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

AIM: To hypothesize a dedicated critical care nurse practitioner (NP) is associated with a decreased length of stay (LOS) from a pediatric chronic ventilator dependent unit (PCVDU). METHODS: We retrospectively reviewed patients requiring care in the PCVDU from May 2001 through May 2011 comparing the 5 years prior to the 5 years post implementation of the critical care NP in 2005. LOS and room charges were obtained. RESULTS: The average LOS decreased from a median of 55 d [interquartile range (IQR): 9.8-108.3] to a median of 12 (IQR: 4.0-41.0) with the implementation of a dedicated critical care NP (P < 1.0001). Post implementation of a dedicated NP, a savings of 25738049 in room charges was noted over 5 years. CONCLUSION: Our data demonstrates a critical care NP coverage model in a PCVDU is associated with a significantly reduced LOS demonstrating that the NP is an efficient and likely cost-effective addition to a medically comprehensive service

Retrospective Analysis of Factors Leading to Pediatric Tracheostomy Decannulation Failure. A Single-Institution Experience

RATIONALE: There is a lack of evidence regarding factors associated with failure of tracheostomy decannulation. OBJECTIVES: We aimed to identify characteristics of pediatric patients who fail a tracheostomy decannulation challenge Methods: A retrospective review was performed on all patients who had a decannulation challenge at a tertiary care center from June 2006 to October 2013. Tracheostomy decannulation failure was defined as reinsertion of the tracheostomy tube within 6 months of the challenge. Data on demographics, indications for tracheostomy, home mechanical ventilation, and comorbidities were collected. Data were also collected on specific airway endoscopic findings during the predecannulation bronchoscopy and airway surgical procedures before decannulation. We attempted to predict the decannulation outcome by analyzing associations. MEASUREMENTS AND MAIN RESULTS: 147 of 189 (77.8%) patients were successfully decannulated on the first attempt. Tracheostomy performed due to chronic respiratory failure decreased odds for decannulation failure (odds ratio = 0.34, 95% confidence interval = 0.15-0.77). Genetic abnormalities (45%) and feeding dysfunction (93%) were increased in the population of patients failing their first attempt. The presence of one comorbidity increased the odds of failure by 68% (odds ratio = 1.68, 95% confidence interval = 1.23-2.29). Decannulation pursuit based on parental expectation of success, rather than medically determined readiness, was associated with a higher chance of failure (P = 0.01). CONCLUSIONS: Our study highlights the role of genetic abnormalities, feeding dysfunction, and multiple comorbidities in patients who fail decannulation. Our findings also demonstrate that the outcome of decannulation may be predicted by the indication for tracheostomy. Patients who had tracheostomy placed for chronic respiratory support had a higher likelihood of success. Absence of a surgically treatable airway obstruction abnormality on the predecannulation bronchoscopy increased the chances of success

Use of Polysomnography to Assess Safe Decannulation in Children

Background Tracheostomy is a lifesaving procedure to secure the airway and provide respiratory support. The decision to decannulate has classically been an individual physician decision without consensus among experts. The objective of this retrospective study was to assess the safety and efficacy of a standard institutional protocol that utilizes the sleep laboratory to assist in the decannulation process. Methods Between 2006 and 2013, patients were identified using a clinical database of decannulation studies. A protocol, finalized in 2005, was implemented for each decannulation attempt. In brief, all patients eligible for decannulation based on physician's assessment undergoes bronchoscopy. Once bronchoscopy findings reveal that the patient's airway is free of significant obstruction, decannulation is conducted in the sleep laboratory. The stoma is covered by an occlusive dressing and respiratory parameters are measured awake and asleep during the day and overnight by polysomnogram (PSG). The patient undergoes re-cannulation if the study shows significant obstruction, hypoventilation, or prolonged desaturation. Results A total of 210 decannulation attempts were performed on 189 patients (16 patients had multiple attempts). One hundred sixty-seven (79.5%) decannulation attempts were successful. Of those successfully decannulated, four (2.4%) were recannulated within 6 months. PSG parameters, specifically the apnea-hypopnea index, percent of total sleep time with oxygen saturation levels less than 90%, and lowest oxygen saturation levels were significantly associated with successful decannulation. No deaths occurred. Conclusions We present a safe and successful decannulation protocol that includes bronchoscopy coupled with PSG evaluation of the patient with the stoma decannulated and covered by an occlusive dressing