A Standardized Discharge Process Decreases Length of Stay for Ventilator-Dependent ChildrenChristopher D. Baker, MD, a, b Sara Martin, RN, c Jodi Thrasher, MSN, b, c Heather M. Moore, PNP, a, b Joyce Baker, RRT, c Steven H. Abman, MD, a, b Jason Gien, MDa, d

aPediatric Heart Lung Center, bDivision of Pediatric

Pulmonary Medicine, and dDivision of Neonatology,

Department of Pediatrics, University of Colorado School

of Medicine, Aurora, Colorado; and cChildren’s Hospital

Colorado, Aurora, Colorado

Dr Baker conceptualized and designed the study,

cofounded the Ventilator Care Program, drafted

the manuscript, and supervised the data collection

and data analyses; Ms Martin contributed to study

design, performed the initial data analyses, and

critically revised the manuscript; Ms Thrasher

contributed to study design, cofounded the

Ventilator Care Program, and critically revised the

manuscript; Ms Moore and Ms Baker contributed to

study design and critically revised the manuscript;

Drs Abman and Gien contributed to study design,

cofounded the Ventilator Care Program, and

critically revised the manuscript; and all authors

approved the fi nal manuscript as submitted.

DOI: 10.1542/peds.2015-0637

Accepted for publication Jul 29, 2015

Address correspondence to Christopher D. Baker,

MD, Pediatric Heart Lung Center, 13123 E. 16th Ave,

Box B-395, Aurora, CO 80045. E-mail: christopher.

baker@ucdenver.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2016 by the American Academy of

Pediatrics

FINANCIAL DISCLOSURE: The authors have

indicated they have no fi nancial relationships

relevant to this article to disclose.

FUNDING: Funded by the National Institutes of

Health grants NIH K12-HL090147-01 (to Dr Baker),

NIH K23-HL121090-01 (to Dr Baker), and NIH 5K08-

The decision to initiate chronic

ventilation via tracheostomy

tube often results in prolonged

hospitalization to achieve medical

stability, train caregivers, provide

adequate home nursing, and

coordinate complex outpatient

care. Extended inpatient care is

costly, specifically as compared with

providing long-term mechanical

ventilation at home.1–5 Thus, although

such patients present infrequently,

children who require tracheostomy

and chronic ventilator therapy pose

substantial challenges and burdens on

caregivers and health care systems.6–8

abstractOBJECTIVE: Children who require chronic mechanical ventilation via

tracheostomy are medically complex and require prolonged hospitalization,

placing a heavy burden on caregivers and hospital systems. We developed

an interdisciplinary Ventilator Care Program to relieve this burden, through

improved communication and standardized care. We hypothesized that

a standardized team approach to the discharge of tracheostomy- and

ventilator-dependent children would decrease length of stay (LOS), reduce

patient costs, and improve safety.

METHODS: We used process mapping to standardize the discharge process for

children requiring chronic ventilation. Interventions included developing

education materials, a Chronic Ventilation Road Map for caregivers,

utilization of the electronic medical record to track discharge readiness,

team-based care coordination, and timely case management to arrange

home nursing. We aimed to decrease overall and pediatric respiratory care

unit LOS as the primary outcomes. We also analyzed secondary outcomes

(mortality, emergency department visits, unplanned readmissions),

and per-patient hospital costs during 2-year “preintervention” and

“postintervention” periods (n = 18 and 30, respectively).

RESULTS: Patient demographics were not different between groups. As

compared with the preintervention cohort, the overall LOS decreased

42% (P = .002). Pediatric respiratory care unit LOS decreased 56% (P =

.001). As a result, unplanned readmissions, emergency department visits,

and mortality were not increased. Direct costs per hospitalization were

decreased by an average of 43% (P = .01).

CONCLUSIONS: Although LOS remained high, a standardized discharge process

for chronically ventilated children by an interdisciplinary Ventilator Care

Program team resulted in decreased LOS and costs without a negative

impact on patient safety.

QUALITY REPORTPEDIATRICS Volume 137 , number 4 , April 2016 :e 20150637

NIH

To cite: Baker CD, Martin S, Thrasher J, et al.

A Standardized Discharge Process Decreases

Length of Stay for Ventilator-Dependent Children.

