palmer
- Hospital for Sick Children, Toronto, Ontario, Canada.,SickKids Research Institute, Toronto, Ontario, Canada
| | - Krista Keilty
- Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Faiza Syed
- Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Tilak Dutta
- Toronto Rehabilitation Centre, Toronto, Ontario, Canada
| | - Maryanne Fellin
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Sally Lindsay
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Laura Beaune
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Reshma Amin
- Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,SickKids Research Institute, Toronto, Ontario, Canada
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8
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Özcan G, Zirek F, Tekin MN, Bakirarar B, Çobanoğlu N. Risk factors for first nonscheduled hospital admissions of pediatric patients on home mechanical ventilation. Pediatr Pulmonol 2021; 56:3374-3379. [PMID: 34297898 DOI: 10.1002/ppul.25581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The number of children on home mechanical ventilation (HMV) has increased. Understanding the reasons for nonscheduled hospital admissions during HMV is critical. This study aims to investigate the risk factors of first nonscheduled hospital admissions of pediatric patients on HMV. METHODS A retrospective analysis of patients on HMV between May 1, 2014 and October 1, 2020 was performed. Patients' demographic characteristics, duration of the education of the primary caregiver; time of first nonscheduled visit; and type of HMV (noninvasive mechanical ventilation [NIV] or invasive mechanical ventilation [IMV]) were analyzed. The reasons for first nonscheduled hospital visits were categorized as respiratory problems and other reasons. RESULTS Of 97 patients, 41 were female (42.3%), and 70 (72%) were on IMV. The median age was 23 months (IQR, 10-91). Twenty-nine patients (30%), were admitted to hospital before scheduled visit with a mean duration of 18.1 ± 11.6 days; of them, 14 (48.2%) admitted because of respiratory problems. IMV increases the risk of first nonscheduled visit compared to NIV (OR, 16.3; 95% CI, 2.1-127.4; p = .008). If a caregiver spends less than 14 days in hospital for education, risk of nonscheduled visits increases (OR, 4.0; 95% CI, 1.5-11.2; p = .007). CONCLUSION A minimum 14 days seems to be necessary for education of the caregivers of the patients with HMV to reduce the number of nonscheduled visits, which is a burden for both patients and healthcare system.
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Affiliation(s)
- Gizem Özcan
- Department of Pediatrics, Faculty of Medicine, Division of Pediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Fazılcan Zirek
- Department of Pediatrics, Faculty of Medicine, Division of Pediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Merve Nur Tekin
- Department of Pediatrics, Faculty of Medicine, Division of Pediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Batuhan Bakirarar
- Department of Biostatistics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Nazan Çobanoğlu
- Department of Pediatrics, Faculty of Medicine, Division of Pediatric Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
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9
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Discharge Practices for Children with Home Mechanical Ventilation across the United States. Key-Informant Perspectives. Ann Am Thorac Soc 2021; 17:1424-1430. [PMID: 32780599 DOI: 10.1513/annalsats.201912-875oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: In 2016, the American Thoracic Society released clinical practice guidelines for pediatric chronic home invasive ventilation pertaining to discharge practices and subsequent management for patients with invasive ventilation using a tracheostomy. It is not known to what extent current U.S. practices adhere to these recommendations.Objectives: Hospital discharge practices and home health services are not standardized for children with invasive home mechanical ventilation (HMV). We assessed discharge practices for U.S. children with HMV.Methods: A survey of key-informant U.S. clinical providers of children with HMV, identified with purposeful and snowball sampling, was conducted. Topics included medical stability, family caregiver training, and discharge guidelines. Close-ended responses were analyzed using descriptive statistics. Responses to open-ended questions were analyzed using open coding with iterative modification for major theme agreement.Results: Eighty-eight responses were received from 157 invitations. Eligible survey responses from 59 providers, representing 44 U.S. states, included 49.2% physicians, 37.3% nurses, 10.2% respiratory therapists, and 3.4% case managers. A minority, 22 (39%) reported that their institution had a standard definition of medical stability; the dominant theme was no ventilator changes 1-2 weeks before discharge. Nearly all respondents' institutions (94%) required that caregivers demonstrate independent care; the majority (78.4%) required two trained HMV caregivers. Three-fourths described codified discharge guidelines, including the use of a discharge checklist, assurance of home care, and caregiver training. Respondents described variable difficulty with obtaining durable medical equipment, either because of insurance or durable-medical-equipment company barriers.Conclusions: This national U.S. survey of providers for HMV highlights heterogeneity in practice realities of discharging pediatric patients with HMV. Although no consensus exists, defining medical stability as no ventilator changes 1-2 weeks before discharge was common, as was having an institutional requirement for training two caregivers. Identification of factors driving heterogeneity, data to inform standards, and barriers to implementation are needed to improve outcomes.
