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A Standardized Discharge Process Decreases Length of Stay for Ventilator-Dependent ChildrenChristopher D. Baker, MD, a, b Sara Martin, RN, c Jodi Thrasher, MSN, b, c Heather M. Moore, PNP, a, b Joyce Baker, RRT, c Steven H. Abman, MD, a, b Jason Gien, MDa, d
aPediatric Heart Lung Center, bDivision of Pediatric
Pulmonary Medicine, and dDivision of Neonatology,
Department of Pediatrics, University of Colorado School
of Medicine, Aurora, Colorado; and cChildren’s Hospital
Colorado, Aurora, Colorado
Dr Baker conceptualized and designed the study,
cofounded the Ventilator Care Program, drafted
the manuscript, and supervised the data collection
and data analyses; Ms Martin contributed to study
design, performed the initial data analyses, and
critically revised the manuscript; Ms Thrasher
contributed to study design, cofounded the
Ventilator Care Program, and critically revised the
manuscript; Ms Moore and Ms Baker contributed to
study design and critically revised the manuscript;
Drs Abman and Gien contributed to study design,
cofounded the Ventilator Care Program, and
critically revised the manuscript; and all authors
approved the fi nal manuscript as submitted.
DOI: 10.1542/peds.2015-0637
Accepted for publication Jul 29, 2015
Address correspondence to Christopher D. Baker,
MD, Pediatric Heart Lung Center, 13123 E. 16th Ave,
Box B-395, Aurora, CO 80045. E-mail: christopher.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2016 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURE: The authors have
indicated they have no fi nancial relationships
relevant to this article to disclose.
FUNDING: Funded by the National Institutes of
Health grants NIH K12-HL090147-01 (to Dr Baker),
NIH K23-HL121090-01 (to Dr Baker), and NIH 5K08-
The decision to initiate chronic
ventilation via tracheostomy
tube often results in prolonged
hospitalization to achieve medical
stability, train caregivers, provide
adequate home nursing, and
coordinate complex outpatient
care. Extended inpatient care is
costly, specifically as compared with
providing long-term mechanical
ventilation at home.1–5 Thus, although
such patients present infrequently,
children who require tracheostomy
and chronic ventilator therapy pose
substantial challenges and burdens on
caregivers and health care systems.6–8
abstractOBJECTIVE: Children who require chronic mechanical ventilation via
tracheostomy are medically complex and require prolonged hospitalization,
placing a heavy burden on caregivers and hospital systems. We developed
an interdisciplinary Ventilator Care Program to relieve this burden, through
improved communication and standardized care. We hypothesized that
a standardized team approach to the discharge of tracheostomy- and
ventilator-dependent children would decrease length of stay (LOS), reduce
patient costs, and improve safety.
METHODS: We used process mapping to standardize the discharge process for
children requiring chronic ventilation. Interventions included developing
education materials, a Chronic Ventilation Road Map for caregivers,
utilization of the electronic medical record to track discharge readiness,
team-based care coordination, and timely case management to arrange
home nursing. We aimed to decrease overall and pediatric respiratory care
unit LOS as the primary outcomes. We also analyzed secondary outcomes
(mortality, emergency department visits, unplanned readmissions),
and per-patient hospital costs during 2-year “preintervention” and
“postintervention” periods (n = 18 and 30, respectively).
RESULTS: Patient demographics were not different between groups. As
compared with the preintervention cohort, the overall LOS decreased
42% (P = .002). Pediatric respiratory care unit LOS decreased 56% (P =
.001). As a result, unplanned readmissions, emergency department visits,
and mortality were not increased. Direct costs per hospitalization were
decreased by an average of 43% (P = .01).
CONCLUSIONS: Although LOS remained high, a standardized discharge process
for chronically ventilated children by an interdisciplinary Ventilator Care
Program team resulted in decreased LOS and costs without a negative
impact on patient safety.
QUALITY REPORTPEDIATRICS Volume 137 , number 4 , April 2016 :e 20150637
NIH
To cite: Baker CD, Martin S, Thrasher J, et al.