Pediatrics. 2016;137(4):e20150637

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BAKER et al

Children may require chronic

ventilation in the neonatal setting

for a number of clinical indications

including severe bronchopulmonary

dysplasia (BPD), congenital

diaphragmatic hernia, airway

malacia, neuromuscular disease,

and other forms of respiratory

insufficiency.9–11 Traumatic brain

injury, paralysis, central neurologic

conditions, progression of chronic

respiratory insufficiency, as well as

postinfectious sequelae may result

in the need for chronic ventilation in

older children.12, 13 Regardless of the

primary cause of chronic respiratory

failure, children with tracheostomy

who require chronic ventilation are

medically complex with significant

morbidity and mortality.14–16

Hospital practice patterns vary as

to whether chronically ventilated

children are cared for exclusively in

neonatal and pediatric intensive care

units or are transferred to step-down

units and/or inpatient wards once

medical stability has been achieved.17

Regardless, the overall length of stay

(LOS) tends to be many months or

years for the most complex patients.

In some centers, those with stable

chronic ventilation requirements

may be transferred to long-term

acute care facilities.18

Our interdisciplinary Ventilator

Care Program (VCP) was formed

in 2006 as a collaboration between

pulmonology, neonatology,

otolaryngology, nursing, respiratory

therapy, and others. The program

originated in the NICU and initially

aimed to improve communication,

standardize approaches to the

common morbidities associated with

the need for chronic ventilation, and

improve outcomes for chronically

ventilated neonates. Due to the need

for coordinated interdisciplinary

care, the program expanded to

include care of older children.

Since its inception, we have held

weekly interdisciplinary inpatient

rounds to discuss the complex

care of these children. With input

from the primary medical service,

nurses, therapists, and caregivers,

the VCP team attempts to accurately

describe each child’s current status

and progress for optimal medical

decision-making. The pulmonary and

neonatology directors of the VCP lead

weekly rounds, provide longitudinal

perspective, and collaborate with

the primary inpatient attending

and care teams to manage and

coordinate the multisystem care of

each patient. Emphasis is placed on

major decisions, such as the timing

of surgical procedures, ventilation

strategies, transition to the portable

ventilator, and discharge planning.

Weekly plans are reviewed after each

child is discussed.

Our VCP team approach has resulted

in a dramatic increase in survival for

infants with severe BPD.19 However,

the duration of the inpatient stays for

these children remained prolonged,

and significant variation in practice

patterns were observed between

patients, with respect to discharge

teaching methods, the use of informal

handouts, and the acquisition

of home nursing. In an effort to

standardize care, we used process

mapping, a method previously

shown to reduce such variance in

care in the emergency department

(ED) and other settings.20, 21 We

hypothesized that implementation

of a standardized discharge process

would result in a timely and safe

home discharge after initiation of

chronic ventilation.

METHODS

We developed a formal quality

improvement project with the goal

of measuring LOS, outcomes, and

per-patient hospital costs before

and after implementation of a

standardized discharge process for

our identified patient population.

The institutional quality review panel

approved the project, determined

that it did not involve human subjects

research, and authorized publication

of this quality report.

Study Design, Setting, and Population

We identified patients who were

discharged from the hospital

from our tertiary care children’s

hospital after initiation of chronic

ventilation during a 2-year

“preintervention” period (March

2011 to February 2013) and during

a “postintervention” period (March

2013 to February 2015). Children

who were weaned from invasive

mechanical ventilation before

discharge, those mechanically

ventilated at home before admission,

those discharged on continuous

intravenous (IV) infusions, and those

who were back-transported to other

hospitals before home discharge

were excluded. Death between

initiation of chronic ventilation and

hospital discharge was also recorded.

Patients who had a tracheostomy

(without mechanical ventilation)

before hospital admission were

included if chronic ventilation was

initiated during the inpatient stay.

Children in both groups were

diagnosed with chronic respiratory

failure or insufficiency due to

neonatal lung disease, neuromuscular

disease, central hypoventilation,

or other disorders and treated in

either our neonatal or PICU for the

acute illness. Once a decision was

made to pursue chronic ventilation,

a tracheostomy was placed by

an otolaryngologist and the first

tracheostomy tube change was

completed 5 to 7 days after surgery

and before transfer to the pediatric

respiratory care unit (PRCU). ICU

care continued until each child

was medically stable for home

discharge on a home ventilator. Our

institution utilizes Trilogy (Philips

Respironics, Murrysville, PA) and

Pulmonetics LTV (CareFusion,

San Diego, CA) ventilators for

chronic ventilation. Stability was

determined by consensus during

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PEDIATRICS Volume 137 , number 4 , April 2016

weekly VCP rounds and consisted

of breathing comfortably with an

oxygen requirement (fraction of

inspired oxygen) of <0.4, maintained

off continuous IV medications, and

without episodes of hypoxemia

for ∼2 weeks. Maximal ventilator

settings for transfer were not

specified. At this time, patients were

transferred to the PRCU, a section of

the inpatient pulmonary floor where

education and discharge planning

are completed. Our program insists

that patients transfer to our PRCU for

focused training and demonstration

of caregiver competency rather than

discharging home directly from the

ICU.