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10
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Attar MA, Pace RA, Schumacher RE. Back Transfer of Infants with Tracheostomies: A Regional Center Experience. J Pediatr Intensive Care 2021; 12:118-124. [PMID: 37082470 PMCID: PMC10113006 DOI: 10.1055/s-0041-1730929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractWe describe our center's experience with the back transfer of infants following tracheostomies. We conducted a retrospective cohort study of infants transferred to pediatric critical care units of our regional center with conditions originating in the neonatal period who underwent tracheostomy during the hospitalization within their first year of life between 2006 and 2017. Recovering patients are discharged home or transferred back to the referring hospitals. We evaluated patient characteristics, destination of discharge and type of pulmonary support at discharge, and mechanical ventilation (MV) or tracheotomy masks (TM). Of the 139 included patients, 72% were transferred to the neonatal intensive care unit, 21% to the pediatric cardiothoracic unit, and 7% to the pediatric intensive care unit. Their median gestational age was 35 weeks. They were admitted at a median 22 days of life and lived at a median distance of 56 miles from our center. Furthermore, 34 infants (24%) were back transferred closer to their homes (23 with MV and 11 with TM), and 84 (60%) were discharged home (53 on MV and 31 on TM). Twenty-one patients (15%) died in the hospital (before discharge or transfer). Back transferred patients on MV had a significantly shorter duration between tracheostomy and transfer compared with those discharged home from our center: MV (median = 22 vs. 103 days, p < 0.0001) and TM (median = 13 vs. 35 days, p < 0.0001). Back transfer of infants with tracheostomies closer to their homes was associated with a significantly shorter hospitalization and more efficient use of the subspecialized resources at the RC.
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Affiliation(s)
- Mohammad A. Attar
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, United States
| | - Rachael A. Pace
- Department of Critical Care Support Services, University of Michigan Health System, Ann Arbor, Michigan, United States
| | - Robert E. Schumacher
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, United States
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11
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Borschuk AP, Williams SE, McClure JM, Kendall M, Mack L, Coleman M, Gurbani N, Benscoter D, Amin R, Stark LJ. A novel behavioral health program for family caregivers of children admitted to a transitional chronic ventilator unit. Pediatr Pulmonol 2021; 56:1635-1643. [PMID: 33647193 DOI: 10.1002/ppul.25327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The care of mechanically ventilated pediatric patients is complex and burdensome. It is essential to adequately support the family caregivers of these children to optimize outcomes; however, there is no literature describing interventions for caregivers in this population. RESEARCH QUESTION This study described a novel behavioral health program and examined its impact on family caregiver engagement and psychological distress on a pediatric inpatient chronic ventilator unit. STUDY DESIGN AND METHODS Electronic chart review was completed with retrospective and prospective participant enrollment for the purposes of longitudinal evaluation of caregiver engagement. For analytic purposes, participants were grouped into three categories: (1) preprogram, (2) postprogram, and (3) postprogram with completion of psychotherapy. RESULTS The behavioral health program was associated with increased caregiver participation in rounds, t = 7.76, p = < .001. Parents who completed a course of psychotherapy within the behavioral health program demonstrated reduced time to training completion (F = 5.89; p < .01), higher staff-rated caregiver engagement (F = 3.69; p < .05), and significantly reduced levels of caregiver distress (t = 2.09; p < .05).
