Jane E. O'Brien

Predictors of Clinical Outcomes and Hospital Resource Use of Children After Tracheotomy

OBJECTIVES: The objectives are to describe health outcomes and hospital resource use of children after tracheotomy and identify patient characteristics that correlate with outcomes and hospital resource use. PATIENTS AND METHODS: A retrospective analysis of 917 children aged 0 to 18 years undergoing tracheotomy from 36 childrens hospitals in 2002 with follow-up through 2007. Children were identified from ICD-9-CM tracheotomy procedure codes. Comorbid conditions (neurologic impairment [NI], chronic lung disease, upper airway anomaly, prematurity, and trauma) were identified with ICD-9-CM diagnostic codes. Patient characteristics were compared with in-hospital mortality, decannulation, and hospital resource use by using generalized estimating equations. RESULTS: Forty-eight percent of children were ≤6 months old at tracheotomy placement. Chronic lung disease (56%), NI (48%), and upper airway anomaly (47%) were the most common underlying comorbid conditions. During hospitalization for tracheotomy placement, children with an upper airway anomaly experienced less mortality (3.3% vs 11.7%; P < .001) than children without an upper airway anomaly. Five years after tracheotomy, children with NI experienced greater mortality (8.8% vs 3.5%; P ≤ .01), less decannulation (5.0% vs 11.0%; P ≤ .01), and more total number of days in the hospital (mean [SE]: 39.5 [4.0] vs 25.6 [2.6] days; P ≤ .01) than children without NI. These findings remained significant (P < .01) in multivariate analysis after controlling for other significant cofactors. CONCLUSIONS: Children with upper airway anomaly experienced less mortality, and children with NI experienced higher mortality rates and greater hospital resource use after tracheotomy. Additional research is needed to explore additional factors that may influence health outcomes in children with tracheotomy.

Health information management and perceptions of the quality of care for children with tracheotomy: A qualitative study

BackgroundChildren with tracheotomy receive health care from an array of providers within various hospital and community health system sectors. Previous studies have highlighted substandard health information exchange between families and these sectors. The aim of this study was to investigate the perceptions and experiences of parents and providers with regard to health information management, care plan development and coordination for children with tracheotomy, and strategies to improve health information management for these children.MethodsIndividual and group interviews were performed with eight parents and fifteen healthcare (primary and specialty care, nursing, therapist, equipment) providers of children with tracheotomy. The primary tracheotomy-associated diagnoses for the children were neuromuscular impairment (n = 3), airway anomaly (n = 2) and chronic lung disease (n = 3). Two independent reviewers conducted deep reading and line-by-line coding of all transcribed interviews to discover themes associated with the objectives.ResultsChildren with tracheotomy in this study had healthcare providers with poorly defined roles and responsibilities who did not actively communicate with one another. Providers were often unsure where to find documentation relating to a childs tracheotomy equipment settings and home nursing orders, and perceived that these situations contributed to medical errors and delayed equipment needs. Parents created a home record that was shared with multiple providers to track the care that their children received but many considered this a burden better suited to providers. Providers benefited from the parent records, but questioned their accuracy regarding critical tracheotomy care plan information such as ventilator settings. Parents and providers endorsed potential improvement in this environment such as a comprehensive internet-based health record that could be shared among parents and providers, and between various clinical sites.ConclusionsParticipants described disorganized tracheotomy care and health information mismanagement that could help guide future investigations into the impact of improved health information systems for children with tracheotomy. Strategies with the potential to improve tracheotomy care delivery could include defined roles and responsibilities for tracheotomy providers, and improved organization and parent support for maintenance of home-based tracheotomy records with web-based software applications, personal health record platforms and health record data authentication techniques.

Clinical Findings and Resource Use of Infants and Toddlers Dependent on Oxygen and Ventilators

Medical records were reviewed to describe characteristics, report clinical and resource measures, and determine if differences exist between the diagnostic groups of prematurity and multiple congenital anomalies/neurologic conditions for initial admissions of 37 infants and toddlers to an inpatient pulmonary rehabilitation program. More than 75% of the children had a tracheostomy at admission and discharge. Forty-six percent of the sample was admitted requiring only oxygen, whereas 51% were discharged requiring only oxygen and not mechanical ventilation. Thirty percent of the children weaned to a less invasive mode of ventilation while just under half of the children were discharged home. Between-group comparisons indicated statistically significant differences for nutritional support at discharge (p < = 0.05) and discharge disposition (P = 0.04). Complete weaning of oxygen or ventilator support during an initial inpatient pulmonary rehabilitation admission occurred less frequently than weaning to a less invasive mode of ventilation. This is an important consideration for referring children to rehabilitation programs, for clinical program improvement activities, and for setting realistic expectations for referral sources, patients and families, clinical staff, and payers. Further study is recommended using clinical data in program planning, in program improvements, and for setting outcome expectations for infants and toddlers dependent on pulmonary technology.