A Standardized Discharge Process Decreases
Length of Stay for Ventilator-Dependent Children.
Pediatrics. 2016;137(4):e20150637
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BAKER et al
Children may require chronic
ventilation in the neonatal setting
for a number of clinical indications
including severe bronchopulmonary
dysplasia (BPD), congenital
diaphragmatic hernia, airway
malacia, neuromuscular disease,
and other forms of respiratory
insufficiency.9–11 Traumatic brain
injury, paralysis, central neurologic
conditions, progression of chronic
respiratory insufficiency, as well as
postinfectious sequelae may result
in the need for chronic ventilation in
older children.12, 13 Regardless of the
primary cause of chronic respiratory
failure, children with tracheostomy
who require chronic ventilation are
medically complex with significant
morbidity and mortality.14–16
Hospital practice patterns vary as
to whether chronically ventilated
children are cared for exclusively in
neonatal and pediatric intensive care
units or are transferred to step-down
units and/or inpatient wards once
medical stability has been achieved.17
Regardless, the overall length of stay
(LOS) tends to be many months or
years for the most complex patients.
In some centers, those with stable
chronic ventilation requirements
may be transferred to long-term
acute care facilities.18
Our interdisciplinary Ventilator
Care Program (VCP) was formed
in 2006 as a collaboration between
pulmonology, neonatology,
otolaryngology, nursing, respiratory
therapy, and others. The program
originated in the NICU and initially
aimed to improve communication,
standardize approaches to the
common morbidities associated with
the need for chronic ventilation, and
improve outcomes for chronically
ventilated neonates. Due to the need
for coordinated interdisciplinary
care, the program expanded to
include care of older children.
Since its inception, we have held
weekly interdisciplinary inpatient
rounds to discuss the complex
care of these children. With input
from the primary medical service,
nurses, therapists, and caregivers,
the VCP team attempts to accurately
describe each child’s current status
and progress for optimal medical
decision-making. The pulmonary and
neonatology directors of the VCP lead
weekly rounds, provide longitudinal
perspective, and collaborate with
the primary inpatient attending
and care teams to manage and
coordinate the multisystem care of
each patient. Emphasis is placed on
major decisions, such as the timing
of surgical procedures, ventilation
strategies, transition to the portable
ventilator, and discharge planning.
Weekly plans are reviewed after each
child is discussed.
Our VCP team approach has resulted
in a dramatic increase in survival for
infants with severe BPD.19 However,
the duration of the inpatient stays for
these children remained prolonged,
and significant variation in practice
patterns were observed between
patients, with respect to discharge
teaching methods, the use of informal
handouts, and the acquisition
of home nursing. In an effort to
standardize care, we used process
mapping, a method previously
shown to reduce such variance in
care in the emergency department
(ED) and other settings.20, 21 We
hypothesized that implementation
of a standardized discharge process
would result in a timely and safe
home discharge after initiation of
chronic ventilation.
METHODS
We developed a formal quality
improvement project with the goal
of measuring LOS, outcomes, and
per-patient hospital costs before
and after implementation of a
standardized discharge process for
our identified patient population.
The institutional quality review panel
approved the project, determined
that it did not involve human subjects
research, and authorized publication
of this quality report.
Study Design, Setting, and Population
We identified patients who were
discharged from the hospital
from our tertiary care children’s
hospital after initiation of chronic
ventilation during a 2-year
“preintervention” period (March
2011 to February 2013) and during
a “postintervention” period (March
2013 to February 2015). Children
who were weaned from invasive
mechanical ventilation before
discharge, those mechanically
ventilated at home before admission,
those discharged on continuous
intravenous (IV) infusions, and those
who were back-transported to other
hospitals before home discharge
were excluded. Death between
initiation of chronic ventilation and
hospital discharge was also recorded.
Patients who had a tracheostomy
(without mechanical ventilation)
before hospital admission were
included if chronic ventilation was
initiated during the inpatient stay.
