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Ledin ER, Eriksson A, Mattsson J. "What choice do you have knowing your child can't breathe?!": Adaptation to Parenthood for Children Who Have Received a Tracheostomy. SAGE Open Nurs 2024; 10:23779608241245502. [PMID: 38601012 PMCID: PMC11005490 DOI: 10.1177/23779608241245502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/22/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024] Open
Abstract
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.
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Affiliation(s)
- Ellinor Rydhamn Ledin
- Department of Ergonomics - CBH, KTH Royal Institute of Technology, Huddinge, Sweden
- Department of Health Sciences, Swedish Red Cross University, Huddinge, Sweden
| | - Andrea Eriksson
- Department of Ergonomics - CBH, KTH Royal Institute of Technology, Huddinge, Sweden
| | - Janet Mattsson
- Department of Nursing and Health Sciences, University of South-Eastern Norway, Campus Vestfold, Norway
- Department of Nursing and Integrated Health Sciences, Kristianstad University, Kristianstad, Sweden
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Liu P, Teplitzky TB, Kou YF, Johnson RF, Chorney SR. Long-Term Outcomes of Tracheostomy-Dependent Children. Otolaryngol Head Neck Surg 2023; 169:1639-1646. [PMID: 37264977 DOI: 10.1002/ohn.393] [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] [Received: 08/23/2022] [Revised: 03/29/2023] [Accepted: 05/13/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To estimate the 1-, 5-, and 10-year survival and decannulation rates of children with a tracheostomy. STUDY DESIGN Ambidirectional cohort. SETTING Tertiary children's hospital. METHODS All patients (<18 years) that had a tracheostomy placed between 2009 and 2020 were included and followed until 21 years of age, decannulation, or death. The Kaplan-Meier method estimated cumulative probabilities of death and decannulation. RESULTS A total of 551 children underwent tracheostomy at a median age of 7.2 months (interquartile range [IQR]: 3.8-49.2). Children were followed for a median of 2.1 years (IQR: 0.7-4.2, range 0-11.5). The cumulative probability of mortality at 1 year was 11.9% (95% confidence interval [CI]: 9.4-15.1), at 5 years was 26.1% (95% CI: 21.6-31.3), and at 10 years was 41.6% (95% CI: 32.7-51.8). Ventilator dependence at index discharge (hazard ratio [HR]: 2.04, 95% CI: 1.10-3.81, p = .03), severe neurologic disability (HR: 2.79, 95% CI: 1.61-4.84, p < .001), and cardiac disease (HR: 1.69, 95% CI: 1.08-2.65, p = .02) were associated with time to death. The cumulative probability of decannulation was 10.4% (95% CI: 8.0-13.5), 44.9% (95% CI: 39.4-50.9), and 54.1% (95% CI: 47.4-61.1) at 1 year, 5 years, and 10 years, respectively. Ventilator dependence (HR: 0.43, 95% CI: 0.31-0.60, p < .001), severe neurologic disability (HR: 0.20, 95% CI: 0.14-0.30, p < .001), and tracheostomy indicated for respiratory failure (HR: 0.68, 95% CI: 0.48-0.96, p = .03) correlated with longer decannulation times. CONCLUSION After tracheostomy, estimated mortality approaches 42% by 10 years and decannulation approaches 54%. Children with ventilator support at discharge and severe neurological disability had poorer long-term survival and longer times to decannulation.
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Affiliation(s)
- Palmila Liu
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Taylor B Teplitzky
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yann-Fuu Kou
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Romaine F Johnson
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Stephen R Chorney
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, USA
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Mirza B, Marouf A, Abi Sheffah F, Marghlani O, Heaphy J, Alherabi A, Zawawi F, Alnoury I, Al-Khatib T. Factors influencing quality of life in children with tracheostomy with emphasis on home care visits: a multi-centre investigation. J Laryngol Otol 2023; 137:1102-1109. [PMID: 36089743 DOI: 10.1017/s002221512200202x] [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: 11/07/2022]
Abstract
OBJECTIVE Only a few studies have assessed the quality of life in children with tracheostomies. This study aimed to evaluate the quality of life and the factors influencing it in these children. METHOD This cross-sectional, two-centre study was conducted on paediatric patients living in the community with a tracheostomy by using the Pediatric Quality of Life Inventory. Clinical and demographic information of patients, as well as parents' socioeconomic factors, were obtained. RESULTS A total of 53 patients met our inclusion criteria, and their parents agreed to participate. The mean age of patients was 6.85 years, and 21 patients were ventilator-dependent. The total paediatric health-related quality of life score was 59.28, and the family impact score was 68.49. In non-ventilator-dependent patients, multivariate analyses indicated that social functioning and health-related quality of life were negatively affected by the duration of tracheostomy. The Quality of Life of ventilator-dependent patients was influenced by care visits and the presence of pulmonary co-morbidities. CONCLUSION Children with tracheostomies have a lower quality of life than healthy children do. Routine care visits by a respiratory therapist and nurses yielded significantly improved quality of life in ventilator-dependent children.
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Affiliation(s)
- B Mirza
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah
| | - A Marouf
- Department of Surgery, Otolaryngology - Head and Neck Surgery Section, King Faisal Specialist Hospital and Research Centre, Jeddah
| | - F Abi Sheffah
- Department of Surgery, Otolaryngology - Head and Neck Surgery Section, King Faisal Specialist Hospital and Research Centre, Jeddah
| | - O Marghlani
- Department of Surgery, Otolaryngology - Head and Neck Surgery Section, King Faisal Specialist Hospital and Research Centre, Jeddah
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - J Heaphy
- Department of Surgery, Otolaryngology - Head and Neck Surgery Section, King Faisal Specialist Hospital and Research Centre, Jeddah
| | - A Alherabi
- Department of Surgery, Otolaryngology - Head and Neck Surgery Section, King Faisal Specialist Hospital and Research Centre, Jeddah
- Department of Otolaryngology - Head and Neck Surgery, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - F Zawawi
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah
| | - I Alnoury
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah
| | - T Al-Khatib
- Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah
- Department of Surgery, Otolaryngology - Head and Neck Surgery Section, King Faisal Specialist Hospital and Research Centre, Jeddah
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Kam K, Patzelt R, Soenen R. Pediatric tracheostomy speaking valves: A multidisciplinary protocol leads to earlier initial trials. J Child Health Care 2023; 27:386-394. [PMID: 35085046 DOI: 10.1177/13674935211070416] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Early speaking valve application in children with tracheostomies is encouraged for language development. Whether an institutional multidisciplinary protocol impacts the patient population and timelines for which a speaking valve is trialed has not been studied. This retrospective study compared speaking valve trials performed at a pediatric quaternary hospital over a 12-year period. Timelines (time between tracheostomy insertion, speech-language pathologist (SLP) consultation, speaking valve order, and trial) and patient characteristics (demographics, tracheostomy classification, and feeding status) were collected. Medians (IQRs) compared timelines before and after a protocol was instituted and compared the timelines between tracheostomy classifications. Median time between tracheostomy insertion and SLP consultation did not change: before protocol-1.8 (7.7) months and after protocol-1.8 (2.4) months. Time between tracheostomy insertion and speaking valve trial decreased: before protocol-34.1 (40.5) months and after protocol-12.9 (8.4) months. Time between tracheostomy insertion and trial was not different between tracheostomy classifications: upper airway obstruction-16.0 (27.1) months, complex medical condition-36.3 (45.8) months, and invasive ventilation-17.5 (22.3) months. An institutional multidisciplinary protocol decreases the time between tracheostomy insertion and speaking valve trial, regardless of the reason the tracheostomy is needed in the pediatric population.
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Affiliation(s)
- Karen Kam
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rebecca Patzelt
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Renee Soenen
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
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Yu J, Zhang F, Jin F, Weng J, Peng Y, Zhou J, Chen Y, Zhang J, Hei M. Patient outcomes after neonatal tracheotomy: A retrospective case-control study. Chin Med J (Engl) 2023; 136:1246-1248. [PMID: 37057727 PMCID: PMC10278698 DOI: 10.1097/cm9.0000000000002269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Indexed: 04/15/2023] Open
Affiliation(s)
- Jie Yu
- Department of Neonatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Fengzhen Zhang
- Center for Clinical Epidemiology and Evidence-Based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Fei Jin
- Department of Neonatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Jingwen Weng
- Department of Neonatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Yaguang Peng
- Department of Otorhinolaryngology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Jingjing Zhou
- Department of Neonatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Yan Chen
- Department of Neonatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Jie Zhang
- Center for Clinical Epidemiology and Evidence-Based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing 100045, China
| | - Mingyan Hei
- Department of Neonatology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
- Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing 100045, China
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Development and implementation of a pre-tracheostomy multidisciplinary conference: An initiative to improve patient selection. Int J Pediatr Otorhinolaryngol 2022; 158:111135. [PMID: 35636083 DOI: 10.1016/j.ijporl.2022.111135] [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: 07/20/2021] [Revised: 02/24/2022] [Accepted: 04/08/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe our institutional experience in implementing a pre-tracheostomy multidisciplinary conference and assess its effects on patient selection and communication between team members and with families. METHODS Descriptive study and retrospective review of patient outcomes in a period prior to (4/2016-1/2018) and following (2/2018-11/2019) implementation of the conference and conference participant survey. RESULTS In the 21 months prior to the conference, 53 patients out of 67 consults (79%) went on to have a tracheostomy. After implementation, 96 patients, 42 females and 54 males, between 2 weeks and 22 years of age were discussed. 58 (60%) of patients referred for tracheostomy ultimately underwent surgery. Of those managed without tracheostomy, 16% were extubated, 11% were managed with noninvasive respiratory support, and 13% of families chose to redirect care. There was no difference in time between consultation and surgery (p = 0.9), or post-surgical length of stay after the conference was implemented (p = 0.9). Survey responses were gathered from 34 conference participants. Respondents agreed that the conference was useful in facilitating communication among the care team (91%), promoting understanding of the patient's treatment options (85%), promoting understanding about long-term outcomes and progression of underlying disease process (79%), clarifying risks, benefits, and alternatives of treatment options (82%), and informing discussions with the family (70%). DISCUSSION Potential benefits of a multidisciplinary pre-tracheostomy conference include improved provider communication and shared decision making between the medical team and family. We found a reduction in the proportion of patients who ultimately underwent tracheostomy as a result of a formal multidisciplinary discussion, but did not find either any delays in care, or reduction in post-operative length of stay. IMPLICATIONS FOR PRACTICE A multidisciplinary team approach to patient selection can foster communication between team members, identify barriers to discharge and quality care at home, and provide caregivers with information necessary to make an informed decision about their child's care.