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Affiliation(s)
- Adrienne P Borschuk
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sara E Williams
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jessica M McClure
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Megan Kendall
- Division of Social Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa Mack
- Division of Patient Services Administration, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michelle Coleman
- Division of Patient Services Administration, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Neepa Gurbani
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Raouf Amin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lori J Stark
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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12
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Popejoy E, Marufu TC, Thomas DA, Gregory R, Frost A, McNarry N, Hurley M, Bean D, Manning JC. A regional evaluation of the health care utilization and outcomes of children and young people with long-term ventilation needs. Child Care Health Dev 2021; 47:70-76. [PMID: 33107083 DOI: 10.1111/cch.12818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Globally, the number of children and young people (CYP) with long-term ventilation (LTV) needs is increasing, with high associated health care costs, due to frequent hospital admissions and contact with community health care services. However, demographic, health care utilization and outcome details of the CYP cared for locally is unknown. This study aimed to examine health care utilization and outcomes for this patient population. METHODS Routinely collected data from 2014 to 2018 were extracted from local LTV team records and from hospital electronic patient records. Descriptive and inferential statistical analysis was performed using SPSS 17. RESULTS A total of 112 CYP aged 0-17 years old were included in the evaluation. Sixty per cent (n = 67) commenced ventilation in hospital, and 62% (n = 69) had at-least one hospitalization event whilst they were on LTV, with a median length of stay of 3 days. Most hospitalizations were unplanned and respiratory in nature. Ninety-five per cent (n = 106) of CYP accessed at least one clinic appointment whilst on LTV, with a median of 20 outpatient clinic appointments during the study period. The majority of CYP received time-intensive support from LTV nurses and physiotherapists during the period that they received LTV. Minimal seasonal variation existed in relation to hospital admissions. Year on year increasing trend of hospital admissions was noted. The observed mortality rate was 3.6% (n = 4), 72.3% (n = 81) remained active on LTV, 14% (n = 16) were liberated from their ventilation and 9% (n = 10) transitioned to adult care by the end of the study. CONCLUSION The study highlights the most common modes of health care utilization for CYP with LTV needs. To enable formalization of future resource planning and accurate assessment of health care utilization in evaluations, there is an urgent need to create a systematic approach for relevant LTV data collection.
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Affiliation(s)
- Emma Popejoy
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Takawira C Marufu
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David A Thomas
- Long Term Ventilation Service, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rachel Gregory
- Long Term Ventilation Service, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Adele Frost
- Long Term Ventilation Service, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nicola McNarry
- Long Term Ventilation Service, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Matthew Hurley
- Long Term Ventilation Service, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dorothy Bean
- School of Nursing, Buckinghamshire New University, UK
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK
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13
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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14
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Foy CM, Koncicki ML, Edwards JD. Liberation and mortality outcomes in pediatric long-term ventilation: A qualitative systematic review. Pediatr Pulmonol 2020; 55:2853-2862. [PMID: 32741115 PMCID: PMC7891895 DOI: 10.1002/ppul.25003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/30/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To provide a systematic review of liberation from positive pressure ventilation and mortality of children with chronic respiratory failure who used long-term invasive and noninvasive ventilation (LTV). METHODS Papers published from 1980 to 2018 were identified using Pubmed MEDLINE, Ovid MEDLINE, Embase, and Cochrane databases. Search results were limited to English-language papers with (a) patients less than 22 years at initiation, (b) patients who used invasive ventilation (IV) via tracheostomy or noninvasive ventilation (NIV), and (c) data on mortality or liberation from LTV. Data were presented using descriptive statistics; changes in outcomes over time were explored using linear regression. Follow-up variability, cohort heterogeneity, and insufficient data precluded combining data to estimate incidences or rates. RESULTS One hundred and thirty papers with 12 704 patients were included. The median number of patients was 37 (interquartile range [IQR] 17-74, range 6-3802). Twenty-five percent of patients were initiated on IV; 75% on NIV. The maximum follow-up ranged from 0.5 to 31.8 years (median 8.8 years). The median proportion of patients liberated in these papers was 3% (IQR 0%-21%). The median proportion of mortality was 18% (IQR 8%-27%). Proportions of liberation and mortality did not significantly change over time. Progression of underlying disease (44%), respiratory illness (19%), and LTV accident (11%) were the most common causes of death. CONCLUSIONS These papers collectively show most patients survive for many years using LTV; in many subgroups, death is a more common outcome than liberation. However, the limitations of these papers preclude robust prognostication.