Children in both groups were
diagnosed with chronic respiratory
failure or insufficiency due to
neonatal lung disease, neuromuscular
disease, central hypoventilation,
or other disorders and treated in
either our neonatal or PICU for the
acute illness. Once a decision was
made to pursue chronic ventilation,
a tracheostomy was placed by
an otolaryngologist and the first
tracheostomy tube change was
completed 5 to 7 days after surgery
and before transfer to the pediatric
respiratory care unit (PRCU). ICU
care continued until each child
was medically stable for home
discharge on a home ventilator. Our
institution utilizes Trilogy (Philips
Respironics, Murrysville, PA) and
Pulmonetics LTV (CareFusion,
San Diego, CA) ventilators for
chronic ventilation. Stability was
determined by consensus during
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PEDIATRICS Volume 137 , number 4 , April 2016
weekly VCP rounds and consisted
of breathing comfortably with an
oxygen requirement (fraction of
inspired oxygen) of <0.4, maintained
off continuous IV medications, and
without episodes of hypoxemia
for ∼2 weeks. Maximal ventilator
settings for transfer were not
specified. At this time, patients were
transferred to the PRCU, a section of
the inpatient pulmonary floor where
education and discharge planning
are completed. Our program insists
that patients transfer to our PRCU for
focused training and demonstration
of caregiver competency rather than
discharging home directly from the
ICU.
Patient Identifi cation
Subjects were identified by surgical
billing code for tracheostomy
placement (or admission with a
tracheostomy) combined with a
hospital charge for mechanical
ventilation on a hospital day when
the child was not admitted to an
ICU. This list was compared with the
VCP’s inpatient census for the study
time period and no discrepancies
were identified.
Interventions
We formed a VCP administrative
team consisting of the medical
director, inpatient and outpatient
advanced practice nurses, and the
director of respiratory care. We
began holding planning meetings
twice each month in July 2012
to plan the quality improvement
project. In January 2013, our team
began working with a process
improvement specialist to build
future state process maps capturing
discharge processes of the population
of interest (Fig 1A). We met with
physician representatives from
the involved medical disciplines
(pulmonology, neonatology, critical
care, otolaryngology, pediatric
residents), as well as respiratory and
developmental therapists, nurses,
case managers, social workers, and
families. A formal process map was
then created and approved by the
team.
In collaboration with family partners,
we developed formal discharge
materials to align with institutional
policies and procedures. We also
reviewed printed educational
materials from other institutions to
ensure completeness of our formal
handouts and then developed unique
instructional videos (materials
available upon request from the
corresponding author). All handouts
and videos were produced in both
English and Spanish. We designed
a “Chronic Ventilation Road Map”
to communicate the discharge
process in family-friendly language
to families and providers (Fig 1B).
A laminated copy of the road map
was placed in each child’s hospital
room and referenced by family and
clinicians throughout the discharge
education process to show progress
over time.
Standardized team-based care
coordination was optimized by
using a dedicated advanced practice
nurse and rehabilitation respiratory
therapist to assist with education
and track progress of all families.
The electronic medical record
was used in a number of ways to
facilitate care coordination activities.
A Best Practice Alert was created
to encourage VCP consultation
whenever a chronically ventilated
child is hospitalized. A Discharge
Readiness Report and documentation
flowsheet track each child’s progress
toward discharge. This report is
projected on a screen during weekly
VCP rounds for the team to review
and update. A separate Caregiver
Skills Checklist documents both the
instruction provided to caregivers
and the caregiver’s demonstration
of competency in each skill.
Standardized Care Coordination
notes were used during weekly
meetings and care conferences.
Tofil et al22 used high-fidelity
simulation training to provide
caregiver education within a home
ventilator program. As part of
our formal training process, we
collaborated with our hospital’s
high-fidelity simulation laboratory to
pilot similar training for caregivers
of VCP patients. Beginning in April
of 2014, caregivers from each
family completed 2 emergency
simulation modules that focused
on management of a plugged
tracheostomy tube and ventilator
malfunction. Skills reinforced by
the training included suctioning,
changing the tracheostomy tube,
performing bag-tracheostomy
ventilation, activating the emergency
medical response system, and
performing full cardiopulmonary
resuscitation.