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7
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Azbell CH, Bakeman A, McCoy JL, Tobey ABJ. Primary versus secondary closure of tracheocutaneous fistula in pediatric patients. Am J Otolaryngol 2022; 43:103213. [PMID: 34823915 DOI: 10.1016/j.amjoto.2021.103213] [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] [Received: 07/22/2021] [Accepted: 09/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Up to 50% of pediatric patients have a persistent tracheocutaneous fistula (TCF) after tracheostomy decannulation. Classically these fistula tracts were excised and completely closed in a multilayered fashion, but recently closure by secondary intention has become the standard of care. However, variations in postoperative care still exist. The primary objectives of this study were to compare outcomes between patients who had a primary closure versus closure by secondary intention after excision of a TCF in children with a tracheostomy placement at one year old or less and to determine if closure by secondary intention will be equally efficacious compared to traditional primary closure. METHODS Patients ages 0-21 years who had a primary or secondary closure of a TCF at a tertiary care children's hospital following decannulation of a tracheostomy tube were reviewed and those with a tracheostomy placement ≤1 year old were included. Demographic information, comorbidities, and surgical information were extracted from inpatient and outpatient charts. Mann-Whitney U test, Fisher's Exact test, and logistic regression to compare outcomes across the two TCF surgical groups. RESULTS A total of 64 patients met inclusion with primary closures in 25 (39.1%) patients and secondary closures in 39(60.9%) patients. Patients who underwent secondary closure had a significantly shorter surgery duration (p < .001), shorter ICU length of stay (p < .001), and shorter postop LOS (p < .001). There were no differences in cardiac complications, respiratory complications, and the need for additional closure surgery between the two techniques, p > .05. Time from decannulation to TCF in months increased with primary closure, p = .010. CONCLUSION Closure of tracheocutaneous fistula by secondary intention is safe and effective and can allow for shorter hospital stays in children with a tracheostomy placement at a year old or less.
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Affiliation(s)
- Christopher H Azbell
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Anna Bakeman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Jennifer L McCoy
- Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Allison B J Tobey
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.
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Tarfa RA, Morris J, Melder KL, McCoy JL, Tobey ABJ. Readmissions and mortality in pediatric tracheostomy patients: Are we doing enough? Int J Pediatr Otorhinolaryngol 2021; 145:110704. [PMID: 33882340 DOI: 10.1016/j.ijporl.2021.110704] [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: 12/01/2020] [Revised: 01/29/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Pediatric patients who undergo tracheostomy tube placement are medically complex with a high risk of morbidity and mortality. They are often premature with multiple cardiopulmonary comorbidities. This study reviews the demographics and outcomes within this population to identify at-risk patient groups at our hospital. METHODS A retrospective chart review of those with pediatric tracheostomy placement from 2015 to 2016 at our hospital was performed (n = 92). Demographic and post-discharge data were collected at 30, 60, and 90-days during the global period. RESULTS Ventilator dependence was the most common reason for placement. 79.3% of patients had two or more major comorbidities. 44% had an emergency department (ED) visit and subsequent hospital admission within the first 90 days post-discharge, with 36% being trach/respiratory-related. The 90-day mortality was 19.6%; however, at the time of chart review, mortality was 35% with only 1 (1.1%) being from trach-related complications. Patients with longer admissions were more likely to die prior to discharge, p = .001. Lastly, patients who died were 3 times more likely to have > 25% no-shows to their outpatient appointments compared to those living throughout the study period. CONCLUSION Our population had a high incidence of ED visits, readmission rates, and mortality; however, trach-related causes remained low. Mortality risk increased with more no-show appointments and residing a further distance from our hospital. Furthermore, multiple co-morbidities, with longer hospital stays also increased risk of mortality. Identifying those with the highest risk for complications will enable us to target families for increased home-care education to decrease readmissions and mortality. LEVEL OF EVIDENCE 4.
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Affiliation(s)
| | | | - Katie L Melder
- University of Pittsburgh Medical Center, Department of Otolaryngology, USA
| | - Jennifer L McCoy
- UPMC Children's Hospital of Pittsburgh, Division of Pediatric Otolaryngology, USA
| | - Allison B J Tobey
- University of Pittsburgh Medical Center, Department of Otolaryngology, USA; UPMC Children's Hospital of Pittsburgh, Division of Pediatric Otolaryngology, USA.
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Koenigs MB, Behzadpour HK, Zalzal GH, Preciado DA. Barriers to Decannulation After Double-Stage Laryngotracheal Reconstruction. Laryngoscope 2021; 131:2141-2147. [PMID: 33635575 DOI: 10.1002/lary.29486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES/HYPOTHESIS To identify any potential barriers for decannulation in children undergoing double-staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself. STUDY DESIGN Case series with chart review. METHODS We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR. RESULTS Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log-rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log-rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log-rank), and race/ethnicity (P = .001 Log-rank). CONCLUSION In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation. LEVEL OF EVIDENCE 4 Laryngoscope, 131:2141-2147, 2021.
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Affiliation(s)
- Maria B Koenigs
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Hengameh K Behzadpour
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - George H Zalzal
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Diego A Preciado
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, District of Columbia, U.S.A
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Davidson C, Jacob B, Brown A, Brooks R, Bailey C, Whitney C, Chorney S, Lenes-Voit F, Johnson RF. Perioperative Outcomes After Tracheostomy Placement Among Complex Pediatric Patients. Laryngoscope 2021; 131:E2469-E2474. [PMID: 33464608 DOI: 10.1002/lary.29402] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare perioperative outcomes after pediatric tracheostomy placement based on patient complexity. STUDY DESIGN Retrospective case series. METHODS All patients that underwent tracheostomy placement at a tertiary children's hospital between 2015 and 2019 were followed. Children with a history of major cardiac surgery, sepsis, or total parental nutrition (TPN) were grouped as complex. Admission length, tracheostomy-related complications, in-hospital mortality, and 30-day readmissions were recorded among complex and non-complex patients. RESULTS A total of 238 children were included. Mean age at tracheostomy was 39.9 months (SD: 61.3), 51% were male and 51% were complex. Complex patients were younger at admission (29.9 vs. 46.8 months, P = .03), more likely to have respiratory failure (81% vs. 53%, P < .001) and more often required mechanical ventilation at discharge (86% vs. 67%, P < .001). An additional 33 days after placement was required for complex children (95% CI: 14-51, P = .001) and this group had more deaths (8% vs. 1%, P = .02); however, both groups had similar complication and readmission rates (P > .05). Total charges were higher among complex patients ($700,267 vs. $338,937, P < .001). Parametric survival analysis identified mechanical ventilation and patient complexity interacting to predict post-tracheostomy admission length. CONCLUSIONS Hospital discharge after pediatric tracheostomy was associated with patient complexity and further influenced by mechanical ventilation. Recognition that cardiac surgery, sepsis, or TPN can predict poorer perioperative outcomes can provide quality improvement strategies for these vulnerable children. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2469-E2474, 2021.
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Affiliation(s)
- Christian Davidson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Benjamin Jacob
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Ashley Brown
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Rebecca Brooks
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Candace Bailey
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Cindy Whitney
- Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Stephen Chorney
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Felicity Lenes-Voit
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Romaine F Johnson
- Department of Otolaryngology Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Department of Pediatric Otolaryngology, Children's Medical Center Dallas, Dallas, Texas, U.S.A
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11
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Sarkar M, Roychowdhoury S, Bhakta S, Raut S, Nandi M. Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation? Indian J Crit Care Med 2021; 25:435-440. [PMID: 34045811 PMCID: PMC8138645 DOI: 10.5005/jp-journals-10071-23791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction With the advancement of pediatric critical care services across India, many children require prolonged mechanical ventilation (MV), and tracheostomy is recommended to them. However, many pediatric intensivists have concerns regarding the safety, feasibility, and outcome of tracheostomy.We aimed to analyze clinical characteristics, indication, duration, and outcome of tracheostomized children with respect to timing of tracheostomy. Materials and methods We conducted a retrospective study from the hospital clinical database of consecutive patients below 12 years who had undergone tracheostomy after admission into the pediatric intensive care unit (PICU) for prolonged ventilation (≥96 hours) from January 2015 to December 2019. The study was approved by the Institutional Ethics Committee. Patients were divided into two groups: tracheostomies done within 14 days of MV (early tracheostomy) and patients with tracheostomies performed after 14 days (late tracheostomy). Patients' age, sex, indications, complications, decannulation rate, length of MV, PICU, and hospital stay were analyzed. Results Of the 1,425 patients on invasive MV, 87 (6.1%) patients required tracheostomy after a mean 13.37 days of MV. The most common indication was encephalopathy 32 (36.7%) followed by acute respiratory distress syndrome 20 (22.9%). Factors like higher pediatric logistic organ dysfunction score, vasoactive inotrop score, incidence of pretracheostomy ventilator-associated pneumonia, and difficulty in obtaining parental consent were associated with late tracheostomy. The early tracheostomy group had a higher decannulation rate (odds ratio, 5.17; p, 0.01) and weaning rate (odds ratio, 5.94; p, 0.032). The late tracheostomy group needed a longer duration of MV, PICU, and hospital stay. Complications of tracheostomy were less in the early tracheostomy patients (odds ratio, 2.95; p, 0.03). Conclusion Early tracheostomy was associated with lower complications, higher successful weaning rates, and less utilization of intensive care facilities in patients receiving prolonged MV. Clinical significance In the context of scarcity of data on the timing of tracheostomy in children with prolonged ventilation (≥96 hours) the study shows that early (<14 days) tracheostomy is associated with a better outcome. How to cite this article Sarkar M, Roychowdhoury S, Bhakta S, Raut S, Nandi M. Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation? Indian J Crit Care Med 2021;25(4):435-440.
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Affiliation(s)
- Mihir Sarkar
- Department of Pediatrics, Calcutta Medical College, Kolkata, West Bengal, India
| | | | - Subhajit Bhakta
- Department of Pediatrics, Calcutta Medical College, Kolkata, West Bengal, India
| | - Sumantra Raut
- Department of Pediatrics, Calcutta Medical College, Kolkata, West Bengal, India
| | - Mousumi Nandi
- Department of Pediatrics, Calcutta Medical College, Kolkata, West Bengal, India
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12
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An Evaluation of Websites Offering Caregiver Education for Tracheostomy and Home Mechanical Ventilation. J Pediatr Nurs 2021; 56:64-69. [PMID: 33186865 DOI: 10.1016/j.pedn.2020.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Parental and familial caregivers of a child with a tracheostomy, and possibly home mechanical ventilation (HMV), face the overwhelming task of learning to medically care for their child prior to discharge. Caregivers may cope by seeking health information on the Internet. This is concerning because information found during an Internet search may not be accurate, comprehensive, or up to date. The purpose of this project was to evaluate the quality and content of websites offering information about tracheostomies and HMV using a valid assessment tool. METHODS A total of 46 websites were identified for evaluation using the DISCERN instrument for quality and reliability, and the Flesch Reading Ease (FRE) and Flesh- Kincaid (FK) grade level instruments for readability. Accuracy of content was determined by expert opinion. FINDINGS Few of the websites met the recommended quality and/or readability levels. The websites recommended had a range of DISCERN scores 21-40, adjusted FRE 61-89.1, and adjusted FK 3.4-6.9. Many of the highest quality websites had a readability level at high school or college levels. DISCUSSION The quality and readability of websites offering caregiver education for tracheostomy and HMV are not at a level suitable for caregivers. There was often a mismatch between DISCERN quality and readability. Many high-quality websites would not be easily read and understood by the general lay population. APPLICATION TO PRACTICE DISCERN alone is not sufficient to determine whether a website should be recommended. One should consider reliability, quality, and readability when developing patient education materials, including those on the Internet.
