Evaluation of a Comprehensive Discharge Planning Program for Young Children with Newly Place Tracheostomy Tubes

Infants and children with newly placed tracheostomies present unique challenges for healthcare providers coordinating hospital discharge. Parental education and discharge planning needs can be complex; disease, parental, societal and healthcare related factors can create barriers prolonging hospitalization beyond medical readiness for discharge. I conducted a retrospective chart review to examine the effectiveness of the discharge process, including staff and family education, for 69 children less than 3 years of age who underwent tracheotomy at North Carolina Children’s Hospital over a 4 year period. Children enrolled in the study had an overall mean length of hospital stay following tracheotomy of 44 days. The median length of stay (LOS) was 28 days with a minimum stay of 4 days and a maximum stay of 203 days. The LOS was 44 days. This study demonstrates that a highly structured, multidisciplinary approach to tracheostomy education and discharge planning may reduce LOS following tracheotomy. More importantly, this paper shows that early identification of factors prolonging length of stay, adaptation to changing parental needs for education and support, and the establishment of trusting relationships between healthcare providers and families may reduce the impact of some barriers that prevent timely hospital discharge for children undergoing tracheostomy placement.Master of Public Healt

A Multidisciplinary Childrens Airway Center: Impact on the Care of Patients With Tracheostomy

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

DNA and Inflammatory Mediators in Bronchoalveolar Lavage Fluid From Children With Acute Inhalational Injuries:

Assess the feasibility of using serial bronchoalveolar lavage fluids (BALF) to characterize the course of cell damage and inflammation in airways of pediatric patients with acute burn or inhalation injury

DNA and Inflammatory Mediators in Bronchoalveolar Lavage Fluid From Children With Acute Inhalational Injuries

OBJECTIVE: Assess the feasibility of using serial bronchoalveolar lavage fluids (BALF) to characterize the course of cell damage and inflammation in airways of pediatric patients with acute burn or inhalation injury. DESIGN: Prospective, longitudinal descriptive pilot study. SETTING: Burn and Pediatric Intensive Care Units in a tertiary-care medical center. SUBJECTS: Six consecutive intubated, mechanically ventilated pediatric patients with acute inhalational injuries were studied. INTERVENTIONS: Serial BALF specimens from clinically-indicated bronchoscopies were used to measure DNA and cytokine levels. MEASUREMENTS AND MAIN RESULTS: BALF DNA levels for the 6 pediatric burn subjects were highest within the first 72 hours after burn injury and declined thereafter. At the early stages after injury, BALF DNA levels (median [min, max] 3789 [1170,11917] ng/ml) were similar to those in adult burn patients and pediatric cystic fibrosis or bronchiectasis patients, and higher than those in pediatric recurrent pneumonia patients. BALF DNA levels in children and adults with inhalation injury correlated significantly with BALF IL-6, IL-8, and TGF-β1 levels. The patient with the most severe early visible airway mucosal damage and soot pattern at bronchoscopy, as well as the most extensive burns, also had the highest average early BALF DNA level (11917ng/ml) and the longest ventilator course and hospital stay. Procedures were well tolerated. CONCLUSIONS: In children with acute burn and inhalational injury, airway cellular damage and inflammation (reflected in high BALF DNA levels) appear to peak during the first 72 hours after burns or inhalation injury followed by a slow decline. Serial analysis of factors in airway secretions is feasible and has the potential to reveal important pathophyisiologic pathways and therapeutic targets for treatment of acute inhalational injuries