Tolerance of one-way in-line speaking valve trials in ventilator dependent children.

BACKGROUND: Despite the advantages of tracheostomy placement in children requiring prolonged mechanical ventilation, vocalization and verbal communication remains limited in this population of children. The lack of these essential elements during a critical period of development can have a negative impact on overall development. In ventilator dependent children, in-line speaking valves (ISV) provide an opportunity for initiating speech and communication. The objective of this study is to examine patient characteristics and risk factors associated with tolerance and success of ISV trials performed with mechanically ventilated children. METHODS: A retrospective cohort study was conducted at a large, tertiary care children's hospital to evaluate the outcomes of ISV trials in ventilator-dependent children with tracheostomies, from 2009 to 2019. The primary endpoints were tolerance of the initial ISV assessment, and successful completion of a trial. We compared demographic and clinical characteristics among children that had a successful ISV trial to those that did not. RESULTS: Eighty-nine patients were included, 56 (62%) were male and 33 (38%) were female. Overall, 76 (85%) patients completed an ISV assessment and trial successfully during their hospitalization. The number of attempts before completing a successful trial varied with 41 (46%) patients succeeding on the first attempt. Children that underwent a tracheostomy for airway obstruction were more likely to fail. CONCLUSIONS: Ventilator-dependent children with complex comorbidities demonstrate excellent tolerance of in-line speaking valves. Patients should be selected for ISV trials in a multidisciplinary setting. Airway obstruction as an indication for tracheostomy placement is a significant predictor of failure for ISV trials.

Interventions to Improve Response Time to Nurse Triage Phone Calls in a Tertiary Care Pediatric Otolaryngology Practice.

Importance: Delay in response for telephone triage calls that need clinician input for resolution can result in delay of care and unintended frustration for patients and families. It can be a challenge to manage calls in a high-volume pediatric otolaryngology practice. Objective: To improve the percentage of nurse triage clinically relevant phone calls returned within 2 hours to parents or caregivers. Design, Setting, and Participants: This was a quality-improvement study of a tertiary care pediatric otolaryngology practice with more than 32 000 clinic visits and more than 9000 surgical patients per year. Interventions: In 2014, a collaborative team was created at our center to determine the optimal time for triage callback to families and to define an optimal process that would allow more rapid response time for calls that the triage nurses needed to escalate to the patient's managing surgeon. Several plan-do-study-act cycles were performed to optimize the process. The utilization of advanced practice nurses as an intermediary step was crucial in allowing a more efficient flow of communication. Main Outcomes and Measures: Percentage of triage phone calls returned within 2-hour time frame. Results: Over 40 months, 4839 clinically relevant phone calls occurred, averaging 128 calls per month. The baseline mean was 101 calls per month, and the postintervention mean was 130 calls per month. Prior to this project, only 42% of calls were being addressed within 2 hours. After our interventions, the average time for caregiver callback within 2 hours decreased from 15.3 hours preintervention to 3.9 hours postintervention. In addition, caregivers received clinician callback within 2.0 hours 76.7% of the time postintervention compared with 42.0% with a baseline shift (difference probability between preintervention and postintervention, 0.21; 95% CI, 0.15-0.27). Outcomes were sustained for 3 years and continue to be monitored. Conclusions and Relevance: The most effective intervention was using advanced practice nurses to efficiently resolve patient triage concerns that were outside the scope of practice of the registered nurse. By establishing clear pathways of communication and standardized education among our team, we successfully improved our processes, which resulted in more optimal care for our patients.

Impact of functional status and medical comorbidities on tracheostomy decannulation in pediatric patients.

PURPOSE: To determine if medical or functional factors influence the ability of a pediatric patient with a tracheostomy to tolerate decannulation. Retrospective evaluation of patients at a tertiary Children's Hospital undergoing evaluation with capped tracheostomy polysomnogram (cPSG) for possible tracheostomy decannulation. Charts were reviewed for demographic information, functional status, cPSG characteristics, and success or failure of decannulation. Statistical analysis was performed to determine which patient factors were predictive of successful decannulation. A total of 139 sleep studies were analyzed in 104 unique children followed for at least 1 year after a cPSG was performed to determine readiness for decannulation. At 1 year after most recent PSG, 79.8% of children were decannulated. There was no significant association between any single comorbid condition and the ability to decannulate. There was no association between individual or total functional status score and successful decannulation. Patients with at least 3 comorbid conditions investigated and a total functional score less than 7 were less likely to be decannulated successfully than other patients (71% vs. 93%, p= 0.04). Functional status and comorbid conditions do not independently predict successful decannulation. Regular multi-disciplinary team reevaluation is indicated in patients with lower functional status, as removal of tracheostomy tube may be successfully accomplished.

Prevention of post-operative pediatric tracheotomy wounds: A multidisciplinary team approach.

OBJECTIVE: Tracheotomy-related pressure wounds have been reported as high as 29%. All advanced stage (stage 3 or 4) wounds are reported by hospitals, and CMS will no longer reimburse healthcare costs to manage them. We present the results of an intensive, multidisciplinary wound prevention strategy starting in the operating room at the time of tracheotomy placement. METHODS: Prospective analysis of a tracheostomy wound care protocol at an academic, tertiary-care pediatric hospital from September 2012 to February 2016. Participants include all patients having undergone tracheostomy placement followed by protocoled daily dressing changes until the first tracheostomy tube change by team consisting a senior level otolaryngology resident or pediatric otolaryngology fellow, certified wound care specialist, respiratory therapist, and bedside nurse. RESULTS: Post-operative tracheostomy-related wound data from 3 years prior to clinical intervention was obtained and compared to the intervention cohort. From March 2010-August 2012, 161 tracheotomy procedures were performed with 36 (22.4%) subsequent pressure wounds; 31% of these were stage 3 or 4 wounds. After multidisciplinary protocol implementation, there have been 121 additional tracheotomy procedures with reduction to 12 (9.9%) total tracheotomy-related wounds (p = 0.0064) and none (0%) were stage 3 or 4 (p = 0.0014). All stage 1 and 2 wounds were identified early, underwent appropriate intervention, and avoided further progression. CONCLUSIONS: This protocol was successful in the elimination of all tracheostomy-related advanced stage, hospital-acquired pressure injuries and led to prompt identification of early stage wounds post-operatively.