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13
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Chorney SR, Patel RC, Boyd AE, Stow J, Schmitt MM, Lipman D, Dailey JF, Nhan C, Giordano T, Sobol SE. Timing the First Pediatric Tracheostomy Tube Change: A Randomized Controlled Trial. Otolaryngol Head Neck Surg 2020; 164:869-876. [PMID: 32928049 DOI: 10.1177/0194599820954137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The first pediatric tracheostomy tube change often occurs within 7 days after placement; however, the optimal timing is not known. The primary objective was to determine the rate of adverse events of an early tube change. Secondary objectives compared rates of significant peristomal wounds, sedation requirements, and expedited intensive care discharges. STUDY DESIGN Prospective randomized controlled trial. SETTING Tertiary children's hospital between October 2018 and April 2020. METHODS A randomized controlled trial enrolled children under 24 months to early (day 4) or late (day 7) first tracheostomy tube changes. RESULTS Sixteen children were enrolled with 10 randomized to an early change. Median age was 5.9 months (interquartile range, 5.4-8.3), and 86.7% required tracheostomy for respiratory failure. All tracheostomy tube changes were performed without adverse events. There were no accidental decannulations. Significant wounds developed in 10% of children with early tracheostomy tube changes and 83.3% of children with late tracheostomy tube changes (odds ratio [OR], 45.0; 95% CI, 2.3-885.6; P = .01). This significant reduction in wound complications justified concluding trial enrollment. Hours of dexmedetomidine sedation (P = .11) and boluses of midazolam during the first 7 days (P = .08) were no different between groups. After the first change, 90% of the early group were discharged from intensive care within 5 weeks compared to 33.3% of patients in the late group (OR, 18.0; 95% CI, 1.2-260.9; P = .03). CONCLUSION The first tracheostomy tube change in children can occur without adverse events on day 4, resulting in fewer significant peristomal wounds and earlier intensive care discharge.
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Affiliation(s)
- Stephen R Chorney
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rosemary C Patel
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Allison E Boyd
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joanne Stow
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mary M Schmitt
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Deborah Lipman
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia F Dailey
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carol Nhan
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Terri Giordano
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Steven E Sobol
- Division of Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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14
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Johnson RF, Brown A, Brooks R. The Family Impact of Having a Child with a Tracheostomy. Laryngoscope 2020; 131:911-915. [PMID: 32797676 DOI: 10.1002/lary.29003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/19/2020] [Accepted: 07/13/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Measure the quality of life among families with children with tracheostomies. METHODS We performed a prospective cross-sectional analysis of families with children with tracheostomies utilizing the PedQL Family Impact Module-a validated quality of life assessment. We determined if scores were impacted by demographics using regression analysis. We also compared the tracheostomy sample's scores to a previously published cohort of children with severe cerebral palsy and birth defects that required home nursing or nursing home placement using the student's t-test. We determined the effect size of the difference between the two groups using the Cohen's d test. RESULTS Ninety-eight families are included in the study. The average (SD) age of tracheostomy placement was 1.6 (3.5) years. The population was 60% (59/98) male and 39% (38/98) Hispanic. The principal reason for tracheostomy was due to respiratory failure (76 out of 98; 78%). The mean (SD) total Family Impact score was 76 (19). The lowest domain score was daily activity problems, mean (SD) = 67 (30) followed by worry (mean = 69, SD = 24). The lowest question score was, "I worry about my child's future," mean (SD) = 52 (37). When compared to the comparison group of medically fragile children, the scores were statistically similar except for communication totals where tracheostomy patients reported superior scores (78.3 vs. 62.9, 95% CI, -26 to -4.8, P = .005, Cohen's d = -0.66). CONCLUSION The presence of a tracheostomy is associated with QOL scores like other medically fragile children. LEVEL OF EVIDENCE 4 Laryngoscope, 131:911-915, 2021.
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Affiliation(s)
- Romaine F Johnson
- Department of Otolaryngology - Head and Neck Surgery, UT Southwestern Medical Center, Dallas, Texas, U.S.A.,Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Ashley Brown
- Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, Texas, U.S.A
| | - Rebecca Brooks
- Children's Health Airway Management Program, Children's Medical Center Dallas, Dallas, Texas, U.S.A
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15
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Brenner MJ, Pandian V, Milliren CE, Graham DA, Zaga C, Morris LL, Bedwell JR, Das P, Zhu H, Lee Y. Allen J, Peltz A, Chin K, Schiff BA, Randall DM, Swords C, French D, Ward E, Sweeney JM, Warrillow SJ, Arora A, Narula A, McGrath BA, Cameron TS, Roberson DW. Global Tracheostomy Collaborative: data-driven improvements in patient safety through multidisciplinary teamwork, standardisation, education, and patient partnership. Br J Anaesth 2020; 125:e104-e118. [PMID: 32456776 DOI: 10.1016/j.bja.2020.04.054] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/17/2020] [Accepted: 04/17/2020] [Indexed: 01/15/2023] Open
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16
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McKelvie B, Pianosi K, Chan J, Tsampalieros A, Benchimol EI, Macdonald KI, Strychowshy J, Vaccani JP, McNally JD. Development and validation of an algorithm of diagnostic and procedural codes for the identification of children hospitalized with a tracheostomy in Ontario, Canada. Pediatr Pulmonol 2020; 55:1503-1511. [PMID: 32250033 DOI: 10.1002/ppul.24757] [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: 11/07/2019] [Revised: 03/11/2020] [Accepted: 03/22/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The requirement for a tracheostomy in children is associated with significant morbidity, mortality, and healthcare utilization. Easy identification of children with tracheostomies would facilitate important research on this population and provide quality improvement initiatives. AIM The purpose of this study is to determine whether an algorithm of diagnostic and procedural codes can accurately identify children hospitalized with a tracheostomy using routinely collected health data. METHODS Chart reviews were performed at the Children's Hospital of Eastern Ontario (CHEO) and the London Health Sciences Center (LHSC) to establish a true positive cohort of pediatric patients with tracheostomies admitted between 2008 and 2016. A multidisciplinary team developed algorithms of diagnostic and procedural codes contained within the Canadian Institute for Health Information Discharge Abstract Database. Algorithms were tested and refined against the true-positive and true-negative cohort. The accuracy of the diagnostic codes related to tracheostomy complications was also evaluated. RESULTS A chart review identified 158 unique children with tracheostomies (77 at CHEO, 81 at LHSC) with 901 individual admissions (401 at CHEO, 507 at LHSC). The best algorithms for identifying children with a tracheostomy had a sensitivity and specificity of more than 99%, a positive predictive value (PPV) of 94.0% and negative predictive value (NPV) of 100%. The algorithm for the identification of tracheostomy-related complications had a sensitivity of 76.7%, a specificity of 65%, PPV of 52.3%, and an NPV of 84.7%. CONCLUSIONS This study provides an algorithm for the accurate identification of children hospitalized in Canada with a tracheostomy, facilitating population-level epidemiological research and quality improvement initiatives.
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Affiliation(s)
- Brianna McKelvie
- Department of Pediatrics, Children's Hospital of Western Ontario, London, Ontario, Canada
| | - Kiersten Pianosi
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Center, Western University, London, Ontario, Canada
| | - Jason Chan
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,ICES uOttawa, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Kristian I Macdonald
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Strychowshy
- Department of Otolaryngology-Head and Neck Surgery, London Health Sciences Center, Western University, London, Ontario, Canada
| | - Jean-Philippe Vaccani
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - James D McNally
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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17
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Sioshansi PC, Balakrishnan K, Messner A, Sidell D. Pediatric tracheostomy practice patterns. Int J Pediatr Otorhinolaryngol 2020; 133:109982. [PMID: 32171147 DOI: 10.1016/j.ijporl.2020.109982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/02/2020] [Accepted: 03/01/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite recent guidelines and the frequency of pediatric tracheostomy, surgical techniques and perioperative management are variable. We aim to describe the post-operative practice patterns following tracheostomy in children. METHODS An electronic cross-sectional survey was distributed to American Society of Pediatric Otolaryngologists (ASPO) members in academic and private practice settings. Responses were collected anonymously and analyzed by percentages of respondents who employ specific management strategies. Statistical analysis of response distributions performed using the Z test of proportions for binary questions and the Mantel-Haenszel chi-square test for questions with more than two options. For questions with ordered categorical responses, Cuzick's nonparametric test of trend was used. RESULTS One-hundred twenty-four responses were received (22.3%). Most respondents were fellowship trained and practiced in academic medical centers. A greater number of tracheostomies were performed by respondents practicing in the Midwest region (p = 0.042). There was no variability in the number of tracheostomies performed based on practitioner age, hospital setting, or fellowship training. The majority perform stoma maturation and/or stay suture techniques intraoperatively and send patients to the intensive care unit postoperatively. The routine use of postoperative paralysis was reported by a minority of respondents and 50% reported the use of sedation. There was a roughly-even distribution of respondents who reported postoperative immobilization, mobilization to a chair, and ambulation respectively. Routine; postoperative airway evaluations were reported by 35% of respondents. Clinic follow-up was; variable. CONCLUSION These results demonstrate ongoing variability in the postoperative management strategies following tracheostomy in children and highlight areas for further study.
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Affiliation(s)
- Pedrom C Sioshansi
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Karthik Balakrishnan
- Department of Otorhinolaryngology-Head & Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anna Messner
- Department of Otolaryngology/Head & Neck Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Douglas Sidell
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA; Pediatric Aerodigestive and Airway Reconstruction Center, Lucile Packard Children's Hospital, Stanford, Stanford, CA, USA.
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18
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Cherney RL, Pandian V, Ninan A, Eastman D, Barnes B, King E, Miller B, Judkins S, Smith AE, Smith NM, Hanley J, Creutz E, Carlson M, Schneider KJ, Shever LL, Casper KA, Davidson PM, Brenner MJ. The Trach Trail: A Systems-Based Pathway to Improve Quality of Tracheostomy Care and Interdisciplinary Collaboration. Otolaryngol Head Neck Surg 2020; 163:232-243. [PMID: 32450771 DOI: 10.1177/0194599820917427] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To implement a standardized tracheostomy pathway that reduces length of stay through tracheostomy education, coordinated care protocols, and tracking patient outcomes. METHODS The project design involved retrospective analysis of a baseline state, followed by a multimodal intervention (Trach Trail) and prospective comparison against synchronous controls. Patients undergoing tracheostomy from 2015 to 2016 (n = 60) were analyzed for demographics and outcomes. Trach Trail, a standardized care pathway, was developed with the Iowa Model of Evidence-Based Practice. Trach Trail implementation entailed monthly tracheostomy champion training at 8-hour duration and staff nurse didactics, written materials, and experiential learning. Trach Trail enrollment occurred from 2018 to 2019. Data on demographics, length of stay, and care outcomes were collected from patients in the Trach Trail group (n = 21) and a synchronous tracheostomy control group (n = 117). RESULTS Fifty-five nurses completed Trach Trail training, providing care for 21 patients placed on the Trach Trail and for synchronous control patients with tracheostomy who received routine tracheostomy care. Patients on the Trach Trail and controls had similar demographic characteristics, diagnoses, and indications for tracheostomy. In the Trach Trail group, intensive care unit length of stay was significantly reduced as compared with the control group, decreasing from a mean 21 days to 10 (P < .05). The incidence of adverse events was unchanged. DISCUSSION Introduction of the Trach Trail was associated with a reduction in length of stay in the intensive care unit. Realizing broader patient-centered improvement likely requires engaging respiratory therapists, speech language pathologists, and social workers to maximize patient/caregiver engagement. IMPLICATIONS FOR PRACTICE Standardized tracheostomy care with interdisciplinary collaboration may reduce length of stay and improve patient outcomes.