Patient Identifi cation

Subjects were identified by surgical

billing code for tracheostomy

placement (or admission with a

tracheostomy) combined with a

hospital charge for mechanical

ventilation on a hospital day when

the child was not admitted to an

ICU. This list was compared with the

VCP’s inpatient census for the study

time period and no discrepancies

were identified.

Interventions

We formed a VCP administrative

team consisting of the medical

director, inpatient and outpatient

advanced practice nurses, and the

director of respiratory care. We

began holding planning meetings

twice each month in July 2012

to plan the quality improvement

project. In January 2013, our team

began working with a process

improvement specialist to build

future state process maps capturing

discharge processes of the population

of interest (Fig 1A). We met with

physician representatives from

the involved medical disciplines

(pulmonology, neonatology, critical

care, otolaryngology, pediatric

residents), as well as respiratory and

developmental therapists, nurses,

case managers, social workers, and

families. A formal process map was

then created and approved by the

team.

In collaboration with family partners,

we developed formal discharge

materials to align with institutional

policies and procedures. We also

reviewed printed educational

materials from other institutions to

ensure completeness of our formal

handouts and then developed unique

instructional videos (materials

available upon request from the

corresponding author). All handouts

and videos were produced in both

English and Spanish. We designed

a “Chronic Ventilation Road Map”

to communicate the discharge

process in family-friendly language

to families and providers (Fig 1B).

A laminated copy of the road map

was placed in each child’s hospital

room and referenced by family and

clinicians throughout the discharge

education process to show progress

over time.

Standardized team-based care

coordination was optimized by

using a dedicated advanced practice

nurse and rehabilitation respiratory

therapist to assist with education

and track progress of all families.

The electronic medical record

was used in a number of ways to

facilitate care coordination activities.

A Best Practice Alert was created

to encourage VCP consultation

whenever a chronically ventilated

child is hospitalized. A Discharge

Readiness Report and documentation

flowsheet track each child’s progress

toward discharge. This report is

projected on a screen during weekly

VCP rounds for the team to review

and update. A separate Caregiver

Skills Checklist documents both the

instruction provided to caregivers

and the caregiver’s demonstration

of competency in each skill.

Standardized Care Coordination

notes were used during weekly

meetings and care conferences.

Tofil et al22 used high-fidelity

simulation training to provide

caregiver education within a home

ventilator program. As part of

our formal training process, we

collaborated with our hospital’s

high-fidelity simulation laboratory to

pilot similar training for caregivers

of VCP patients. Beginning in April

of 2014, caregivers from each

family completed 2 emergency

simulation modules that focused

on management of a plugged

tracheostomy tube and ventilator

malfunction. Skills reinforced by

the training included suctioning,

changing the tracheostomy tube,

performing bag-tracheostomy

ventilation, activating the emergency

medical response system, and

performing full cardiopulmonary

resuscitation.

Arrangement of private duty

nursing (PDN) and durable medical

equipment was prioritized. As soon

as the need for chronic ventilation

was determined, the ICU case

manager and respiratory therapist

identified the appropriate home care

agencies and made initial contact.

Case management also ensured that

each child’s insurance coverage was

appropriate for the provision of

in-home PDN.

Although family care conferences

took place before our formal quality

improvement project, we began

to require 2 essential conferences

with each family, a Transition Care

Conference (when a child is ready to

transfer from the ICU to the PRCU)

and a Discharge Care Conference

(in the days before discharge).

Additional care conferences were

scheduled as needed. Because

we prioritized the arrangement

of PDN to occur earlier in the

hospitalization, PDN staff members

were able to attend these critical

meetings. Every effort was made to

have a representative from the PDN

agency present at the Transition and

Discharge Care Conferences.