Arrangement of private duty
nursing (PDN) and durable medical
equipment was prioritized. As soon
as the need for chronic ventilation
was determined, the ICU case
manager and respiratory therapist
identified the appropriate home care
agencies and made initial contact.
Case management also ensured that
each child’s insurance coverage was
appropriate for the provision of
in-home PDN.
Although family care conferences
took place before our formal quality
improvement project, we began
to require 2 essential conferences
with each family, a Transition Care
Conference (when a child is ready to
transfer from the ICU to the PRCU)
and a Discharge Care Conference
(in the days before discharge).
Additional care conferences were
scheduled as needed. Because
we prioritized the arrangement
of PDN to occur earlier in the
hospitalization, PDN staff members
were able to attend these critical
meetings. Every effort was made to
have a representative from the PDN
agency present at the Transition and
Discharge Care Conferences.
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FIGURE 1A, Process map. VCP team members participated in process mapping sessions to determine the necessary steps for a safe discharge. In the fi gure, color-coding indicates the provider responsible for completing each task. ENT, Ear Nose Throat specialist (otolaryngologist); PT, physical therapy; OT, occupational therapy; RT, respiratory therapy; SW, social work; DME, durable medical equipment; CM, case management; Ox, oximetry; WOB, work of breathing. B, Chronic ventilation road map. The road map outlines the discharge process in a “family friendly” manner. The map emphasizes the collaborative team approach to care and the focus on caregiver education.
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PEDIATRICS Volume 137 , number 4 , April 2016
Data Collection
A dashboard was developed to collect
patient data for tracking of quality
metrics on an ongoing basis. Protected
health information was stored
securely on a password protected
hospital network. The primary study
outcomes were overall hospital
LOS and PRCU LOS (the time from
ICU transfer to discharge home).
Secondary outcomes included the
time from tracheostomy placement
to hospital discharge and balancing
metrics of patient safety: 1-year
mortality, ED visits (within 6 months),
and unplanned hospital readmissions
(within 30 days and 12 months).
Direct hospital costs were also
compared. If a child already had a
tracheostomy tube at admission, the
time from tracheostomy placement
to discharge was considered to be
equal to the overall LOS. The hospital
readmission rate was calculated by
dividing the total readmissions in
the given time period by the number
of patients in a cohort, permitting
readmission rates of greater than
100%. Planned hospitalizations for
ventilator weaning, decannulation,
or other anticipated reasons were
excluded. In the postintervention
cohort, 12-month unplanned
readmissions and mortality were only
available for 16 of 30 patients, as a full
year had not passed since discharge
at the time of data collection. The
hospital finance department provided
cost data by using the EPSi software
package (Allscripts, Chicago, IL).
Direct hospital costs did not include
physician charges. In addition to the
reported quality metrics, we reviewed
each patient’s electronic medical
record to obtain the demographic and
clinical data reported.
Statistical Analysis
Primary and secondary outcome
measures were compared with
2-sample t testing and 1-year
mortality was compared with a χ2
test for association. Nonparametric
demographic data were compared
by Mann-Whitney testing and
presented as medians with ranges.
Outcomes were reviewed over time
utilizing statistical process control
I-charts. SD and control limits were
calculated with the average moving
range method. All standard rules for
special cause variation were applied
to control charts. Centerlines were
shifted at the point of statistical
special cause. All statistical testing
and I-charts were completed by using
Minitab Statistical Software version
17 (State College, PA). Significance
level was set at α = 0.05.
RESULTS
A total of 48 subjects were studied;
18 in the preintervention cohort and
30 in the postintervention cohort.
Six additional children (3 in each
cohort) died in the hospital after
initiation of chronic ventilation, but
before initial discharge. One child
was discharged on IV treprostinil
and was excluded. One child in the
preintervention cohort was weaned
from mechanical ventilation before
discharge due to lack of homecare
services in a rural area and was thus
excluded. Two children (1 in each
cohort) were back-transported to
regional hospitals in other states and
were thus also excluded. No children
were transferred to subacute care,
as a facility for chronically ventilated
children does not exist in our state.