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Affiliation(s)
- Rebecca L Cherney
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | | | - Ashly Ninan
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Debra Eastman
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brian Barnes
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Elizabeth King
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Brianne Miller
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Samantha Judkins
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Alfred E Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Nan M Smith
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA
| | - Julie Hanley
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Eileen Creutz
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Megan Carlson
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA
| | - Kevin J Schneider
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Leah L Shever
- University of Michigan Hospital and Health Center, Ann Arbor, Michigan, USA.,University of Michigan School of Nursing, Ann Arbor, Michigan, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | | | - Michael J Brenner
- Global Tracheostomy Quality Improvement Collaborative, Raleigh, North Carolina, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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19
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Ishihara T, Tanaka H. Factors affecting tracheostomy in critically ill paediatric patients in Japan: a data-based analysis. BMC Pediatr 2020; 20:237. [PMID: 32434537 PMCID: PMC7237622 DOI: 10.1186/s12887-020-02144-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been an increasing number of children surviving with high medical needs, for whom tracheostomy and/or home ventilation is part of their chronic disease management. The purpose of this study was to describe the indications, epidemiology, frequency, and associated factors for tracheostomy in critically ill paediatric patients using the data available in the Japanese Registry of Paediatric Acute Care (JaRPAC). METHODS This multicentre epidemiologic study collected data concerning paediatric tracheostomy from the JaRPAC database. Patients were divided into two groups: those with or without tracheostomies when they were discharged from the Intensive Care Unit (ICU) or Paediatric Intensive Care Unit (PICU). Consecutive patients aged ≤16 years who did not undergo tracheostomy when admitted to ICU or PICU between April 2014 and March 2017 were included. RESULTS A total of 23 hospitals participated, involving 6199 paediatric patients registered in the JaRPAC database during the study period. Of the registered paediatric patients, 5769 (95%) patients were admitted to the ICUs or PICUs without tracheostomies. Among the patients, 181 patients (3.1%) had undergone tracheostomies. There were significant differences in chronic conditions (134, 74.0% versus 3096, 55.4%, p < 0.01), chromosomal anomalies (19, 10.5% versus 326, 5.8%, p < 0.01), urgent admission (151, 83.4% versus 3093, 55.4%, p < 0.01). More tracheostomies were performed on patients who were admitted for respiratory failure (61, 33.7% versus 926, 16.1%, p < 0.01) and for post-cardiac pulmonary arrest (CPA) resuscitation (40, 22.1% versus 71, 1.1%, p < 0.01). CONCLUSIONS This is the first report to use a large-scale registry of critically ill paediatric patients in Japan to describe the interrelated factors of tracheostomies. Chronic conditions (especially for neuromuscular disease), chromosomal anomaly, admission due to respiratory failure, or treatment for post-CPA resuscitation all had the possibility to be risk factors for tracheostomy.
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Affiliation(s)
- Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Urayasu-city, Chiba, Japan.
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Urayasu-city, Chiba, Japan
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Friesen TL, Zamora SM, Rahmanian R, Bundogji N, Brigger MT. Predictors of Pediatric Tracheostomy Outcomes in the United States. Otolaryngol Head Neck Surg 2020; 163:591-599. [DOI: 10.1177/0194599820917620] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives To investigate the outcomes of pediatric tracheostomy as influenced by demographics and comorbidities. Study Design Retrospective national database review. Setting Fifty-two children’s hospitals across the United States. Subjects and Methods Hospitalization records from Pediatric Health Information System database dated 2010 to 2018 with patients younger than 18 years and procedure codes for tracheostomy were extracted. The primary outcome was total length of stay. The secondary outcomes were 30-day readmission, mortality, and posttracheostomy length of stay. Results A total of 14,155 children were included in the analysis. The median total length of stay was 77 days and increased from 59 to 103 days between 2010 and 2018 ( P < .001). The median posttracheostomy length of stay was 34 days and also increased from 27 to 49 days ( P < .001). On multivariate regression analyses, the total and posttracheostomy lengths of stay were significantly increased in children younger than 1 year, patients of black race, hospitals in the non-West regions, those discharged to home, and those with comorbidities. Socioeconomic indicators such as insurance type and estimated household income were associated with no difference or small effect sizes. Regions and comorbidities were associated with differences in 30-day readmission (overall 26%), while in-hospital mortality was primarily associated with age and comorbidities (overall 8.6%). Conclusion Pediatric tracheostomy requires substantial health care resources with length of stay escalating over recent years. Age, race, region, discharge destination, and comorbidities were associated with differences in length of stay.
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Affiliation(s)
- Tzyynong L. Friesen
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, California, USA
- Division of Otolaryngology, Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Steven M. Zamora
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Ronak Rahmanian
- Department of Otolaryngology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nour Bundogji
- University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Matthew T. Brigger
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, California, USA
- Division of Otolaryngology, Rady Children’s Hospital San Diego, San Diego, California, USA
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21
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Bergeron Gallant K, Sauthier M, Kawaguchi A, Essouri S, Quintal MC, Emeriaud G, Jouvet P. Tracheostomy, respiratory support, and developmental outcomes in neonates with severe lung diseases: Retrospective study in one center. Arch Pediatr 2020; 27:270-274. [PMID: 32280047 DOI: 10.1016/j.arcped.2020.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/27/2019] [Accepted: 03/28/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Pediatric tracheostomy has evolved significantly in the past few decades and the optimal timing to perform it in children with respiratory assistance is still debated. The objective of this study was to describe the indications, timing, complications, and outcomes of infants on respiratory support who had a tracheostomy in a tertiary pediatric intensive care unit (PICU). METHODS All children younger than 18 months of corrected age requiring respiratory support for at least 1 week and who had a tracheostomy between January 2005 and December 2015 were included. Their demographic and clinical data and their outcomes at 24 months of corrected age were collected and analyzed after approval from the CHU Sainte-Justine ethics committee. RESULTS During the study period, 18 children (14 preterm infants, 4 polymalformative syndromes, and 2 diaphragmatic hernias) were included. The median corrected age at tracheostomy was 97 days (0-289 days) and 94.4% were elective. The indications for tracheostomy were ventilation for more than 7 days with (61.1%) or without (38.9%) orolaryngotracheal anomaly. The median number of consultants involved per patient was 16 consultants (10-23 consultants). The median hospital length of stay was 122 days (8-365 days) before tracheostomy and 235 days (22-891 days) after tracheostomy. The median invasive ventilation time was 68 days (8-168 days) before tracheostomy and 64 days (5-982 days) after tracheostomy. In terms of complications, there were nine cases of tracheitis and five cases of tracheal granulomas. At 24 months of corrected age, 17 of 18 children survived, one of/17 was still hospitalized, three of 17 were decannulated, three of 17 received respiratory support via their tracheostomy, 11 of 17 were fed with a gastrostomy, and all had neurodevelopmental delay. CONCLUSION Tracheostomy in infants requiring at least 1 week of ventilation is performed for complex cases and is favored for orolaryngotracheal anomalies. Clinicians should anticipate the need for developmental care in this population.
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Affiliation(s)
- K Bergeron Gallant
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada; University of Montreal, Montreal, Canada
| | - M Sauthier
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada; University of Montreal, Montreal, Canada
| | - A Kawaguchi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada; University of Montreal, Montreal, Canada; University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - S Essouri
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada; University of Montreal, Montreal, Canada
| | - M C Quintal
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada; University of Montreal, Montreal, Canada
| | - G Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada; University of Montreal, Montreal, Canada
| | - P Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Montreal, Canada; University of Montreal, Montreal, Canada.
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22
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Esianor BI, Jiang ZY, Diggs P, Yuksel S, Roy S, Huang Z. Pediatric tracheostomies in patients less than 2 years of age: Analysis of complications and long-term follow-up. Am J Otolaryngol 2020; 41:102368. [PMID: 31859007 DOI: 10.1016/j.amjoto.2019.102368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 12/03/2019] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Zi Yang Jiang
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Sancak Yuksel
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Soham Roy
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Zhen Huang
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA.
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23
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Brenner M, O'Shea MP, Larkin P, Berry J. Key constituents for integration of care for children assisted with long-term home ventilation: a European study. BMC Pediatr 2020; 20:71. [PMID: 32061253 PMCID: PMC7023713 DOI: 10.1186/s12887-020-1979-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The number of children requiring long-term home ventilation has consistently increased over the last 25 years. Given the growing population of children with complex care needs (CCNs), this was an important area of focus within the Models of Child Health Appraised (MOCHA) project, funded by the European Union (EU) under the Horizon 2020 programme. We examined the structures and processes of care in place for children with CCNs and identified key constituents for effective integration of care for these children at the community and acute care interface across 30 EU/ European Economic Area (EEA) countries. METHODS This was a non-experimental descriptive study with an embedded qualitative element. Data were collected by a Country Agent in each of the 30 countries, a local expert in child health services. Data were analysed using descriptive statistics and a thematic analysis was undertaken of the free text data provided. RESULTS A total of 27 surveys were returned from a possible 30 countries (90.0%) countries. One respondent indicated that their country does not have children on long-term ventilation (LTV) in the home, therefore, responses of 26 countries (86.7%) were analysed. None of the responding countries reported that they had all of the core components in place in their country. Three themes emerged from the free text provided: 'family preparedness for transitioning to home', 'coordinated pathway to specialist care' and 'legal and governance structures'. CONCLUSIONS While the clinical care of children on LTV in the acute sector has received considerable attention, the results identify the need for an enhanced focus on the care required following discharge to the community setting. The results highlight the need for a commitment to supporting care delivery that acknowledges the complexity of contemporary child health issues and the context of the families that become their primary care givers.
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Affiliation(s)
- Maria Brenner
- School of Nursing & Midwifery, Trinity College Dublin University of Dublin, 24 D'Olier Street, Dublin 2, Ireland.
| | - Miriam P O'Shea
- School of Nursing & Midwifery, Trinity College Dublin University of Dublin, 24 D'Olier Street, Dublin 2, Ireland
| | - Philip Larkin
- Institut Universitaire de Formation et de Recherche en Soins, Bureau 01/157, SV-A Secteur Vennes, Rte de la Corniche 10, CH-1010, Lausanne, Switzerland
| | - Jay Berry
- Department of Medicine and Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, USA
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24
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Kana LA, Shuman AG, Helman J, Krawcke K, Brown DJ. Disparities and ethical considerations for children with tracheostomies during the COVID-19 pandemic. J Pediatr Rehabil Med 2020; 13:371-376. [PMID: 33104051 DOI: 10.3233/prm-200749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Lulia A Kana
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Andrew G Shuman
- University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Helman
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kelly Krawcke
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David J Brown
- University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.,Office for Health Equity and Inclusion, Michigan Medicine, Ann Arbor, MI, USA
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25
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Quinlan C, Piccione J, Kim JY, Beck SE, Brooks L, Chandy-Patel R, Escobar E, Afolabi-Brown O. The role of polysomnography in tracheostomy decannulation of children with bronchopulmonary dysplasia. Pediatr Pulmonol 2019; 54:1676-1683. [PMID: 31424180 DOI: 10.1002/ppul.24474] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/23/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with bronchopulmonary dysplasia (BPD) may require tracheostomy for long-term mechanical ventilation. Polysomnography (PSG) may predict successful decannulation in children, however it is unclear how this success compares with children without a PSG. To better evaluate this role, we compared decannulation outcomes between tracheostomy-dependent children with BPD who underwent PSG before decannulation to those who did not. METHODS This is a retrospective cohort study between 1 January 2007 and 1 June 2017 of tracheostomy-dependent children with BPD who were clinically considered for decannulation. Patient demographics, PSG results, and medical comorbidities were abstracted from medical records and compared between groups. Decannulation outcomes were compared between children with BPD who underwent PSG before decannulation and those who did not. RESULTS One hundred twenty-five patients with BPD were considered for tracheostomy decannulation. Forty-six (37%) had a pre-decannulation PSG while 79 (63%) did not. Nineteen (41%) patients did not undergo decannulation within 6 months of the PSG. One (3%) patient with pre-decannulation PSG failed decannulation. Four (5%) patients without pre-decannulation PSG failed decannulation. Nineteen patients with PSG and no decannulation had significantly higher obstructive apnea-hypopnea index (OAHI) (13.62 vs 2.68 events per hour, P = 0.004), higher end-tidal CO 2 max (52.84 vs 48.03 mm Hg, P = 0.035), and were older at PSG (median age, 6.04 vs 4.04 years, P = 0.008). CONCLUSIONS While successful decannulation can be achieved without a PSG in some patients, PSG is a valuable tool to identify BPD patients undergoing clinical evaluation for decannulation who would benefit from treatment of OSA before decannulation.