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BAKER et al e4

FIGURE 1A, Process map. VCP team members participated in process mapping sessions to determine the necessary steps for a safe discharge. In the fi gure, color-coding indicates the provider responsible for completing each task. ENT, Ear Nose Throat specialist (otolaryngologist); PT, physical therapy; OT, occupational therapy; RT, respiratory therapy; SW, social work; DME, durable medical equipment; CM, case management; Ox, oximetry; WOB, work of breathing. B, Chronic ventilation road map. The road map outlines the discharge process in a “family friendly” manner. The map emphasizes the collaborative team approach to care and the focus on caregiver education.

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PEDIATRICS Volume 137 , number 4 , April 2016

Data Collection

A dashboard was developed to collect

patient data for tracking of quality

metrics on an ongoing basis. Protected

health information was stored

securely on a password protected

hospital network. The primary study

outcomes were overall hospital

LOS and PRCU LOS (the time from

ICU transfer to discharge home).

Secondary outcomes included the

time from tracheostomy placement

to hospital discharge and balancing

metrics of patient safety: 1-year

mortality, ED visits (within 6 months),

and unplanned hospital readmissions

(within 30 days and 12 months).

Direct hospital costs were also

compared. If a child already had a

tracheostomy tube at admission, the

time from tracheostomy placement

to discharge was considered to be

equal to the overall LOS. The hospital

readmission rate was calculated by

dividing the total readmissions in

the given time period by the number

of patients in a cohort, permitting

readmission rates of greater than

100%. Planned hospitalizations for

ventilator weaning, decannulation,

or other anticipated reasons were

excluded. In the postintervention

cohort, 12-month unplanned

readmissions and mortality were only

available for 16 of 30 patients, as a full

year had not passed since discharge

at the time of data collection. The

hospital finance department provided

cost data by using the EPSi software

package (Allscripts, Chicago, IL).

Direct hospital costs did not include

physician charges. In addition to the

reported quality metrics, we reviewed

each patient’s electronic medical

record to obtain the demographic and

clinical data reported.

Statistical Analysis

Primary and secondary outcome

measures were compared with

2-sample t testing and 1-year

mortality was compared with a χ2

test for association. Nonparametric

demographic data were compared

by Mann-Whitney testing and

presented as medians with ranges.

Outcomes were reviewed over time

utilizing statistical process control

I-charts. SD and control limits were

calculated with the average moving

range method. All standard rules for

special cause variation were applied

to control charts. Centerlines were

shifted at the point of statistical

special cause. All statistical testing

and I-charts were completed by using

Minitab Statistical Software version

17 (State College, PA). Significance

level was set at α = 0.05.

RESULTS

A total of 48 subjects were studied;

18 in the preintervention cohort and

30 in the postintervention cohort.

Six additional children (3 in each

cohort) died in the hospital after

initiation of chronic ventilation, but

before initial discharge. One child

was discharged on IV treprostinil

and was excluded. One child in the

preintervention cohort was weaned

from mechanical ventilation before

discharge due to lack of homecare

services in a rural area and was thus

excluded. Two children (1 in each

cohort) were back-transported to

regional hospitals in other states and

were thus also excluded. No children

were transferred to subacute care,

as a facility for chronically ventilated

children does not exist in our state.

Patient characteristics were similar

between study groups (Table 1).

There were more male children in

both cohorts.

As shown in Table 1, severe BPD

after premature birth was the most

common indication for chronic

ventilation. Tracheomalacia

and bronchomalacia were more

frequently diagnosed in the

postintervention group. Pulmonary

hypertension complicated the course

of many children.

The 2 primary study outcomes,

overall LOS and PRCU LOS, were

significantly decreased in the

postintervention cohort (Table 2).

Mean overall LOS decreased from

249 to 143.4 days (42% reduction, P

= .002), and PRCU LOS was decreased

from 111.8 to 49.7 days (56%

reduction, P = .001). The statistical

process control I-chart for overall

LOS (Fig 2A) reveals that some

patients continued to require lengthy

hospitalizations in excess of 300 days

even after the intervention. However,

the I-chart in Figure 2B demonstrates

a sustained reduction in PRCU

LOS over the 2-year period after

implementation of the standardized

process. The time from tracheostomy

placement to discharge was also

decreased from 196.8 to 116.1 days

(41% reduction, P = .003). LOS within

the ICU was decreased by 32% after

the intervention, but this difference

was not statistically significant due to

the large variance within each study

group.

