Nurse practitioner coverage is associated with a decrease in length of stay in a pediatric chronic ventilator dependent unit

Factors influencing the length of stay among patients admitted to a tertiary pediatric intensive care unit in Saudi Arabia

This study aimed to assess the variables contributing to the length of stay in the pediatric intensive care unit. This study utilized a retrospective design by analyzing data from the Virtual Pediatric Systems web-based database. The study was conducted in a tertiary hospital-King Fahad Medical City in Riyadh, Saudi Arabia-from January 1, 2014 to December 31, 2019. The patients were admitted to intensive care with complex medical and surgical diseases. The variables were divided into quantitative and qualitative parameters, including patient data, Pediatric Risk of Mortality III score, and complications. Data from 3,396 admissions were analyzed. In this cohort, the median and mean length of stay were 2.8 (interquartile range, 1.08-7.04) and 7.43 (standard deviation, 14.34) days, respectively. The majority of long-stay patients-defined as those staying longer than 30 days-were less than 12 months of age (44.79%), had lower growth parameters (p < 0.001), and had a history of admission to pediatric intensive care units. Moreover, the majority of long-stay patients primarily suffered from respiratory diseases (51.53%) and had comorbidities and complications during their stay (p < 0.001). Multivariate analysis of all variables revealed that central line-associated bloodstream infections (p < 0.001), external ventricular drain insertion (p < 0.005), tracheostomy (p < 0.001), and use of mechanical ventilation (p < 0.001) had the most significant associations with a longer stay in the pediatric intensive care unit. The factors associated with longer stays included the admission source, central nervous system disease comorbidity, and procedures performed during the stay. Factors such as respiratory support were also associated with prolonged intensive care unit stays.

Mechanical Ventilation During Chronic Lung Disease

For infants with the most severe forms of chronic lung disease, regardless of etiology, chronic mechanical ventilation can provide stability, reduce acute respiratory events, and alleviate increased work of breathing. This approach prioritizes the baby's growth and development during early life. Once breathing comfortably, these infants can tolerate developmental therapies with the goal of achieving the best neurocognitive outcomes possible.

Chronic respiratory failure in bronchopulmonary dysplasia

Although survival has improved dramatically for extremely preterm infants, those with the most severe forms of bronchopulmonary dysplasia (BPD) fail to improve in the neonatal period and go on to develop chronic respiratory failure. When careful weaning of respiratory support is not tolerated, the difficult decision of whether or not to pursue chronic ventilation via tracheostomy must be made. This requires shared decision-making with an interdisciplinary medical team and the child's family. Although they suffer from increased morbidity and mortality, the majority of these children will survive to tolerate ventilator liberation and tracheostomy decannulation. Care coordination for the technology-dependent preterm infant is complex, but there is a growing consensus that chronic ventilation can best support neurodevelopmental progress and improve long-term outcomes.

Comparison of the Outcome of Patient Management with Physician Extenders Only and with both Residents and Extenders

This was a retrospective study that aimed to determine the treatment outcome of patients seen in the trauma unit of the Johnson City Medical Center (JCMC). The study included 2844 patients in the trauma registry and evaluated age, sex, injury severity score (ISS), length of stay (LOS) in the intensive care unit (ICU), overall hospital lengths of stay (LOS), ventilator days, discharge disposition, and complications between one group managed by extenders only and the second managed by both residents and extenders. The sample size of the two groups was similar (group one = 1446 and group two = 1398) and the proportions of males and females in the two groups were identical (males = 65%, females = 35%). Both groups had similar mechanisms of injury, although group one had a higher percentage of falls (32.9% vs. 22.03%) and group two had a higher proportion of motor vehicle crash (MVC) traumas (40.41% vs 30%). There was no significant difference in those discharged home and deaths between the two groups. (χ²(1, N = 2258) = 0.04, p = 0.82). Complications showed statistical significance when looking at extenders vs. residents plus extenders for all complications (χ²(7, N = 196) = 38.73, p ≤ 0.0001). It is possible that having extenders only versus both extenders and residents had no significant difference among the patient outcomes based on the variables age, sex, ISS, ICU days, overall hospital LOS, and ventilator days; however, when observing complications between the two groups, it is possible that patients are more likely to have complications due to overall hospital LOS in the residents plus extenders group.

Long-term ventilation for children with chronic lung disease of infancy

PURPOSE OF REVIEW

Modern medical advances have resulted in an increased survival after extremely preterm birth. However, some infants will develop severe bronchopulmonary dysplasia (BPD) and fail to wean from invasive or noninvasive positive pressure support. It remains unclear which infants will benefit from tracheostomy placement for chronic ventilation. Once the decision to pursue chronic ventilation has been made, questions remain with respect to the timing of tracheotomy surgery, optimal strategies for mechanical ventilation, and multidisciplinary care in both the inpatient and outpatient settings. The appropriate time for weaning mechanical ventilation and tracheostomy decannulation has similarly not been determined.

RECENT FINDINGS

Although there remains a paucity of randomized controlled trials involving infants with severe BPD, a growing body of evidence suggests that chronic ventilation via tracheostomy is beneficial to support the growth and development of severely affected preterm children. However, delivering such care is not without risk. Chronic ventilation via tracheostomy requires complex care coordination and significant resource utilization.

SUMMARY

When chronic respiratory insufficiency limits a preterm infant's ability to grow and develop, chronic invasive ventilation may facilitate neurodevelopmental progress and may lead to an improved long-term outcome.