Hospital length of stay, discharge disposition, and reimbursement by clinical program group in pediatric post-acute rehabilitation

OBJECTIVE To describe hospital length of stay (LOS), discharge disposition, and reimbursement by clinical group for children admitted to pediatric post-acute rehabilitation. METHODS Demographic and financial information for all admissions (n=382) for calendar years 2010 and 2011 were combined. Clinical groups (Active Rehabilitation, Medically Complex, Ventilator Dependent, Neonates) were delineated and compared by LOS, discharge disposition, and per diem and per admission reimbursement, as well as by age, gender, admission number, and payer using descriptives, chi-square, or analysis of variance. LOS, discharge disposition, and reimbursement were also examined by payer and/or admission number. RESULTS Clinical groups differed by LOS (p=0.008), discharge disposition (p < 0.001), age (p < 0.001), admission number (p < 0.001), and payer (p < 0.001). Although per diem reimbursement was not statistically significant between groups, total admission reimbursement was highest for the Ventilator group due to a significantly longer LOS (mean=57.78 days, SD=56.33, p=0.008). LOS nor discharge disposition was significantly different if the payer was public or private. Children were more likely discharged home from a first admission (r=0.321, p < 0.001) than a subsequent admission, and private payers had a significantly greater (p< 0.001) mean daily reimbursement rate. CONCLUSION Hospital LOS, discharge disposition, and reimbursement vary by clinical group in pediatric post-acute rehabilitation.

Ventilator weaning outcomes in chronic respiratory failure in children.

The purpose of this study was to describe mechanical ventilation weaning outcomes for children with chronic respiratory failure discharged from one of six post-acute rehabilitation facilities. Demographic, clinical and outcome data were collected from the medical record. Forty-four children were included in this prospective series; 20 (45%) were weaned off the ventilator at discharge. Children required significantly lower levels of ventilatory support at discharge than admission. Hourly use on the ventilator decreased from admission to discharge for the full cohort and for the subgroup who required a ventilator at discharge. Seventy-five percent of the children discharged with a ventilator had a portable unit. We conclude that nearly half of the children using mechanical ventilation achieve weaning during a postacute rehabilitation admission, whereas others have positive outcomes in severity, hours off the ventilator or portability of equipment.

Pediatric Post–Acute Hospital Care: Striving for Identity and Value

The landscape of hospital care for children is changing. Hospital clinicians are challenged to provide high-quality care to 2 increasingly complex groups of children: (1) healthy children admitted for high-severity acute illnesses or injury and (2) children admitted with lifelong, and often disabling, chronic conditions. Hospitalizations for both of these groups are becoming more prevalent, lengthy, and costly. In many situations, these children need weeks, or sometimes months, to recover from their illness or injury, with a sustained intensity of daily caregiving needs throughout their recovery period. Pediatric post-acute hospital care is a little-known and underused option in pediatric health care that could substantially help these children stabilize in a less restrictive and less costly environment than acute care hospitals can provide. In this commentary, we (1) propose the need and place for pediatric post-acute care hospitals along the continuum of care, (2) discuss the characteristics of children currently cared for in pediatric post-acute care hospitals, (3) suggest research opportunities and challenges, and (4) present issues related to the cost and value of pediatric post-acute care hospitals.

Outcomes of post-acute hospital episodes for young children requiring airway support

In this descriptive study, we examined changes in invasive and non-invasive airway support; studied the rates of home discharge vs. long-term care or acute hospitalization; and examined the relationship between the level of airway support and discharge to home for 92 children (<3 years of age) with 104 admission-discharge episodes to a consortium of pediatric rehabilitation hospitals over a one-year period. We found a significant reduction (p < 0.001) in the level of airway support between admission and discharge. In 21 of 47 (45%) episodes, children weaned from mechanical ventilation to a less restrictive type of support. Sixty percent of the children had final discharges to home. There was a significant, though fair correlation (Spearman Rho = −0.344, p = 0.001) between home discharge and level of airway support. These outcomes data provide a multi-site baseline for understanding expected changes in airway support and home discharge rates of young children who are admitted to a post-acute inpatient program.