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Affiliation(s)
- Courtney Quinlan
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph Piccione
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ji-Young Kim
- Clinical and Translational Research Center, Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Suzanne E Beck
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Sleep Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lee Brooks
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Sleep Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rosemary Chandy-Patel
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emma Escobar
- Biostatistical and Informatics Cores of the Clinical and Translation Research Center of Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Olufunke Afolabi-Brown
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Sleep Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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26
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Pandian V, Boisen S, Mathews S, Brenner MJ. Speech and Safety in Tracheostomy Patients Receiving Mechanical Ventilation: A Systematic Review. Am J Crit Care 2019; 28:441-450. [PMID: 31676519 DOI: 10.4037/ajcc2019892] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To synthesize evidence of the safety and effectiveness of phonation in patients with fenestrated tracheostomy tubes. METHODS PubMed, CINAHL, Scopus, Cochrane, and Web of Science databases were searched. The research question was, "Are fenestrated tracheostomy tubes a safe and effective option to facilitate early phonation in patients undergoing tracheostomy?" Studies of fenestrated tracheostomy tubes were assessed for risk of bias and quality of evidence. Data were abstracted, cross-checked for accuracy, and synthesized. RESULTS Of the 160 studies identified, 13 met inclusion criteria, including 6 clinical studies (104 patients), 6 case reports (13 patients), and 1 nationwide clinician survey. The primary indications for a tracheostomy were chronic ventilator dependence (83%) and airway protection (17%). Indications for fenestrated tracheostomy included inaudible phonation and poor voice intelligibility. Patients with fenestrated tubes achieved robust voice outcomes. Complications included granulation tissue (6 patients [5%]), malpositioning (1 patient [0.9%]), decreased oxygen saturation (3 patients [2.6%]), increased blood pressure (1 patient [0.9%]), increased peak pressures (2 patients [1.7%]), and air leakage (1 patient [0.9%]); subcutaneous emphysema also occurred frequently. Patient-reported symptoms included shortness of breath (4 patients [3.4%]), anxiety (3 patients [2.6%]), and chest discomfort (1 patient [0.9%]). CONCLUSIONS Fenestrated devices afford benefits for speech and decannulation but carry risks of granulation, aberrant airflow, and acclimation challenges. Findings highlight the need for continued innovation, education, and quality improvement around the use of fenestrated devices.
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Affiliation(s)
- Vinciya Pandian
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
| | - Sarah Boisen
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
| | - Shifali Mathews
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
| | - Michael J. Brenner
- Vinciya Pandian is an associate professor, Johns Hopkins School of Nursing, Baltimore, Maryland. Sarah Boisen is an intensive care unit nurse, The Johns Hopkins Hospital, Baltimore, Maryland. Shifali Mathews is a BS student and research assistant, Johns Hopkins School of Nursing. Michael J. Brenner is an associate professor, Department of Otolaryngology–Head & Neck Surgery, Michigan Medicine–University of Michigan, Ann Arbor, Michigan
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27
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Santiago R, Howard M, Dombrowski ND, Watters K, Volk MS, Nuss R, Costello JM, Rahbar R. Preoperative augmentative and alternative communication enhancement in pediatric tracheostomy. Laryngoscope 2019; 130:1817-1822. [DOI: 10.1002/lary.28288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 08/05/2019] [Accepted: 08/19/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rachel Santiago
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
- Augmentative Communication ProgramBoston Children's Hospital Boston Massachusetts
| | - Michelle Howard
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
- Augmentative Communication ProgramBoston Children's Hospital Boston Massachusetts
| | - Natasha D. Dombrowski
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
| | - Karen Watters
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
- Department of OtolaryngologyHarvard Medical School Boston Massachusetts U.S.A
| | - Mark S. Volk
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
- Department of OtolaryngologyHarvard Medical School Boston Massachusetts U.S.A
| | - Roger Nuss
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
- Department of OtolaryngologyHarvard Medical School Boston Massachusetts U.S.A
| | - John M. Costello
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
- Augmentative Communication ProgramBoston Children's Hospital Boston Massachusetts
| | - Reza Rahbar
- Department of Otolaryngology and Communication EnhancementBoston Children's Hospital Boston Massachusetts
- Department of OtolaryngologyHarvard Medical School Boston Massachusetts U.S.A
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28
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Espinel AG, Scriven K, Shah RK. Tracheostomy manipulations: Impact on tracheostomy safety. Pediatr Investig 2019; 3:141-145. [PMID: 32851308 PMCID: PMC7331310 DOI: 10.1002/ped4.12141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/12/2019] [Indexed: 11/12/2022] Open
Abstract
IMPORTANCE Tracheotomy is one of the riskiest procedures for composite morbidity within pediatric otolaryngology. During the postoperative period, each time the tracheostomy tube is manipulated, there is opportunity for morbidity (e.g. a patient is vulnerable to accidental decannulation and airway loss). OBJECTIVE To identify areas of improvement in caring for "fresh tracheostomy" patients by determining the number of times a tracheostomy tube is manipulated from placement until discharge. The hypothesis is that the more a tracheostomy is manipulated, the higher probability of morbidity. METHODS A quality improvement initiative was conducted to map the care of patients who underwent tracheostomy placement over 12 months. Tracheostomy care and manipulation by all providers were reviewed. Complications, wound care, and respiratory treatments were also evaluated. RESULTS Patients were hospitalized for an average of 39 days (7-140) following tracheostomy. The first tracheostomy tube change occurred on average 6 days (5-10) following placement. Tracheostomy tubes were manipulated an average of 6 (2.5-11.9) times a day to amount to 216 (51-1091) times between placement and discharge. Bedside nurses and respiratory therapists were responsible for 95% of these actions; physicians accounted for 4%. There were 6 tracheostomy related complications. Three were accidental decannulations resulting in cardiopulmonary arrest. One of these caused long term patient morbidity. Patients with more than 4 manipulations per day during the 2 weeks following tracheostomy tube placement, were more likely to have a tracheostomy related complication than those with less than 4 (OR: 12.5; 95% CI: 1.2-130.6; P = 0.0349). INTERPRETATION While uncommon, complications related to tracheostomy can have serious long term effects and at best prolongs length of stay for patients. Reducing the number of tracheostomy manipulations may provide safer postoperative care ultimately reducing morbidity and potentially mortality; children on average have 6 tracheotomy manipulations/day with only 2% being by the physician.
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Affiliation(s)
| | - Kelly Scriven
- Division of OtolaryngologyChildren's National Medical CenterWashingtonDCUSA
| | - Rahul K Shah
- Division of OtolaryngologyChildren's National Medical CenterWashingtonDCUSA
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29
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Factors Impacting Physician Recommendation for Tracheostomy Placement in Pediatric Prolonged Mechanical Ventilation: A Cross-Sectional Survey on Stated Practice. Pediatr Crit Care Med 2019; 20:e423-e431. [PMID: 31246744 DOI: 10.1097/pcc.0000000000002046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize the stated practices of qualified Canadian physicians toward tracheostomy for pediatric prolonged mechanical ventilation and whether subspecialty and comorbid conditions impact attitudes toward tracheostomy. DESIGN Cross sectional web-based survey. SUBJECTS Pediatric intensivists, neonatologists, respirologists, and otolaryngology-head and neck surgeons practicing at 16 tertiary academic Canadian pediatric hospitals. INTERVENTIONS Respondents answered a survey based on three cases (Case 1: neonate with bronchopulmonary dysplasia; Cases 2 and 3: children 1 and 10 years old with pediatric acute respiratory distress syndrome, respectively) including a series of alterations in relevant clinical variables. MEASUREMENTS AND MAIN RESULTS We compared respondents' likelihood of recommending tracheostomy at 3 weeks of mechanical ventilation and evaluated the effects of various clinical changes on physician willingness to recommend tracheostomy and their impact on preferred timing (≤ 3 wk or > 3 wk of mechanical ventilation). Response rate was 165 of 396 (42%). Of those respondents who indicated they had the expertise, 47 of 121 (38.8%), 23 of 93 (24.7%), and 40 of 87 (46.0%) would recommend tracheostomy at less than or equal to 3 weeks of mechanical ventilation for cases 1, 2, and 3, respectively (p < 0.05 Case 2 vs 3). Upper airway obstruction was associated with increased willingness to recommend earlier tracheostomy. Life-limiting condition, severe neurologic injury, unrepaired congenital heart disease, multiple organ system failure, and noninvasive ventilation were associated with a decreased willingness to recommend tracheostomy. CONCLUSION This survey provides insight in to the stated practice patterns of Canadian physicians who care for children requiring prolonged mechanical ventilation. Physicians remain reluctant to recommend tracheostomy for children requiring prolonged mechanical ventilation due to lung disease alone at 3 weeks of mechanical ventilation. Prospective studies characterizing actual physician practice toward tracheostomy for pediatric prolonged mechanical ventilation and evaluating the impact of tracheostomy timing on clinically important outcomes are needed as the next step toward harmonizing care delivery for such patients.
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30
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Greene ZM, Davenport J, Fitzgerald S, Russell JD, McNally P. Tracheostomy speaking valve modification in children: A standardized approach leads to widespread use. Pediatr Pulmonol 2019; 54:428-435. [PMID: 30656861 DOI: 10.1002/ppul.24209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 11/04/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Tracheostomy is associated with negative effects on voice, speech, and feeding/swallowing. Speaking valves have beneficial effects in these areas but are often contra-indicated in children with airway problems due to high transtracheal pressure (TTP). Valves are modified by drilling to reduce excessive TTP. We hypothesized that a standardized approach to assessment and valve modification by drilling improves valve tolerance and allows widespread successful use. METHODS Following development of a standardized multidisciplinary protocol for patient selection, valve modification and valve prescription at our center, we retrospectively collected information from clinical notes relating to clinical indication and medical history of all children undergoing speaking valve assessment from February 2014 to June 2017. We designed a questionnaire which was delivered to the parents of children receiving both modified and standard valves enquiring about voice, feeding, communication, and suctioning. RESULTS Data on 45 children were collected. Thirteen had normal TTP and were given standard valves and 32 had high TTP, all of whom had their valves modified resulting in good tolerance. 17 Children were on positive pressure ventilation at the time of placement. The survey response rate was 83%. Parents report a high degree of satisfaction with modified valves and report positive effects in terms of voice, speech, and feeding/swallowing similar to those reported for standard valves. CONCLUSIONS Speaking valves can be successfully and safely modified in children, providing valves to many patients previously deemed unsuitable. We report positive parental experiences of these modified valves in line with those reported with standard valves.