The secondary outcomes were

not negatively impacted by the

intervention (Table 2). One-year

mortality after discharge was 17%

in the preintervention cohort (1

patient with cardiopulmonary arrest

at home; 2 with septic shock) and

0% in the 16 patients with available

data at the writing of this article (P

= .09). The 12-month unplanned

readmission rate in these patients

was reduced by 47%, but this change

was not statistically significant (P =

.13). ED visits within 6 months and

the 30-day unplanned readmission

rate remained unchanged.

Mean direct hospital costs were

significantly decreased by 43% per

hospitalization (P = .01). A portion

of this cost reduction may have been

due to a variety of hospital-wide

resource stewardship initiatives

unrelated to this particular study.

DISCUSSION

We studied the impact of a novel

standardized discharged process

for ventilator dependent children

within an interdisciplinary VCP

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BAKER et al

at our institution. Through an

organized quality improvement

intervention, we achieved a

striking reduction in the duration

of hospitalization required

for implementation of chronic

ventilation via tracheostomy.

Furthermore, by emphasizing

caregiver education and consistency

of care, morbidity and mortality

were not increased as a result of the

shorter hospitalization.

The medical management of children

with chronic respiratory failure

can be complex.23 Although we

demonstrate here the benefits of

a standardized discharge process,

the importance of interdisciplinary

collaborative decision-making

to develop a customized care

plan for each child cannot be

overemphasized. Many of these

children suffer from severe

parenchymal lung disease, airways

disease, congenital heart disease, and

pulmonary hypertension. The VCP

team requests that the neonatology

or critical care primary team consult

pulmonology and otolaryngology

before tracheostomy placement to

ensure that caregivers understand

the benefits, risks, and time course

of chronic ventilation including the

lengthy hospital stay. Gastrostomy

tube feedings are nearly always

necessary, and empirical gastric

fundoplication is requested for

children at greatest risk of aspiration

in the setting of gastroesophageal

reflux. Our hospital’s

interdisciplinary pulmonary

hypertension team (consisting

of pulmonary, cardiology, and

intensivist providers) is consulted

for children with pulmonary vascular

disease. The role of developmental

therapists (physical, occupational,

and speech–language pathology) who

see the children regularly is critical

for determining medical stability,

readiness for transition to the home

ventilator, and discharge timing.

Our results reveal that overall

LOS was significantly lower in the

postintervention cohort, but the

corresponding I-chart failed to reveal

a sustained reduction. This is because

the most severely affected children,

particularly those born extremely

premature, have multisystem

disease and will continue to require

prolonged hospitalization to reach

medical stability. The medical

complexity of a child is expected to

result in greater costs. However,

the sustained decrease in PRCU

e6

TABLE 1 Patient Characteristics

Preintervention, n

= 18

Postintervention,

n = 30

P

Characteristics

Gender (boy, girl) 14, 4 19, 11 .35

Gestational age, median (range), wk 34.5 (23–40) 33 (23–40) .44

Birth weight, median (range), g 2236 (425–4049) 1419 (340–3400) .35

Age at admission, median (range), y 0.3 (0–10.8) 0.5 (0–25.2) .32

Age at discharge, median (range), y 1.1 (0.6–11.2) 1.0 (0.4–25.3) .48

Preexisting tracheostomy, % (n) 11 (2) 20 (6) .69

Procedures, % (n)

Ductus arteriosus ligated 28 (5) 23 (7) .75

Gastrostomy tube 94 (17) 97 (29) .99

Gastric fundoplication 78 (14) 62 (18)a .35

ECMO during admission 6 (1) (7 d) 0 (0) .19

Diagnoses, % (n)

BPD 44 (8) 53 (16) .77

Congenital diaphragmatic hernia 11 (2) 3 (1) .55

Neuromuscular disease 11 (2) 10 (3) .90

Spinal cord injury/trauma 11 (2) 3 (1) .28

Congenital heart disease 28 (5) 17 (5) .47

Genetic/chromosomal anomaly 17 (3) 27 (8) .50

Oncology/bone marrow transplant 11 (2) 0 (0) .14

Airway malaciaa 17 (3) 37 (11) .20

Pulmonary hypertension 33 (6) 23 (7) .51

Upper airway obstruction 11 (2) 27 (8) .28

Pulmonary interstitial glycogenosis 0 (0) 7 (2) .52

Intrauterine growth restriction 11 (2) 7 (2) .62

Seizure disorder/infantile spasms 11 (2) 17 (5) .60

Postoperative extubation failure 6 (1) 3 (1) .71

Training

High-fi delity simulation completed 0 (0) 57 (17) <.001

Comparison of the preintervention (March 2011 to February 2013) and postintervention (March 2013 to February 2015)

cohorts. ECMO, extracorporeal membrane oxygenation.a Fundoplication status unknown for 1 older subject in the postintervention cohort.