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Affiliation(s)
- Candice M Foy
- Division of Pediatric Hospital Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Monica L Koncicki
- Section of Critical Care, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jeffrey D Edwards
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Valegos College of Physician and Surgeons, New York, New York
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15
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16
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Rasooly IR, Shults J, Guevara JP, Feudtner C. State Variation in Posthospital Home Nursing for Commercially Insured Medically Complex Children. Pediatrics 2020; 146:peds.2019-2465. [PMID: 32641356 PMCID: PMC7397731 DOI: 10.1542/peds.2019-2465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Home nursing is essential for children with medical complexity (CMC), but provision varies substantially across states. Our objectives were to quantify state-to-state variability in distribution of posthospitalization home nursing to commercially insured CMC and to rank-order states. METHODS Retrospective cohort study of hospitalized commercially insured children with ≥1 complex chronic condition from birth to 18 years of age in the Truven MarketScan database. Cohort eligibility criteria were hospital discharge between January 2013 and November 2016 and at least 30 days of follow-up after discharge. Two primary outcome measures were used: receipt of any home nursing within 30 days of hospital discharge (yes or no) and number of days of posthospitalization home nursing (1-30 days). A composite metric encompassing both receipt and quantity was created by evaluating the 95th percentile of days of home nursing (0-30 days). RESULTS Overall, 9.9% of the sample received home nursing. After we adjusted for patient characteristics, the probability of receiving home nursing varied across states, ranging from 3.4% to 19.2%. Among home nursing recipients, the adjusted median home nursing days across states ranged from 6.6 to 24.5 days. The adjusted 95th percentile of days of home nursing (across the entire of sample, including recipients and nonrecipients of home nursing) ranged from 6.8 to 22.6 days. CONCLUSIONS We observed striking state-to-state variability in receipt of home nursing and mean number of days of posthospitalization home nursing among commercially insured CMC after adjustment for demographic and clinical differences. This suggests opportunities for state-level improvement.
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Affiliation(s)
- Irit R. Rasooly
- Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania; and,Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania
| | - Justine Shults
- Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania; and,Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania
| | - James P. Guevara
- Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania; and,Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania; and,Perelman School of Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania
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17
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Mohsin H. Home Ventilation for Children in Oman, Are We Prepared for this New Reality? Oman Med J 2019; 34:389-390. [PMID: 31555413 PMCID: PMC6745422 DOI: 10.5001/omj.2019.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Hussain Mohsin
- Department of Child Health, Royal Hospital, Muscat, Oman
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18
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Abstract
PURPOSE OF REVIEW Modern medical advances have resulted in an increased survival after extremely preterm birth. However, some infants will develop severe bronchopulmonary dysplasia (BPD) and fail to wean from invasive or noninvasive positive pressure support. It remains unclear which infants will benefit from tracheostomy placement for chronic ventilation. Once the decision to pursue chronic ventilation has been made, questions remain with respect to the timing of tracheotomy surgery, optimal strategies for mechanical ventilation, and multidisciplinary care in both the inpatient and outpatient settings. The appropriate time for weaning mechanical ventilation and tracheostomy decannulation has similarly not been determined. RECENT FINDINGS Although there remains a paucity of randomized controlled trials involving infants with severe BPD, a growing body of evidence suggests that chronic ventilation via tracheostomy is beneficial to support the growth and development of severely affected preterm children. However, delivering such care is not without risk. Chronic ventilation via tracheostomy requires complex care coordination and significant resource utilization. SUMMARY When chronic respiratory insufficiency limits a preterm infant's ability to grow and develop, chronic invasive ventilation may facilitate neurodevelopmental progress and may lead to an improved long-term outcome.
