Preventing Complications of Pediatric Tracheostomy Through Standardized Wound Care and Parent Education.

Importance: Pediatric tracheostomy is commonly performed for upper airway obstruction and prolonged mechanical ventilation. Children undergoing tracheostomy typically have multiple chronic medical problems that place them at high risk for readmission and additional complications. Objective: To determine whether the institution of a postoperative protocol for parent education and wound care with a nurse trained in tracheostomy care decreases the rate of readmission and other complications. Design, Setting, and Participants: A case series and medical record review was conducted of children 18 years and younger who underwent tracheostomy at a tertiary pediatric medical center between January 1, 2009, and December 31, 2014. Intervention: A postoperative tracheostomy care and education protocol. Main Outcomes and Measures: Overall 30-day readmission rate, 30-day tracheostomy-related readmission rate, tracheostomy wound complications, and additional factors that may have affected readmission rates and wound complications (age at the time of tracheostomy, discharge location, indication for tracheostomy). Results: A total of 191 children (118 boys and 73 girls) were included; of these, 112 participated in the education protocol and 79 children did not. Following institution of the education protocol, there was no decrease in the overall readmission rate (26.8% before the protocol vs 26.6% after the protocol; difference, 0.2%; 95% CI, -12.5% to 13.0%) or in the tracheostomy-related readmission rate (10.1% before the protocol vs 7.1% after the protocol; difference, 3.0%; 95% CI, -5.0% to 11.0%). Overall, 68.6% of readmissions were associated with medical comorbidities (95% CI, 55.9% to 81.3%). There was a significant decrease in tracheostomy-related wound complications after institution of the protocol (31.6% to 17.9%; difference, 13.7%; 95% CI, 1.6% to 26.0%). Multiple logistic regression analysis showed that children who were discharged home were significantly more likely to be readmitted for a tracheostomy-related complication than were patients discharged to an advanced care facility (odds ratio, 14.47; 95% CI, 3.08 to 67.92). Conclusions and Relevance: Tracheostomy care requires expertise for all caregivers and is challenging for people without specialized training. Specialized nursing and education protocols are associated with decreased complications of tracheostomy wounds. Children who are discharged directly to home are at higher risk for readmission compared with children discharged to advanced care facilities. Further development of caregiver education protocols is necessary to continue to reduce readmissions and tracheostomy-related complications.

The Global Tracheostomy Collaborative: one institution's experience with a new quality improvement initiative.

OBJECTIVE: Given the low frequency of adverse events after tracheostomy, individual institutions struggle to collect outcome data to generate effective quality improvement protocols. The Global Tracheostomy Collaborative (GTC) is a multi-institutional, multi-disciplinary organization that utilizes a prospective database to collect data on patients undergoing tracheostomy. We describe our institution's preliminary experience with this collaborative. It was hypothesized that entry into the database would be non-burdensome and could be easily and accurately initiated by skilled specialists at the time of tracheostomy placement and completed at time of patient discharge. METHODS: Demographic, diagnostic, and outcome data on children undergoing tracheostomy at our institution from January 2013 to June 2015 were entered into the GTC database, a database collected and managed by REDCap (Research Electronic Data Capture). All data entry was performed by pediatric otolaryngology fellows and all post-operative updates were completed by a skilled tracheostomy nurse. Tracked outcomes included accidental decannulation, failed decannulation, tracheostomy tube obstruction, bleeding/tracheoinnominate fistula, and tracheocutaneous fistula. RESULTS: Data from 79 patients undergoing tracheostomy at our institution were recorded. Database entry was straightforward and entry of patient demographic information, medical comorbidities, surgical indications, and date of tracheostomy placement was completed in less than 5min per patient. The most common indication for surgery was facilitation of ventilation in 65 patients (82.3%). Average time from admission to tracheostomy was 62.6 days (range 0-246). Stomal breakdown was seen in 1 patient. A total of 72 patients were tracked to hospital discharge with 53 patients surviving (88.3%). No mortalities were tracheostomy-related. CONCLUSION: The Global Tracheostomy Collaborative is a multi-institutional, multi-disciplinary collaborative that collects data on patients undergoing tracheostomy. Our experience proves proof of concept of entering demographics and outcome data into the GTC database in a manner that was both accurate and not burdensome to those participating in data entry. In our tertiary care, pediatric academic medical center, tracheostomy continues to be a safe procedure with no major tracheostomy-related morbidities occurring in this patient population involvement with the GTC has shown opportunities for improvement in communication and coordination with other tracheostomy-related disciplines.