TABLE 2 Patient Outcomes Before and After Implementation of Standardized Discharge Process

Preintervention,

n = 18

Postintervention,

n = 30

P

Primary outcomes

Overall hospital LOS, mean (SD), d 249 (117) 143.4 (97) .002

PRCU LOS, mean (SD), d 111.8 (73) 49.7 (33) .001

Secondary outcomes

Tracheostomy placement to discharge, mean

(SD), d

197 (99) 116 (73) .003

ICU LOS, mean (SD), d 137 (140) 94 (97) .18

1-y mortality, a % (n) 17 (3) 0 (0) .09

ED visits within 6 mo, % (n) 61 (11) 48 (12) .48

Readmissions within 30 d, % (n) 17 (3) 17 (5) .99

Readmissions within 12 mo, a % (n) 161 (29) 88 (14) .13

Direct cost per patient -×$1000, mean (SD) 590 (371) 336 (284) .01

Primary and secondary outcomes in the preintervention and postintervention cohorts. Hospital readmission rates were

calculated by dividing the total readmissions in a given time period by the number of patients in the cohort, permitting

readmission rates of greater than 100%.a One-year mortality and 12-mo readmission data were only available for 16 patients in the postintervention cohort,

because a full-year had not passed when the data were collected.

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PEDIATRICS Volume 137 , number 4 , April 2016

LOS after our quality improvement

intervention reveals that some

of the high cost is due to clinical

inefficiencies and logistical delays

in arranging for PDN and durable

medical equipment. Thus, timely care

coordination is critical for addressing

these issues and controlling costs.

Fortunately, the majority of

chronically ventilated children will

improve over time.11, 12, 24, 25 We

view tracheostomy placement, not

e7

FIGURE 2Statistical process control I-charts demonstrate LOS and PRCU LOS for all patients. Each dot represents an individual hospital admission. The primary intervention involved implementation of the new standardized process with road map and education handouts. Red dots indicate failed tests for special cause. A, Mean overall LOS was signifi cantly reduced after the intervention (Table 2), but LOS remained elevated for some patients after the intervention. B, The intervention resulted in a sustained reduction in PRCU LOS as demonstrated by the centerline shift. UCL, upper control limit.

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BAKER et al

as a care failure, but rather as a

proactive way to support children

through important developmental

time periods to optimize long-term

outcomes.26 Tracheostomy placement

is only part of an organized strategy

to provide chronic ventilation

allowing the focus to shift from acute

care issues toward enhancement

of long-term outcomes. Significant

delays in providing the ventilatory

support necessary to manage chronic

respiratory insufficiency, air hunger,

and dyspnea can adversely affect

long-term developmental outcomes,

and tracheostomy placement permits

sustained mechanical ventilation,

relieves distress, and provides the

respiratory stability necessary to

enhance neurocognitive, behavioral,

and developmental outcomes.

Rather than reserving tracheostomy

placement for the most futile of

cases, this proactive approach has

led to many successful outcomes.

Despite this, disease severity was not

different between study groups and

thus not the reason for our positive

results.

Given the relatively small number

of children who require chronic

ventilation, conducting randomized

controlled trials in this population

is challenging. This quality

improvement project did not test

the utility of a specific clinical

intervention, but rather focused on

the improvements observed with

implementation of a formal quality

improvement initiative. In line with

the Plan-Do-Study-Act cycle approach

to quality assurance, this project is

ongoing and will continue to monitor

outcomes in this population.27 Some

of the improvements in care, such

as high-fidelity simulation training,

were implemented after the formal

intervention point. Improvements

currently in progress include

the development of additional

educational videos, a partnership

with our child life specialists to create

a program for siblings of ventilator-

dependent children including age-

appropriate handouts and videos,

and a bilingual video providing the

fathers’ perspective.