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19
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Sobotka SA, Gaur DS, Goodman DM, Agrawal RK, Berry JG, Graham RJ. Pediatric patients with home mechanical ventilation: The health services landscape. Pediatr Pulmonol 2019; 54:40-46. [PMID: 30461228 PMCID: PMC7286281 DOI: 10.1002/ppul.24196] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 10/29/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Children with invasive home mechanical ventilation (HMV) are a growing population with complex health service needs. Single institution studies provide insight into successful program structures and outcomes. Our study objectives were to assess health service structures, providers, and programs caring for this population throughout the U.S., and to understand barriers to high-quality care. DESIGN Using purposeful sampling with capture-recapture and snowball sampling methods, we identified key informants for care of the U.S. pediatric HMV population. Informants received web-based surveys with two reminders. Survey domains included respondent characteristics, HMV team composition, and barriers to care. RESULTS Survey response was 71% with 101 completed. Respondents caring for patients in 45 states included physicians (61%), nurses (20%), therapists (12%), case managers (4%), and social workers (2%). Half (53%) of physicians were fellowship trained, most commonly pulmonology (22%) and critical care medicine (13%). The majority (65%) of providers described a dedicated HMV service. The majority (61%) of respondents from a HMV service provided both inpatient and outpatient care. Nearly all respondents (96%) described an inadequate supply of home nurses and 88% reported inadequate respite facilities. CONCLUSIONS Children with HMV assistance receive care from a diverse group of providers with varied team structure. Heterogeneity may reflect patient diversity and provider interest, increasing efficacy but challenging standardization nationwide. Despite team structure variability, similar home care difficulties were universally experienced. Data suggest that the home nursing shortage is a national impediment to quality and efficient discharge with limited community-based support for this vulnerable population.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois
| | | | - Denise M Goodman
- Division of Pediatric Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rishi K Agrawal
- Division of Hospital-Based Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Robert J Graham
- Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
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20
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Weaver MS, Wichman B, Bace S, Schroeder D, Vail C, Wichman C, Macfadyen A. Measuring the Impact of the Home Health Nursing Shortage on Family Caregivers of Children Receiving Palliative Care. J Hosp Palliat Nurs 2018; 20:260-265. [PMID: 29910692 PMCID: PMC5976226 DOI: 10.1097/njh.0000000000000436] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The national nursing shortage translates into a gap in home nursing care available to children with complex, chronic medical conditions and their family caregivers receiving palliative care consultations. A total of 38 home health nursing surveys were completed by families receiving pediatric palliative care consultation services at a freestanding children's hospital in the Midwest. The gap in the average number of nursing hours allotted versus received was 40 h/wk per family, primarily during evening hours. Parents missed an average of 23 hours of employment per week to provide hands-on nursing care at home, ranking stress regarding personal employment due to nursing shortage at 6.2/10. Families invested an average of 10 h/mo searching for additional nursing coverage and often resorted to utilizing more than 6 different home nurse coverage personnel per month. Families reported multiple delays to hospital discharges (mean, 15 days per delay) due to inability to find home nursing coverage. Respiratory technology and lack of Medicaid coverage (P < .02) correlated with the gap in home nursing access. This study examines how the pediatric home nursing shortage translates into a lived experience for families with children with complex medical conditions receiving palliative care.
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Affiliation(s)
- Meaghann S Weaver
- is pediatric palliative care and pediatric oncology physician, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is undergraduate research scholar, Saint Louis University, St Louis, Missouri
- is palliative care social worker, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is palliative care nurse case manager, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is nurse practitioner, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is biostatistician, Division of Biostatistics, Department of Public Health, University of Nebraska, Omaha, Nebraska
- is pediatric intensive care and pediatric palliative care physician, Division of Pediatric Critical Care, Children's Hospital and Medical Center Omaha, NE
| | - Brittany Wichman
- is pediatric palliative care and pediatric oncology physician, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is undergraduate research scholar, Saint Louis University, St Louis, Missouri
- is palliative care social worker, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is palliative care nurse case manager, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is nurse practitioner, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is biostatistician, Division of Biostatistics, Department of Public Health, University of Nebraska, Omaha, Nebraska
- is pediatric intensive care and pediatric palliative care physician, Division of Pediatric Critical Care, Children's Hospital and Medical Center Omaha, NE
| | - Sue Bace
- is pediatric palliative care and pediatric oncology physician, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is undergraduate research scholar, Saint Louis University, St Louis, Missouri
- is palliative care social worker, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is palliative care nurse case manager, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is nurse practitioner, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is biostatistician, Division of Biostatistics, Department of Public Health, University of Nebraska, Omaha, Nebraska
- is pediatric intensive care and pediatric palliative care physician, Division of Pediatric Critical Care, Children's Hospital and Medical Center Omaha, NE
| | - Denice Schroeder
- is pediatric palliative care and pediatric oncology physician, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is undergraduate research scholar, Saint Louis University, St Louis, Missouri
- is palliative care social worker, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is palliative care nurse case manager, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is nurse practitioner, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is biostatistician, Division of Biostatistics, Department of Public Health, University of Nebraska, Omaha, Nebraska
- is pediatric intensive care and pediatric palliative care physician, Division of Pediatric Critical Care, Children's Hospital and Medical Center Omaha, NE
| | - Catherine Vail
- is pediatric palliative care and pediatric oncology physician, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is undergraduate research scholar, Saint Louis University, St Louis, Missouri
- is palliative care social worker, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is palliative care nurse case manager, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is nurse practitioner, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is biostatistician, Division of Biostatistics, Department of Public Health, University of Nebraska, Omaha, Nebraska
- is pediatric intensive care and pediatric palliative care physician, Division of Pediatric Critical Care, Children's Hospital and Medical Center Omaha, NE
| | - Chris Wichman
- is pediatric palliative care and pediatric oncology physician, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is undergraduate research scholar, Saint Louis University, St Louis, Missouri
- is palliative care social worker, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is palliative care nurse case manager, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is nurse practitioner, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is biostatistician, Division of Biostatistics, Department of Public Health, University of Nebraska, Omaha, Nebraska
- is pediatric intensive care and pediatric palliative care physician, Division of Pediatric Critical Care, Children's Hospital and Medical Center Omaha, NE
| | - Andrew Macfadyen
- is pediatric palliative care and pediatric oncology physician, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is undergraduate research scholar, Saint Louis University, St Louis, Missouri
- is palliative care social worker, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is palliative care nurse case manager, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is nurse practitioner, Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Nebraska
- is biostatistician, Division of Biostatistics, Department of Public Health, University of Nebraska, Omaha, Nebraska
- is pediatric intensive care and pediatric palliative care physician, Division of Pediatric Critical Care, Children's Hospital and Medical Center Omaha, NE
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21
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van der Poel LAJ, Booth J, Argent A, van Dijk M, Zampoli M. Home Ventilation in South African Children: Do Socioeconomic Factors Matter? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2017; 30:163-170. [PMID: 35923010 DOI: 10.1089/ped.2016.0727] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Poor socioeconomic circumstances and poverty are perceived to be barriers to successful home ventilation. Pediatric home ventilation has escalated rapidly in high-income countries but is underreported and underfunded in low-middle income countries. A retrospective chart review covering the past 20 years was carried out at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, a low-middle income country. Data collection included demographics, socioeconomic and family factors, clinical information, and ventilation-related information. Fifty-five children received home ventilation between 1994 and December 2015 from a median age of 3.5 years (range 0.4-17.6). Thirty-nine (71%) children received invasive ventilation and 16 (29%) children received mask-assisted ventilation. Most common primary diagnosis was a neuromuscular disease (60%). Twenty-six children (47%) were still on home ventilation in December 2015, 8 (15%) had been weaned off ventilation, and 21 (38%) had died. Median time between initiation of ventilation and discharge was 15 days (range 1-52) for mask-assisted ventilation and 88 days (8-991) for tracheostomy-assisted ventilation. Of the total 40 readmissions in the first year of home ventilation, 34 (85%) were emergency readmissions mainly necessitated by respiratory infections (n = 26; 65%). Despite a high prevalence of socioeconomic challenges, 89% of the children were successfully discharged on home ventilation. Main cause of death was acute infections (n = 11; 52%). Pediatric home ventilation in South Africa is feasible despite difficult socioeconomic circumstances. Survival outcome was comparable with that of high-income countries. However, a high level of psychosocial support and interventions is needed.