Patient characteristics were similar
between study groups (Table 1).
There were more male children in
both cohorts.
As shown in Table 1, severe BPD
after premature birth was the most
common indication for chronic
ventilation. Tracheomalacia
and bronchomalacia were more
frequently diagnosed in the
postintervention group. Pulmonary
hypertension complicated the course
of many children.
The 2 primary study outcomes,
overall LOS and PRCU LOS, were
significantly decreased in the
postintervention cohort (Table 2).
Mean overall LOS decreased from
249 to 143.4 days (42% reduction, P
= .002), and PRCU LOS was decreased
from 111.8 to 49.7 days (56%
reduction, P = .001). The statistical
process control I-chart for overall
LOS (Fig 2A) reveals that some
patients continued to require lengthy
hospitalizations in excess of 300 days
even after the intervention. However,
the I-chart in Figure 2B demonstrates
a sustained reduction in PRCU
LOS over the 2-year period after
implementation of the standardized
process. The time from tracheostomy
placement to discharge was also
decreased from 196.8 to 116.1 days
(41% reduction, P = .003). LOS within
the ICU was decreased by 32% after
the intervention, but this difference
was not statistically significant due to
the large variance within each study
group.
The secondary outcomes were
not negatively impacted by the
intervention (Table 2). One-year
mortality after discharge was 17%
in the preintervention cohort (1
patient with cardiopulmonary arrest
at home; 2 with septic shock) and
0% in the 16 patients with available
data at the writing of this article (P
= .09). The 12-month unplanned
readmission rate in these patients
was reduced by 47%, but this change
was not statistically significant (P =
.13). ED visits within 6 months and
the 30-day unplanned readmission
rate remained unchanged.
Mean direct hospital costs were
significantly decreased by 43% per
hospitalization (P = .01). A portion
of this cost reduction may have been
due to a variety of hospital-wide
resource stewardship initiatives
unrelated to this particular study.
DISCUSSION
We studied the impact of a novel
standardized discharged process
for ventilator dependent children
within an interdisciplinary VCP
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at our institution. Through an
organized quality improvement
intervention, we achieved a
striking reduction in the duration
of hospitalization required
for implementation of chronic
ventilation via tracheostomy.
Furthermore, by emphasizing
caregiver education and consistency
of care, morbidity and mortality
were not increased as a result of the
shorter hospitalization.
The medical management of children
with chronic respiratory failure
can be complex.23 Although we
demonstrate here the benefits of
a standardized discharge process,
the importance of interdisciplinary
collaborative decision-making
to develop a customized care
plan for each child cannot be
overemphasized. Many of these
children suffer from severe
parenchymal lung disease, airways
disease, congenital heart disease, and
pulmonary hypertension. The VCP
team requests that the neonatology
or critical care primary team consult
pulmonology and otolaryngology
before tracheostomy placement to
ensure that caregivers understand
the benefits, risks, and time course
of chronic ventilation including the
lengthy hospital stay. Gastrostomy
tube feedings are nearly always
necessary, and empirical gastric
fundoplication is requested for
children at greatest risk of aspiration
in the setting of gastroesophageal
reflux. Our hospital’s
interdisciplinary pulmonary
hypertension team (consisting
of pulmonary, cardiology, and
intensivist providers) is consulted
for children with pulmonary vascular
disease. The role of developmental
therapists (physical, occupational,
and speech–language pathology) who
see the children regularly is critical
for determining medical stability,
readiness for transition to the home
ventilator, and discharge timing.