Although not directly related to the

discharge process, we also have an

interdisciplinary VCP outpatient

clinic. The outpatient team consists

of a pediatric pulmonologist,

nurse practitioner, respiratory

therapist, outpatient nurse, and

speech–language pathologist. A

dedicated dietitian and social worker

are available as needed. Quality

improvement is an ongoing priority

of the VCP clinic and we speculate

that this contributed to why quality/

safety metrics were not diminished in

the setting of a more timely hospital

discharge.

Process mapping with the VCP

team members was highly useful

for identifying the steps involved

in discharging a child with chronic

ventilation. However, the process

as outlined in the map is does not

encompass all aspects of care and is

only an example of how such care

can be arranged. Any institution

that cares for similar patients must

account for regional and center-

based differences.

CONCLUSIONS

We used a formal quality

improvement initiative to

demonstrate that implementation

of a standardized discharge process

for children requiring chronic home

ventilation via tracheostomy tube

reduced LOS and hospital costs.

Importantly, this intervention did

not compromise patient safety as

measured by mortality, ED visits, and

hospital readmissions.

ACKNOWLEDGMENTS

The authors thank John Kinsella, MD,

Dan Hyman, MD, Cloy Van Eman,

RRT, Monte Leidholm, RRT, Marilyn

Willis, RN, Roberta Cox, RRT, Alicia

Grenolds, PNP, Jessica Dawson, RN,

Sasha Jacobs-Lowry, RN, and Heather

Richards for their many contributions

to the VCP and its patients.

e8

ABBREVIATIONS

BPD:  bronchopulmonary

dysplasia

ED:  emergency department

IV:  intravenous

LOS:  length of stay

PDN:  private duty nursing

PRCU:  pediatric respiratory care

unit

VCP:  ventilator care program

HL102261 (to Dr Gien); Children’s Hospital Colorado Patient Safety grant (to Dr Baker); and University of Colorado School of Medicine Bridge Funding (to Dr

Baker). Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

REFERENCES

1. Bach JR, Intintola P, Alba

AS, Holland IE. The ventilator-

assisted individual. Cost analysis

of institutionalization vs

rehabilitation and in-home

management. Chest.

1992;101(1):26–30

2. King AC. Long-term home mechanical

ventilation in the United States. Respir

Care. 2012;57(6):921–930; discussion

930–922

3. Benneyworth BD, Gebremariam A,

Clark SJ, Shanley TP, Davis

MM. Inpatient health care

utilization for children dependent

on long-term mechanical

ventilation. Pediatrics. 2011;127(6).

Available at: www. pediatrics. org/

cgi/ content/ full/ 127/

6/ e1533

by guest on August 21, 2020www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 137 , number 4 , April 2016

4. Amin R, Sayal A, Syed F, et al How long

does it take to initiate a child on long-

term invasive ventilation? Results

from a Canadian pediatric home

ventilation program. Can Respir J.

2015;22(2):103–108

5. Cohen E, Berry JG, Camacho X,

Anderson G, Wodchis W, Guttmann A.

Patterns and costs of health care use

of children with medical complexity.

Pediatrics. 2012;130(6). Available at:

www. pediatrics. org/ cgi/ content/ full/

130/ 6/ e1463

6. Gowans M, Keenan HT, Bratton

SL. The population prevalence of

children receiving invasive home

ventilation in Utah. Pediatr Pulmonol.

2007;42(3):231–236

7. Cox CE, Carson SS, Govert JA, Chelluri

L, Sanders GD. An economic evaluation

of prolonged mechanical ventilation.

Crit Care Med. 2007;35(8):1918–1927

8. Van Pelt DC, Milbrandt EB, Qin L, et

al. Informal caregiver burden among

survivors of prolonged mechanical

ventilation. Am J Respir Crit Care Med.

2007;175(2):167–173

9. Northway WH Jr, Rosan RC,

Porter DY. Pulmonary disease

following respirator therapy

of hyaline-membrane disease.

Bronchopulmonary dysplasia. N Engl J

Med. 1967;276(7):357–368

10. Allen J, Zwerdling R, Ehrenkranz R,

et al; American Thoracic Society.

Statement on the care of the child with

chronic lung disease of infancy and

childhood. Am J Respir Crit Care Med.

2003;168(3):356–396

11. Cristea AI, Carroll AE, Davis SD,

Swigonski NL, Ackerman VL.

Outcomes of children with severe

bronchopulmonary dysplasia who

were ventilator dependent at home.

Pediatrics. 2013;132(3). Available at:

www. pediatrics. org/ cgi/ content/ full/

132/ 3/ e727

12. