Twice-Daily Huddles Improves Collaborative Problem Solving in the Respiratory Care Department.

BACKGROUND: Lean Six Sigma processes are used in health care systems to increase safety and efficiency. Daily huddles, one tool of the Lean Six Sigma process, have been used to increase patient safety, facilitate efficiency in problem solving, promote optimal patient outcomes, and reduce poor communication. Huddle utilization by respiratory care departments has not been previously reported. We describe our process of implementing daily huddles and the impact on departmental problem solving. METHOD: A descriptive study of a quality improvement intervention and a retrospective study of prospectively collected data were performed. The respiratory care department was trained in the utilization of a daily huddle process to resolve issues and identify process improvement opportunities. Huddles were performed at the beginning of each shift. Process improvement opportunities were raised by the respiratory therapy staff using the following categories: Safety/Service, Methods, Equipment, Supplies, and Associates. Opportunities were placed within 3 categories; quick hits (resolution in 1-3 d), complex problems (resolution in 3-7 d), and projects (resolution in > 7 d). All opportunities included a problem statement, an immediate countermeasure, a problem leader, and a due date. Items requiring interdisciplinary support were escalated to the organizational patient care services huddle. We evaluated the number and nature of process improvement opportunities raised in huddles from January 1 through December 31, 2018, to better understand the impact of daily huddles. RESULTS: A total of 366 process improvement opportunities were raised during huddles. Of those, 245 (67%) were quick hits, 77 (21%) were complex, and 44 (12%) were projects. Resolution of 174 (47.5%) opportunities was completed using only the resources of the respiratory care department, and 157 (43%) were resolved with additional interdisciplinary involvement. A small portion 35 (9.5%) of opportunities required escalation to the organizational multidisciplinary huddle for resolution. All process improvement opportunities were resolved at the end of the study period (mean ± SD of 30.5 ± 7.7 per month). CONCLUSIONS: Twice-daily huddles implemented by our respiratory care department allowed for identification and timely resolution of process improvement opportunities.

Overfeeding and obesity in young children with positive pressure ventilation via tracheostomy following cardiac surgery.

OBJECTIVES: Infants with CHD requiring positive pressure ventilation via tracheostomy are especially vulnerable to malnutrition following cardiac surgery. Current post-operative feeding recommendations may overestimate the caloric needs. DESIGN: We retrospectively studied infants requiring tracheostomy after cardiac surgery. Anthropometric and nutritional data were collected, including caloric goals, weight-for-age z score, length-for-age z score, and weight-for-length z score. Changes in anthropometrics over time were compared to ascertain the impact of nutritional interventions. Data were shown as mean ± standard deviation. RESULTS: Nineteen infants with CHD required tracheostomy at 160 ± 109 days (7-364 days), 13 had reparative surgery, and 6 had palliative surgery for single ventricle. The indications for tracheostomy consisted of airway abnormality/obstruction (n = 13), chronic respiratory failure (n = 7), and/or vocal cord paresis (n = 2). Initial maintenance nutritional target was set at 100-130 cal/kg per day. Fourteen patients (73.7%) became obese (maximum weight-for-length z score: 2.59 ± 0.47) under tracheostomy and gastrostomy feeding, whereas five patients did not (weight-for-length z score: 0.2 ± 0.83). Eight obese patients (weight-for-length z score: 2.44 ± 0.85) showed effective reduction of obesity within 6 months (weight-for-length z score: 0.10 ± 0.20; p < 0.05 compared with pre-adjustment) after appropriate feeding adjustment (40-90 cal/kg per day). Overall mortality was high (31.6%) in this population. CONCLUSION: Standard nutritional management resulted in overfeeding and obesity in young children with CHD requiring positive pressure ventilation via tracheostomy. Optimal nutritional management in this high-risk population requires close individualised management by multidisciplinary teams.

Home discharge of technology-dependent children: evaluation of a respiratory-therapist driven family education program.

BACKGROUND: Initial hospital discharge to home of technology-dependent children requires extensive training and education of the family caregivers. Education of adult family members should promote positive interactions in a nonthreatening manner while facilitating the development of the knowledge and skills to competently and independently provide all aspects of the medical care. We utilize a training program for adult family members of children who have undergone tracheostomy to facilitate long-term mechanical ventilatory support and who are being prepared for their initial discharge from the hospital to home. A dedicated respiratory therapist family educator directs this program. Multiple teaching tools, activities, and training sessions, based on adult learning theory, are utilized to develop appropriate clinical skills to manage children with tracheostomies and the associated technological supports. METHODS: We evaluated the effectiveness of our program by administering a written test to caregivers, at the start and the conclusion of their training. We also surveyed the caregivers about their satisfaction with the educational program and the respiratory therapist family educator's performance. We also surveyed employees of the durable medical equipment companies used by the families, regarding the caregivers' knowledge and competency in the home one month following discharge. RESULTS: Our program was associated with a statistically significant improvement in caregiver test performance, and the caregivers expressed a high degree of satisfaction with the program. The employees of the durable medical equipment companies perceived a high degree of knowledge and competence on the part of the home caregivers. CONCLUSION: Our training program appears to have a positive impact on the educational preparation of caregivers.

Hospital discharge of respiratory-technology-dependent children: role of a dedicated respiratory care discharge coordinator.

BACKGROUND: Preparation of respiratory-technology-dependent children for hospital discharge presents many challenges. Adequate training and education of parental caregivers, discharge planning, and coordination with the durable-medical-equipment and home-nursing companies must be completed. A process using multiple respiratory therapists (RTs) to achieve this may not be efficient. METHODS: We evaluated our model, in which a dedicated RT discharge coordinator provides education and coordinates discharge planning of respiratory-technology-dependent pediatric patients. This system provides a single contact for caregivers and outside agencies, a single respiratory-care educator for the caregivers, and a clinical pathway that involves the entire multidisciplinary team. Patient length of stay and customer satisfaction were evaluated before and after implementation of the discharge-coordinator program. RESULTS: Our dedicated-RT-discharge-coordinator model was associated with rapid initiation of frequent family-training sessions. Durable-medical-equipment-company personnel reported that they had increased satisfaction with the quality of training of the family caregivers. The members of the hospital multidisciplinary team had increased satisfaction with the discharge process. Patient length of stay nonsignificantly decreased after the implementation of the discharge-coordinator program. CONCLUSIONS: There are several advantages to using a dedicated RT-discharge-coordinator system for home-discharge preparation of respiratory-technology-dependent children.