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Affiliation(s)
- Zelda M Greene
- Departments of Speech and Language Therapy, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Jim Davenport
- Departments of Clinical Engineering, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Siobhan Fitzgerald
- Departments of Paediatric Otorhinolaryngology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - John D Russell
- Departments of Paediatric Otorhinolaryngology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Paul McNally
- Departments of Respiratory Medicine, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
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31
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Chisholm AG, Little BD, Johnson RF. Validating peritonsillar abscess drainage rates using the Pediatric hospital information system data. Laryngoscope 2019; 130:238-241. [PMID: 30761539 DOI: 10.1002/lary.27836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To evaluate the accuracy of the Children's Hospital Association's Pediatric Health Information System (PHIS) registry data in determining surgical drainage rates as compared to a chart review on the same cohort of children with diagnosis of peritonsillar abscess. STUDY DESIGN Retrospective analysis. METHODS Our analysis included 200 children, ages 2 to 17 years, treated for a peritonsillar abscess from 2011 to 2016. The primary outcome was to determine the sensitivity, specificity, predictive values, receiver operating characteristics (ROC), and likelihood ratios of surgical drainage rates comparing the PHIS database to manual chart review of the same patients. RESULTS One hundred and fifteen (58%) children underwent drainage by chart review, whereas 87 (44%) had a drainage procedure by PHIS data. Age was a significant predictor of abscess drainage by chart review (age coefficient = 0.10; standard error = 0.04; 2 = 5.8; P = 0.02; odds ratio = 1.1; 95% confidence interval [CI] = 1.01-1.19). When using the chart review as the reference value for surgical drainage, the PHIS data had a sensitivity of 76% and 100% specificity. The positive and negative predictive values were 100% and 75%, respectively. The ROC area was 0.88 (95% CI, 84 to 92). Cases that lacked a clear procedure note composed the false negative cases in the PHIS. CONCLUSION At our institution, the PHIS Administrative data was adequate at predicting surgical drainage of the peritonsillar abscess when compared to chart review. LEVEL OF EVIDENCE 4 Laryngoscope, 130:238-241, 2020.
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Affiliation(s)
- Allison G Chisholm
- Pediatric Otolaryngology, Cook Children's Medical Center, Fort Worth, Texas, U.S.A
| | - Benjamin D Little
- American University of Antigua School of Medicine, Coolidge, Antigua
| | - Romaine F Johnson
- Department of Otolaryngology-Pediatric Otolaryngology Division, UT Southwestern Medical Center and Children's Medical Center Dallas, Dallas, Texas, U.S.A
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32
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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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33
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Doherty C, Neal R, English C, Cooke J, Atkinson D, Bates L, Moore J, Monks S, Bowler M, Bruce IA, Bateman N, Wyatt M, Russell J, Perkins R, McGrath BA. Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies. Anaesthesia 2018; 73:1400-1417. [PMID: 30062783 DOI: 10.1111/anae.14307] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 01/09/2023]
Abstract
Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.
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Affiliation(s)
- C Doherty
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Neal
- Paediatric Intensive Care Medicine, Paediatrics, Birmingham Children's Hospital, Birmingham, UK
| | - C English
- Department of Paediatric ENT, Manchester University NHS Foundation Trust, Manchester, UK
| | - J Cooke
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - D Atkinson
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - L Bates
- Department of Anaesthesia and Intensive Care Medicine, Royal Bolton Hospital, Bolton, UK
| | - J Moore
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Monks
- Department of Anaesthesia, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - M Bowler
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - I A Bruce
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - N Bateman
- Department of Paediatric Otolaryngology, Royal Manchester Children's Hospital, Manchester, UK
| | - M Wyatt
- Department of Paediatric Otolaryngology, Great Ormond Street Hospital, London, UK
| | - J Russell
- Department of Paediatric ENT, Our Lady's Children's Hospital, Dublin, Ireland
| | - R Perkins
- Department of Paediatric Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Department of Anaesthesia and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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McKeon M, Munhall D, Walsh BK, Nuss R, Rahbar R, Volk M, Watters K. A standardized, closed-loop system for monitoring pediatric tracheostomy-related adverse events. Laryngoscope 2018; 128:2419-2424. [DOI: 10.1002/lary.27251] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/06/2018] [Accepted: 04/02/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Mallory McKeon
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
| | - Daphne Munhall
- Department of Respiratory Care; Boston Children's Hospital; Boston Massachusetts
| | - Brian K. Walsh
- Department of Health Professions; Liberty University; Lynchburg Virginia
- Department of Anaesthesia ; Harvard Medical School; Boston Massachusetts
| | - Roger Nuss
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Mark Volk
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Karen Watters
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts
- Department of Otolaryngology; Harvard Medical School; Boston Massachusetts U.S.A
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Chen CH, Chang JH, Hsu CH, Chiu NC, Peng CC, Jim WT, Chang HY, Lee KS. A 12-year-experience with tracheostomy for neonates and infants in northern Taiwan: Indications, hospital courses, and long-term outcomes. Pediatr Neonatol 2018; 59:141-146. [PMID: 28780390 DOI: 10.1016/j.pedneo.2017.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 02/23/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Tracheostomy is a valuable procedure in infants and neonates with chronic respiratory failure or severe airway obstruction. The aim of this study is to identify the indication, hospital course, and long-term outcome in a cohort of infants who required tracheostomy in a neonatal and pediatric tertiary care center in northern Taiwan. METHODS Medical records of infants, who underwent tracheostomy between January 2002 and December 2013, were retrospectively reviewed. Demographics, indication for tracheostomy, hospital course, discharge disposition, further hospitalization and surgery, and long-term outcome data were collected. RESULTS Fifty-six patients were enrolled. The median gestational age was 38.0 weeks, and median birth weight was 2770 g. he median age at tracheostomy was 104.5 days. The primary indications for tracheostomy were airway obstruction in 35 patients (62.5%), craniofacial anomalies in 7 (12.5%), neuromuscular disorder in 7 (12.5%), cardiopulmonary disorder in 5 (8.9%), and brain injury-related problem in 2 (3.6%). Twenty-two patients (39.3%) were decannulated successfully, and the median time from tracheostomy to decannulation was 2.1 years. Overall mortality rate was 3.6%, but no death was related to tracheostomy. Forty-nine patients underwent regular follow-up at our hospital, and 46 patients (93.9%) required further hospitalization, and 30 (61.2%) underwent further surgery related to a respiratory problem or tracheostomy. Ratio of delayed growth at the time of tracheostomy (28.6%) did not have significant difference at 1 year of age (21.4%) and 2 years of age (25.0%). CONCLUSION In this study, the most common indication for tracheostomy in neonates and infants was airway obstruction. Excluding patients with neuromuscular diseases, a successful decannulation rate of >50% can be achieved.
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Affiliation(s)
- Chia-Huei Chen
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Jui-Hsing Chang
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Chyong-Hsin Hsu
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Nan-Chang Chiu
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Chun-Chin Peng
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Wai-Tim Jim
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Hung-Yang Chang
- Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Kuo-Sheng Lee
- MacKay Medical College, New Taipei City, Taiwan; Department of Otorhinolaryngology and Head & Neck Surgery, MacKay Memorial Hospital, Taipei, Taiwan; Department of Pediatric Otorhinolaryngology and Head & Neck Surgery, MacKay Children's Hospital, Taipei, Taiwan.
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Shay S, Shapiro NL, Bhattacharyya N. Revisits after pediatric tracheotomy: Airway concerns result in returns. Int J Pediatr Otorhinolaryngol 2018; 104:5-9. [PMID: 29287880 DOI: 10.1016/j.ijporl.2017.10.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 10/10/2017] [Accepted: 10/10/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Children undergoing tracheotomy represent a medically vulnerable patient population, and understanding the reasons for revisiting the hospital setting following tracheotomy is critical for improving the quality of care for these patients. This study aims to investigate the incidence and characteristics of revisits following pediatric tracheotomy. METHODS Cross-sectional, population-based study using state databases. The State Inpatient Databases and State Emergency Department Databases for California, Florida, Iowa and New York 2010-11 were linked and examined for cases of pediatric tracheotomy (patients < 18.0 years) and corresponding subsequent 30-day post-discharge revisits. Demographic and descriptive data were analyzed determining the revisit rate, revisit diagnoses, procedures, and discharge dispositions. RESULTS 2,248 pediatric tracheotomy cases were extracted (60.8% male, mean age 8.3 years). There were 373 inpatient or emergency department revisits (30-day revisit rate, 16.6%), of which 34.3% occurred within 48 h after discharge. Of these, 59.2% were inpatient readmissions. There were ≤10 deaths during these revisits (30-day revisit mortality rate, ≤2.7%). The most common primary revisit diagnoses were "fitting of prosthesis and adjustment of devices" (25.7%, likely representing adjustment/replacement of the tracheotomy tube), respiratory failure (11.0%), intracranial injury (5.4%), pneumonia (4.0%), "other upper respiratory disease" (3.8%), and "complications of surgical procedures or medical care" (3.8%). The most common revisit procedures were endotracheal intubation (11.4%), mechanical ventilation (8.8%), and replacement of tracheostomy tube (≤2.7%). Children discharged to a skilled care facility (47.1%) were more likely than those discharged to home (52.9%) to have a revisit (23.3% versus 12.0%, respectively; p < 0.001). CONCLUSIONS Children undergoing tracheotomy have a substantial 30-day revisit rate, most notably during the first 48 h after discharge, often involving tracheotomy tube or pulmonary complications. Improvements in discharge planning should target prevention of these complications.
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Affiliation(s)
- Sophie Shay
- Department of Head and Neck Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA.
| | - Nina L Shapiro
- Department of Head and Neck Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Neil Bhattacharyya
- Department of Otology & Laryngology, Harvard Medical School, Boston, MA, USA
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Yu H, Mamey MR, Russell CJ. Factors associated with 30-day all-cause hospital readmission after tracheotomy in pediatric patients. Int J Pediatr Otorhinolaryngol 2017; 103:137-141. [PMID: 29224755 PMCID: PMC5728177 DOI: 10.1016/j.ijporl.2017.10.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine factors associated with post-tracheotomy hospital readmission within 30 days of discharge. METHODS Children 18 years and younger who underwent tracheotomy at Children's Hospital Los Angeles (CHLA) between 1/1/2005 and 12/31/2013 with at least 30 days of follow-up at CHLA were identified through ICD-9 procedure codes. Patient characteristics and covariates were obtained by linking manual chart review and administrative data. We used multivariate logistic regression to identify the independent association between risk factors and the primary outcome of 30-day all-cause same-hospital readmission. RESULTS Of the 273 patients included, the median age at admission was 6 months [interquartile range (IQR): 1-51 months]. Among this primarily male (60.8%) and Hispanic (66.3%) cohort with a high proportion of discharge on positive pressure ventilation (47.1%), the 30-day readmission rate was 22% (n = 60). Of the readmissions, 92% (n = 55) were unplanned and 64% (n = 35) were associated with acute respiratory illnesses. Multivariate regression analysis demonstrated that, among patients ≤12 months, discharge on positive pressure ventilation [adjusted odds ratio (aOR) = 2.88, 95% confidence interval (CI) = 1.19-6.97] was associated with increased odds of readmission, while gastrostomy tube placement during the tracheotomy hospitalization (aOR = 0.42, 95% CI = 0.19-0.96) and prematurity (aOR = 0.35, 95% CI = 0.15-0.83) were associated with decreased odds of readmission. In patients >1 year of age, increased length of hospitalization (aOR = 1.01 per hospital day, 95% CI = 1-1.02) and presence of comorbid malignancy (aOR = 6.03, 95% CI = 1.25-29.16) were associated with increased odds of readmission. CONCLUSIONS Over one-fifth of children undergoing tracheotomy had an unplanned hospital readmission within 30 days after discharge. Because the majority of readmissions were unplanned and due to acute respiratory illnesses, future research should investigate how discharge procedures and improved care coordination may lower readmission rates in high-risk patients (e.g., patients discharged on positive pressure ventilation).
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Affiliation(s)
- Helena Yu
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mary Rose Mamey
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA,Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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They Are Not Just Little Tracheostomy Tubes…or Are They? Pediatr Crit Care Med 2017; 18:992-993. [PMID: 28976465 DOI: 10.1097/pcc.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hartnick C, Diercks G, De Guzman V, Hartnick E, Van Cleave J, Callans K. A quality study of family-centered care coordination to improve care for children undergoing tracheostomy and the quality of life for their caregivers. Int J Pediatr Otorhinolaryngol 2017; 99:107-110. [PMID: 28688550 DOI: 10.1016/j.ijporl.2017.05.025] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/31/2017] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Christopher Hartnick
- Massachusetts Eye and Ear, Boston, MA, United States; Massachusetts General Hospital for Children, Boston, MA, United States.
| | | | | | | | | | - Kevin Callans
- Massachusetts Eye and Ear, Boston, MA, United States; Massachusetts General Hospital for Children, Boston, MA, United States
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Russell CJ, Mack WJ, Schrager SM, Wu S. Care Variations and Outcomes for Children Hospitalized With Bacterial Tracheostomy-Associated Respiratory Infections. Hosp Pediatr 2017; 7:16-23. [PMID: 27998905 DOI: 10.1542/hpeds.2016-0104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Identify hospital-level care variations and association with length of stay (LOS) and hospital revisit in children with tracheostomies hospitalized for bacterial respiratory tract infections (bRTIs). METHODS A multicenter, retrospective cohort study that used the Pediatric Health Information System database between 2007 and 2014 of patients with tracheostomies aged ≤18 years with a primary diagnosis of bRTI (eg, tracheitis) or a primary diagnosis of a bRTI symptom (eg, cough) and a secondary diagnosis of bRTI. Primary outcomes were LOS and 30-day all-cause revisit rates. Secondary outcomes included hospital-level diagnostic testing and anti-Pseudomonas antibiotic use. We used mixed-effects negative binomial (for LOS) and logistic (for revisit) regression to explore the relationship between hospital-level diagnostic test utilization and the outcomes. RESULTS Data representing 4137 unique patients with a median age of 3 years (interquartile range: 1-9 years) were included. Median LOS was 4 days (interquartile range: 3-8 days), and the 30-day revisit rate was 24.9%. Use of diagnostic testing and empirical anti-Pseudomonas antibiotics varied significantly among hospitals (all P values <.001). After adjusting for patient and hospital characteristics, compared with low test utilization hospitals, there were no differences in 30-day all-cause revisit rates in moderate (adjusted odds ratio: 1.19; 95% confidence interval [CI]: 0.93-1.52) or high (adjusted odds ratio: 1.07; 95% CI: 0.82-1.39) utilization hospitals. LOS in hospitals with moderate (% difference: -0.8%; 95% CI: -14.4-14.9%) or high (% difference: 13.9%; 95% CI: -0.7-30.6%) test utilization was not significantly longer. CONCLUSIONS Given that care variations were not associated with outcomes, future research should focus on standardizing diagnosis and treatment of bRTIs and readmission prevention in this population.
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Affiliation(s)
- Christopher J Russell
- Department of Pediatrics and .,Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Wendy J Mack
- Division of Biostatistics, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Susan Wu
- Department of Pediatrics and.,Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Riley CA, Barton BM, Lawlor CM, Cai DZ, Riley PE, McCoul ED, Hasney CP, Moore BA. NSQIP as a Predictor of Length of Stay in Patients Undergoing Free Flap Reconstruction. OTO Open 2017; 1:2473974X16685692. [PMID: 30480171 PMCID: PMC6239043 DOI: 10.1177/2473974x16685692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 11/29/2016] [Accepted: 12/02/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The National Surgical Quality Improvement Program (NSQIP) calculator was created to improve outcomes and guide cost-effective care in surgery. Patients with head and neck cancer (HNC) undergo ablative and free flap reconstructive surgery with prolonged postoperative courses. METHODS A case series with chart review was performed on 50 consecutive patients with HNC undergoing ablative and reconstructive free flap surgery from October 2014 to March 2016 at a tertiary care center. Comorbidities and intraoperative and postoperative variables were collected. Predicted length of stay was tabulated with the NSQIP calculator. RESULTS Thirty-five patients (70%) were male. The mean (SD) age was 67.2 (13.4) years. The mean (SD) length of stay (LOS) was 13.5 (10.3) days. The mean (SD) NSQIP-predicted LOS was 10.3 (2.2) days (P = .027). DISCUSSION The NSQIP calculator may be an inadequate predictor for LOS in patients with HNC undergoing free flap surgery. Additional study is necessary to determine the accuracy of this tool in this patient population. IMPLICATIONS FOR PRACTICE Head and neck surgeons performing free flap reconstructive surgery following tumor ablation may find that the NSQIP risk calculator underestimates the LOS in this population.
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Affiliation(s)
- Charles A. Riley
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Blair M. Barton
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Claire M. Lawlor
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - David Z. Cai
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Phoebe E. Riley
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
| | - Edward D. McCoul
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
- Department of Otorhinolaryngology,
Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of
Queensland, New Orleans, Louisiana, USA
| | - Christian P. Hasney
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
- Department of Otorhinolaryngology,
Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of
Queensland, New Orleans, Louisiana, USA
| | - Brian A. Moore
- Department of Otolaryngology–Head and
Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana,
USA
- Department of Otorhinolaryngology,
Ochsner Clinic Foundation, New Orleans, Louisiana, USA
- Ochsner Clinical School, University of
Queensland, New Orleans, Louisiana, USA
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Mortimer H, Kubba H. A retrospective case series of 318 tracheostomy-related adverse events over 6 years - a Scottish context. Clin Otolaryngol 2016; 42:936-940. [PMID: 27759914 DOI: 10.1111/coa.12774] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
| | - H Kubba
- Royal Hospital for Sick Children, Glasgow, UK
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Funamura JL, Yuen S, Kawai K, Gergin O, Adil E, Rahbar R, Watters K. Characterizing mortality in pediatric tracheostomy patients. Laryngoscope 2016; 127:1701-1706. [DOI: 10.1002/lary.26361] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Jamie L. Funamura
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Sonia Yuen
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Ozgul Gergin
- Department of Otolaryngology; Umraniye Education and Research Hospital; Istanbul Turkey
| | - Eelam Adil
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
| | - Karen Watters
- Department of Otolaryngology and Communication Enhancement; Boston Children's Hospital; Boston Massachusetts U.S.A
- Department of Otology and Laryngology; Harvard Medical School; Boston Massachusetts U.S.A
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Schweiger C, Manica D, Becker CF, Abreu LSP, Manzini M, Sekine L, Kuhl G. Tracheostomy in children: a ten-year experience from a tertiary center in southern Brazil. Braz J Otorhinolaryngol 2016; 83:627-632. [PMID: 27599810 PMCID: PMC9449076 DOI: 10.1016/j.bjorl.2016.08.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/01/2016] [Accepted: 08/10/2016] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Children may require tracheostomy due to many different health conditions. Over the last 40 years, indications of tracheostomy have endorsed substantial modifications. OBJECTIVE To evaluate pediatric patients warranted tracheostomy at our Hospital, in regard to their indications, associated comorbidities, complications and decannulation rates. METHODS Retrospective study concerning patients under 18 years of age undergoing tracheostomy in a tertiary health care center, from January 2006 to November 2015. RESULTS 123 children required a tracheostomy after ENT evaluation during the study period. A proportion of 63% was male, and 56% was under one year of age. Glossoptosis was the most common indication (30%), followed by subglottic stenosis (16%) and pharyngomalacia (11%). The mortality rate was 31%. By the end of this review, 35 children (28.4%) had been decannulated, and the fewer the number of comorbidities, the greater the decannulation rate (0.77±0.84 vs. 1.7±1.00 comorbidities; p<0.001). CONCLUSION Tracheostomy in children is a relatively frequent procedure at our hospital. The most common indications are glossoptosis and subglottic stenosis. A high mortality rate was found, potentially substantiated by the high number of critical care patients with chronic neurological conditions in this cohort. Our decannulation rate is slightly below other series, probably because of the greater amount of patients with comorbidities.
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Affiliation(s)
- Cláudia Schweiger
- Hospital de Clínicas de Porto Alegre, Serviço de Otorrinolaringologia, Porto Alegre, RS, Brazil.
| | - Denise Manica
- Hospital de Clínicas de Porto Alegre, Serviço de Otorrinolaringologia, Porto Alegre, RS, Brazil
| | - Carolina Fischer Becker
- Hospital de Clínicas de Porto Alegre, Serviço de Otorrinolaringologia, Porto Alegre, RS, Brazil
| | | | - Michelle Manzini
- Hospital de Clínicas de Porto Alegre, Serviço de Otorrinolaringologia, Porto Alegre, RS, Brazil
| | - Leo Sekine
- Universidade Federal do Rio Grande do Sul (UFRGS), Programa de Pós-graduação em Epidemiologia, Porto Alegre, RS, Brazil
| | - Gabriel Kuhl
- Hospital de Clínicas de Porto Alegre, Serviço de Otorrinolaringologia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Departamento de Oftalmologia e Otorrinolaringologia, Porto Alegre, RS, Brazil
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Children and Young Adults Who Received Tracheostomies or Were Initiated on Long-Term Ventilation in PICUs. Pediatr Crit Care Med 2016; 17:e324-34. [PMID: 27367044 PMCID: PMC5113027 DOI: 10.1097/pcc.0000000000000844] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize patients who received tracheostomies for airway compromise or were initiated on long-term ventilation for chronic respiratory failure in PICUs and to examine variation in the incidence of initiation, patient characteristics, and modalities across sites. DESIGN Retrospective cross-sectional analysis. SETTINGS Seventy-three North American PICUs that participated in the Virtual Pediatric Systems, LLC. PATIENTS PICU patients admitted between 2009 and 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 115,437 PICU patients, 1.8% received a tracheostomy or were initiated on long-term ventilation; 1,034 received a tracheostomy only, 717 were initiated on invasive ventilation, and 381 were initiated on noninvasive ventilation. Ninety percent had substantial chronic conditions and comorbidities, including more than 50% with moderate or worse cerebral disability upon discharge. Seven percent were initiated after a catastrophic injury/event. Across sites, there was variation in incidence of tracheotomy and initiation of long-term ventilation, ranging from 0% to 4.6%. There also was variation in patient characteristics, time to tracheotomy, number of extubations prior to tracheostomy, and the use of invasive ventilation versus noninvasive ventilation. CONCLUSIONS Although the PICU incidence of initiation of tracheostomies and long-term ventilation was relatively uncommon, it suggests that thousands of children and young adults receive these interventions each year in North American PICUs. The majority of them have conditions and comorbidities that impose on-going care needs, beyond those required by artificial airways and long-term ventilation themselves.