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Affiliation(s)
| | - Jane Booth
- Department of Paediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Argent
- Department of Paediatric Intensive Care, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Monique van Dijk
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marco Zampoli
- Department of Paediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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22
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Abstract
Although precise numbers are difficult to obtain, the population of patients receiving long-term ventilation has increased over the last 20 years, and includes patients with chronic lung diseases, neuromuscular diseases, spinal cord injury, and children with complex disorders. This article reviews the equipment and logistics involved with ventilation outside of the hospital. Discussed are common locations for long-term ventilation, airway and secretion management, and many of the potential challenges faced by individuals on long-term ventilation.
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Affiliation(s)
- Sarina Sahetya
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Allgood
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter C Gay
- Pulmonary and Critical Care, The Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Noah Lechtzin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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23
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Zhang H, Zhang J, Zhao S. Airway damage of prematurity: The impact of prolonged intubation, ventilation, and chronic lung disease. Semin Fetal Neonatal Med 2016; 21:246-53. [PMID: 27129915 DOI: 10.1016/j.siny.2016.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Over the past four decades, advances in neonatal intensive care have led to the survival of smaller and more immature infants. The improved survival of very low birth weight infants is associated with long term respiratory morbidity, most frequently in the form of bronchopulmonary dysplasia. In this review, we will discuss the pathogenesis, risk factor as well as management of commonly seen acquired airway disorders associated with prematurity, prolonged intubation and ventilation.
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Affiliation(s)
- Huayan Zhang
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Jie Zhang
- Department of Otolaryngology, Beijing Children's Hospital, Beijing, China
| | - Shunying Zhao
- Department of Pulmonary Medicine, Beijing Children's Hospital, Beijing, China
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Baker CD, Martin S, Thrasher J, Moore HM, Baker J, Abman SH, Gien J. A Standardized Discharge Process Decreases Length of Stay for Ventilator-Dependent Children. Pediatrics 2016; 137:peds.2015-0637. [PMID: 26966133 PMCID: PMC4811306 DOI: 10.1542/peds.2015-0637] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Children who require chronic mechanical ventilation via tracheostomy are medically complex and require prolonged hospitalization, placing a heavy burden on caregivers and hospital systems. We developed an interdisciplinary Ventilator Care Program to relieve this burden, through improved communication and standardized care. We hypothesized that a standardized team approach to the discharge of tracheostomy- and ventilator-dependent children would decrease length of stay (LOS), reduce patient costs, and improve safety. METHODS We used process mapping to standardize the discharge process for children requiring chronic ventilation. Interventions included developing education materials, a Chronic Ventilation Road Map for caregivers, utilization of the electronic medical record to track discharge readiness, team-based care coordination, and timely case management to arrange home nursing. We aimed to decrease overall and pediatric respiratory care unit LOS as the primary outcomes. We also analyzed secondary outcomes (mortality, emergency department visits, unplanned readmissions), and per-patient hospital costs during 2-year "preintervention" and "postintervention" periods (n = 18 and 30, respectively). RESULTS Patient demographics were not different between groups. As compared with the preintervention cohort, the overall LOS decreased 42% (P = .002). Pediatric respiratory care unit LOS decreased 56% (P = .001). As a result, unplanned readmissions, emergency department visits, and mortality were not increased. Direct costs per hospitalization were decreased by an average of 43% (P = .01). CONCLUSIONS Although LOS remained high, a standardized discharge process for chronically ventilated children by an interdisciplinary Ventilator Care Program team resulted in decreased LOS and costs without a negative impact on patient safety.
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Affiliation(s)
| | - Sara Martin
- Children’s Hospital Colorado, Aurora, Colorado
| | - Jodi Thrasher
- Division of Pediatric Pulmonary Medicine, and,Children’s Hospital Colorado, Aurora, Colorado
| | - Heather M. Moore
- Pediatric Heart Lung Center,,Division of Pediatric Pulmonary Medicine, and
| | - Joyce Baker
- Children’s Hospital Colorado, Aurora, Colorado
| | - Steven H. Abman
- Pediatric Heart Lung Center,,Division of Pediatric Pulmonary Medicine, and
| | - Jason Gien
- Pediatric Heart Lung Center,,Division of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and
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