Our results reveal that overall
LOS was significantly lower in the
postintervention cohort, but the
corresponding I-chart failed to reveal
a sustained reduction. This is because
the most severely affected children,
particularly those born extremely
premature, have multisystem
disease and will continue to require
prolonged hospitalization to reach
medical stability. The medical
complexity of a child is expected to
result in greater costs. However,
the sustained decrease in PRCU
e6
TABLE 1 Patient Characteristics
Preintervention, n
= 18
Postintervention,
n = 30
P
Characteristics
Gender (boy, girl) 14, 4 19, 11 .35
Gestational age, median (range), wk 34.5 (23–40) 33 (23–40) .44
Birth weight, median (range), g 2236 (425–4049) 1419 (340–3400) .35
Age at admission, median (range), y 0.3 (0–10.8) 0.5 (0–25.2) .32
Age at discharge, median (range), y 1.1 (0.6–11.2) 1.0 (0.4–25.3) .48
Preexisting tracheostomy, % (n) 11 (2) 20 (6) .69
Procedures, % (n)
Ductus arteriosus ligated 28 (5) 23 (7) .75
Gastrostomy tube 94 (17) 97 (29) .99
Gastric fundoplication 78 (14) 62 (18)a .35
ECMO during admission 6 (1) (7 d) 0 (0) .19
Diagnoses, % (n)
BPD 44 (8) 53 (16) .77
Congenital diaphragmatic hernia 11 (2) 3 (1) .55
Neuromuscular disease 11 (2) 10 (3) .90
Spinal cord injury/trauma 11 (2) 3 (1) .28
Congenital heart disease 28 (5) 17 (5) .47
Genetic/chromosomal anomaly 17 (3) 27 (8) .50
Oncology/bone marrow transplant 11 (2) 0 (0) .14
Airway malaciaa 17 (3) 37 (11) .20
Pulmonary hypertension 33 (6) 23 (7) .51
Upper airway obstruction 11 (2) 27 (8) .28
Pulmonary interstitial glycogenosis 0 (0) 7 (2) .52
Intrauterine growth restriction 11 (2) 7 (2) .62
Seizure disorder/infantile spasms 11 (2) 17 (5) .60
Postoperative extubation failure 6 (1) 3 (1) .71
Training
High-fi delity simulation completed 0 (0) 57 (17) <.001
Comparison of the preintervention (March 2011 to February 2013) and postintervention (March 2013 to February 2015)
cohorts. ECMO, extracorporeal membrane oxygenation.a Fundoplication status unknown for 1 older subject in the postintervention cohort.
TABLE 2 Patient Outcomes Before and After Implementation of Standardized Discharge Process
Preintervention,
n = 18
Postintervention,
n = 30
P
Primary outcomes
Overall hospital LOS, mean (SD), d 249 (117) 143.4 (97) .002
PRCU LOS, mean (SD), d 111.8 (73) 49.7 (33) .001
Secondary outcomes
Tracheostomy placement to discharge, mean
(SD), d
197 (99) 116 (73) .003
ICU LOS, mean (SD), d 137 (140) 94 (97) .18
1-y mortality, a % (n) 17 (3) 0 (0) .09
ED visits within 6 mo, % (n) 61 (11) 48 (12) .48
Readmissions within 30 d, % (n) 17 (3) 17 (5) .99
Readmissions within 12 mo, a % (n) 161 (29) 88 (14) .13
Direct cost per patient -×$1000, mean (SD) 590 (371) 336 (284) .01
Primary and secondary outcomes in the preintervention and postintervention cohorts. Hospital readmission rates were
calculated by dividing the total readmissions in a given time period by the number of patients in the cohort, permitting
readmission rates of greater than 100%.a One-year mortality and 12-mo readmission data were only available for 16 patients in the postintervention cohort,
because a full-year had not passed when the data were collected.
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PEDIATRICS Volume 137 , number 4 , April 2016
LOS after our quality improvement
intervention reveals that some
of the high cost is due to clinical
inefficiencies and logistical delays
in arranging for PDN and durable
medical equipment. Thus, timely care
coordination is critical for addressing
these issues and controlling costs.
Fortunately, the majority of
chronically ventilated children will
improve over time.11, 12, 24, 25 We
view tracheostomy placement, not
e7
FIGURE 2Statistical process control I-charts demonstrate LOS and PRCU LOS for all patients. Each dot represents an individual hospital admission. The primary intervention involved implementation of the new standardized process with road map and education handouts. Red dots indicate failed tests for special cause. A, Mean overall LOS was signifi cantly reduced after the intervention (Table 2), but LOS remained elevated for some patients after the intervention. B, The intervention resulted in a sustained reduction in PRCU LOS as demonstrated by the centerline shift. UCL, upper control limit.