Weaning children from mechanical ventilation in a post-acute care setting

As medical and technological advances have made it possible to prolong the life of children with chronic respiratory failure, children are being referred to post-acute inpatient rehabilitation programmes. In these settings, children can be weaned from their ventilators and receive medical and rehabilitative care in a developmentally supportive environment at a lower financial cost than in an intensive care unit. There is strong evidence that weaning children from mechanical ventilation has beneficial effects on their functionality, ease of care and quality of life. There is, however, little scientific evidence describing how often successful weaning is achieved or the most effective methods. The purpose of this article is to present a consensus report detailing a structured approach to weaning children from mechanical ventilation in a post-acute care setting. This study proposes a Weaning Severity Index and a Weaning Algorithm for use in the assessment and implementation of the weaning process in post-acute rehabilitation. Future clinical studies are needed to validate the suggested approach to ventilator weaning and to determine whether or not the weaning algorithm results in beneficial patient outcomes. A raíz de que los avances médicos y tecnológicos han hecho posible prolongar la vida de los niños con falla respiratoria crónica, estos están siendo referidos a programas de rehabilitación postaguda intrahospitalaria. En esta situación, los niños pueden ser separados de sus ventiladores y recibir un manejo médico y de rehabilitación en un medio ambiente de apoyo en desarrollo, con un costo financiero más bajo que el de una unidad de cuidados intensivos. Existe fuerte evidencia de que la separación de los niños de la ventilación mecánica tiene efectos benéficos en su función, facilidad de manejo y calidad de vida. Sin embargo hay poca evidencia científica que describa que tan frecuente se obtiene una separación del ventilador en forma exitosa o el método más efectivo. El propósito de este artículo es presentar un reporte consensuado, detallando una estrategia estructurada para separar a los niños de la ventilación mecánica en una situación de manejo postagudo. Proponemos el Weaning Severity Index y Weaning Algorithm para su uso en la evaluación e implementación del proceso de separación del ventilador, en la rehabilitación post aguda. Se necesitan estudios clínicos en un futuro para validar la estrategia que sugerimos en la separación del ventilador, y para determinar si el algoritmo de separación tiene un resultado benéfico en los pacientes. Palabras clave: destete, ventilación mecánica en niños, rehabilitación.

Re-admissions to inpatient paediatric pulmonary rehabilitation.

Objective : To describe re-admission rates, identify reasons for re-admission and examine characteristics of children requiring re-admission to inpatient pulmonary rehabilitation. Methodology : Retrospective record review of infants and toddlers (less than three years of age) requiring oxygen or ventilator support discharged from an inpatient paediatric pulmonary rehabilitation programme between 1992 and 1999. Results : Forty-one initial admissions resulted in 45 readmissions with a mean re-admission rate of 1.1 (SD = 1.41) re-admissions per child. Children with re-admissions ( n = 22, 54%) required significantly more ventilator support ( p = 0.001) and nursing care ( p = 0.001) and were transferred to acute care more frequently ( p = 0.002) than children without re-admissions. One-half of the children re-admitted to inpatient pulmonary rehabilitation were re-admitted two or more times. Conclusions : Based on this cohort of children, dependence on supplemental oxygen and/or mechanical ventilation and medical complexity may be indicators that children will require re-admission to rehabilitation following a transfer back to acute care. Further examination of re-admission rates and reasons and childrens clinical characteristics may have predictive value and provide practice improvement opportunities.

Unplanned readmissions to acute care from a pediatric postacute care hospital: incidence, clinical reasons, and predictive factors.

OBJECTIVE To identify the incidence, clinical reasons, and predictive factors for unplanned readmissions to acute care from a pediatric postacute care hospital. METHODS A retrospective cohort analysis of all discharges between October 1, 2011, and September 30, 2013 (n=298), in 1 pediatric postacute care hospital was conducted. Descriptive statistics were used to summarize the incidence and assess the clinical reasons for all readmissions to an acute care hospital. Logistic regression was used to identify predictive factors of any unplanned readmission to an acute care hospital. RESULTS Thirty percent of all postacute care hospital discharges were unplanned readmissions to an acute care hospital. The primary clinical reasons for unplanned readmissions to acute care were respiratory decompensation (54%) and infection (20%). Requiring invasive mechanical ventilation, being <1 year of age, and having a postacute care length of stay<30 days were the 3 predictive factors. CONCLUSIONS This is the first study to examine readmission to acute care from a postacute care hospital and to identify age, length of stay, and dependence on mechanical ventilation as predictive factors. Understanding which children are likely to require an unplanned readmission may allow providers to develop strategies to minimize this occurrence.