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Gergin O, Adil EA, Kawai K, Watters K, Moritz E, Rahbar R. Indications of pediatric tracheostomy over the last 30 years: Has anything changed? Int J Pediatr Otorhinolaryngol 2016; 87:144-7. [PMID: 27368463 DOI: 10.1016/j.ijporl.2016.06.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
IMPORTANCE Recent reports have shown that the indications for pediatric tracheostomy have evolved over time. OBJECTIVE To review the indications for pediatric tracheostomy over the last 30 years. DESIGN Retrospective chart review. SETTING Tertiary referral children's hospital. PARTICIPANTS Patients who underwent tracheostomy. INTERVENTION Surgical tracheostomy placement. MAIN OUTCOMES AND MEASURES Medical records for patients who underwent surgical tracheostomy over the 30-year study period (1984-2014) were reviewed. Patient characteristics including age, gender, birth-weight, gestational age and death were collected and compared with the primary indication for tracheostomy using bivariable analysis. RESULTS Five hundred and one patients met inclusion criteria. The most common primary indications for tracheostomy were cardiopulmonary disease (34%) and neurological impairment (32%), followed by airway obstruction (19%), craniofacial (11%), and traumatic injury (4%). Over the last five years (2010-14) cardiopulmonary disease became the most common indication for tracheostomy. CONCLUSIONS and RELEVANCE The indications for pediatric tracheostomy have evolved over the past 30 years. Infectious causes of airway obstruction and tracheostomy have almost disappeared. Tracheostomy is now most commonly performed in very premature patients with cardiopulmonary or neurological impairment who require prolonged ventilator support.
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Affiliation(s)
- Ozgul Gergin
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | - Eelam A Adil
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA
| | - Ethan Moritz
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | - Reza Rahbar
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA; Department of Otology and Laryngology, Harvard Medical School, Boston, MA, USA.
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Bauer E, Mahida JB, Boomer LA, Lutmer JE, Minneci PC, Deans KJ, Elmaraghy CA. Outcomes following neuromuscular blockade in patients receiving tracheostomies. Int J Pediatr Otorhinolaryngol 2016; 84:101-5. [PMID: 27063762 DOI: 10.1016/j.ijporl.2016.02.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/19/2016] [Accepted: 02/26/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study is to determine whether the use of neuromuscular blockade agents (NMBAs) in pediatric patients following tracheostomy is associated with increased rates of complications or a prolonged length of stay. METHODS This was a single-center retrospective chart review of pediatric patients undergoing tracheostomy placement between 2010 and 2013 who were admitted to the pediatric or neonatal intensive care units and did or did not receive NMBA within 7 days post-procedure. RESULTS Out of 114 included patients, 26 (23%) received NMBAs during the postoperative period. Patients receiving NMBAs were more likely to have cardiac disease and preoperative respiratory failure but less likely to have neurologic disease. Patients receiving NMBAs had a longer median postoperative length of stay (33 vs. 23 days, p=0.043) and were more likely to have postoperative ileus (12% vs. 3%, p=0.037). CONCLUSION In patients undergoing tracheostomy placement, use of NMBAs is associated with prolonged postoperative hospital courses. NMBAs are not associated with a higher likelihood of postoperative complications.
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Affiliation(s)
- Eric Bauer
- The Ohio State University College of Medicine, Columbus, OH, United States
| | - Justin B Mahida
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States; Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Laura A Boomer
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jeffrey E Lutmer
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States; Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States; Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Charles A Elmaraghy
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, United States.
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Watters K, O'Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy. Laryngoscope 2016; 126:2611-2617. [PMID: 27060012 DOI: 10.1002/lary.25972] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/18/2016] [Accepted: 02/16/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children. STUDY DESIGN Retrospective cohort study. METHODS Children (0-16 years) in Medicaid from 10 states undergoing tracheostomy in 2009, identified with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes and followed through 2011, were selected using the Truven Health Medicaid Marketscan Database (Truven Health Analytics, Inc., Ann Arbor, MI). Patient demographic and clinical characteristics were assessed with likelihood of death and tracheostomy complication using chi-square tests and logistic regression. Healthcare use and spending across the care continuum (hospital, outpatient, community, and home) were reported. RESULTS A total of 502 children underwent tracheostomy in 2009, with 34.1% eligible for Medicaid because of disability. Median age at tracheostomy was 8 years (interquartile range 1-16 years), and 62.7% had a complex chronic condition. Two-year rates of in-hospital mortality and tracheostomy complication were 8.9% and 38.8%, respectively. In multivariable analysis, the highest likelihood of mortality occurred in children age < 1 year compared with 13+ years (odds ratio [OR] 7.3; 95% confidence interval [CI], 3.2-17.1); the highest likelihood of tracheostomy complication was in children with a complex chronic condition versus those without a complex chronic condition (OR 3.3; 95% CI, 1.1-9.9). Total healthcare spending in the 2 years following tracheostomy was $53.3 million, with hospital, home, and primary care constituting 64.4%, 9.4%, and 0.5% of total spending, respectively. CONCLUSION Mortality and morbidity are high, and spending on primary and home care is small following tracheostomy in children with Medicaid. Future studies should assess whether improved outpatient and community care might improve their health outcomes. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2611-2617, 2016.
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Affiliation(s)
- Karen Watters
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts.
| | - Margaret O'Neill
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Hannah Zhu
- Department of Pediatrics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Robert J Graham
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Matthew Hall
- Children's Hospital Association, Overland Park, KS, U.S.A
| | - Jay Berry
- Department of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Abode KA, Drake AF, Zdanski CJ, Retsch-Bogart GZ, Gee AB, Noah TL. A Multidisciplinary Children's Airway Center: Impact on the Care of Patients With Tracheostomy. Pediatrics 2016; 137:e20150455. [PMID: 26755695 DOI: 10.1542/peds.2015-0455] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children with complex airway problems see multiple specialists. To improve outcomes and coordinate care, we developed a multidisciplinary Children's Airway Center. For children with tracheostomies, aspects of care targeted for improvement included optimizing initial hospital discharge, promoting effective communication between providers and caregivers, and avoiding tracheostomy complications. METHODS The population includes children up to 21 years old with tracheostomies. The airway center team includes providers from pediatric pulmonology, pediatric otolaryngology/head and neck surgery, and pediatric gastroenterology. Improvement initiatives included enhanced educational strategies, weekly care conferences, institutional consensus guidelines and care plans, personalized clinic schedules, and standardized intervals between airway examinations. A patient database allowed for tracking outcomes over time. RESULTS We initially identified 173 airway center patients including 123 with tracheostomies. The median number of new patients evaluated by the center team each year was 172. Median hospitalization after tracheostomy decreased from 37 days to 26 days for new tracheostomy patients <1 year old discharged from the hospital. A median of 24 care plans was evaluated at weekly conferences. Consensus protocol adherence increased likelihood of successful decannulation from 68% to 86% of attempts. The median interval of 8 months between airway examinations aligned with published recommendations. CONCLUSIONS For children with tracheostomies, our Children's Airway Center met and sustained goals of optimizing hospitalization, promoting communication, and avoiding tracheostomy complications by initiating targeted improvements in a multidisciplinary team setting. A multidisciplinary approach to management of these patients can yield measurable improvements in important outcomes.
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Affiliation(s)
- Kathleen A Abode
- University of North Carolina Health Care System, Chapel Hill, North Carolina; and Division of Pulmonology, Department of Pediatrics, and
| | - Amelia F Drake
- Division of Pulmonology, Department of Pediatrics, and Division of Pediatric Otolaryngology, Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Carlton J Zdanski
- Division of Pulmonology, Department of Pediatrics, and Division of Pediatric Otolaryngology, Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Amanda B Gee
- Division of Pulmonology, Department of Pediatrics, and
| | - Terry L Noah
- Division of Pulmonology, Department of Pediatrics, and
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Lavin J, Shah R, Greenlick H, Gaudreau P, Bedwell J. The Global Tracheostomy Collaborative: one institution's experience with a new quality improvement initiative. Int J Pediatr Otorhinolaryngol 2016; 80:106-8. [PMID: 26746621 DOI: 10.1016/j.ijporl.2015.11.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 11/18/2015] [Accepted: 11/23/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Given the low frequency of adverse events after tracheostomy, individual institutions struggle to collect outcome data to generate effective quality improvement protocols. The Global Tracheostomy Collaborative (GTC) is a multi-institutional, multi-disciplinary organization that utilizes a prospective database to collect data on patients undergoing tracheostomy. We describe our institution's preliminary experience with this collaborative. It was hypothesized that entry into the database would be non-burdensome and could be easily and accurately initiated by skilled specialists at the time of tracheostomy placement and completed at time of patient discharge. METHODS Demographic, diagnostic, and outcome data on children undergoing tracheostomy at our institution from January 2013 to June 2015 were entered into the GTC database, a database collected and managed by REDCap (Research Electronic Data Capture). All data entry was performed by pediatric otolaryngology fellows and all post-operative updates were completed by a skilled tracheostomy nurse. Tracked outcomes included accidental decannulation, failed decannulation, tracheostomy tube obstruction, bleeding/tracheoinnominate fistula, and tracheocutaneous fistula. RESULTS Data from 79 patients undergoing tracheostomy at our institution were recorded. Database entry was straightforward and entry of patient demographic information, medical comorbidities, surgical indications, and date of tracheostomy placement was completed in less than 5min per patient. The most common indication for surgery was facilitation of ventilation in 65 patients (82.3%). Average time from admission to tracheostomy was 62.6 days (range 0-246). Stomal breakdown was seen in 1 patient. A total of 72 patients were tracked to hospital discharge with 53 patients surviving (88.3%). No mortalities were tracheostomy-related. CONCLUSION The Global Tracheostomy Collaborative is a multi-institutional, multi-disciplinary collaborative that collects data on patients undergoing tracheostomy. Our experience proves proof of concept of entering demographics and outcome data into the GTC database in a manner that was both accurate and not burdensome to those participating in data entry. In our tertiary care, pediatric academic medical center, tracheostomy continues to be a safe procedure with no major tracheostomy-related morbidities occurring in this patient population involvement with the GTC has shown opportunities for improvement in communication and coordination with other tracheostomy-related disciplines.
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Affiliation(s)
- Jennifer Lavin
- Division of Pediatric Otolaryngology, Children's National Medical Center, United States
| | - Rahul Shah
- Division of Pediatric Otolaryngology, Children's National Medical Center, United States
| | - Hannah Greenlick
- Division of Pediatric Otolaryngology, Children's National Medical Center, United States
| | - Philip Gaudreau
- Division of Pediatric Otolaryngology, Children's National Medical Center, United States
| | - Joshua Bedwell
- Division of Pediatric Otolaryngology, Children's National Medical Center, United States.
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