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BAKER et al
as a care failure, but rather as a
proactive way to support children
through important developmental
time periods to optimize long-term
outcomes.26 Tracheostomy placement
is only part of an organized strategy
to provide chronic ventilation
allowing the focus to shift from acute
care issues toward enhancement
of long-term outcomes. Significant
delays in providing the ventilatory
support necessary to manage chronic
respiratory insufficiency, air hunger,
and dyspnea can adversely affect
long-term developmental outcomes,
and tracheostomy placement permits
sustained mechanical ventilation,
relieves distress, and provides the
respiratory stability necessary to
enhance neurocognitive, behavioral,
and developmental outcomes.
Rather than reserving tracheostomy
placement for the most futile of
cases, this proactive approach has
led to many successful outcomes.
Despite this, disease severity was not
different between study groups and
thus not the reason for our positive
results.
Given the relatively small number
of children who require chronic
ventilation, conducting randomized
controlled trials in this population
is challenging. This quality
improvement project did not test
the utility of a specific clinical
intervention, but rather focused on
the improvements observed with
implementation of a formal quality
improvement initiative. In line with
the Plan-Do-Study-Act cycle approach
to quality assurance, this project is
ongoing and will continue to monitor
outcomes in this population.27 Some
of the improvements in care, such
as high-fidelity simulation training,
were implemented after the formal
intervention point. Improvements
currently in progress include
the development of additional
educational videos, a partnership
with our child life specialists to create
a program for siblings of ventilator-
dependent children including age-
appropriate handouts and videos,
and a bilingual video providing the
fathers’ perspective.
Although not directly related to the
discharge process, we also have an
interdisciplinary VCP outpatient
clinic. The outpatient team consists
of a pediatric pulmonologist,
nurse practitioner, respiratory
therapist, outpatient nurse, and
speech–language pathologist. A
dedicated dietitian and social worker
are available as needed. Quality
improvement is an ongoing priority
of the VCP clinic and we speculate
that this contributed to why quality/
safety metrics were not diminished in
the setting of a more timely hospital
discharge.
Process mapping with the VCP
team members was highly useful
for identifying the steps involved
in discharging a child with chronic
ventilation. However, the process
as outlined in the map is does not
encompass all aspects of care and is
only an example of how such care
can be arranged. Any institution
that cares for similar patients must
account for regional and center-
based differences.
CONCLUSIONS
We used a formal quality
improvement initiative to
demonstrate that implementation
of a standardized discharge process
for children requiring chronic home
ventilation via tracheostomy tube
reduced LOS and hospital costs.
Importantly, this intervention did
not compromise patient safety as
measured by mortality, ED visits, and
hospital readmissions.
ACKNOWLEDGMENTS
The authors thank John Kinsella, MD,
Dan Hyman, MD, Cloy Van Eman,
RRT, Monte Leidholm, RRT, Marilyn
Willis, RN, Roberta Cox, RRT, Alicia
Grenolds, PNP, Jessica Dawson, RN,
Sasha Jacobs-Lowry, RN, and Heather
Richards for their many contributions
to the VCP and its patients.
e8
ABBREVIATIONS
BPD: bronchopulmonary
dysplasia
ED: emergency department
IV: intravenous
LOS: length of stay
PDN: private duty nursing
PRCU: pediatric respiratory care
unit
VCP: ventilator care program
HL102261 (to Dr Gien); Children’s Hospital Colorado Patient Safety grant (to Dr Baker); and University of Colorado School of Medicine Bridge Funding (to Dr
Baker). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
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originally published online March 10, 2016; Pediatrics Steven H. Abman and Jason Gien
Christopher D. Baker, Sara Martin, Jodi Thrasher, Heather M. Moore, Joyce Baker,Ventilator-Dependent Children
A Standardized Discharge Process Decreases Length of Stay for
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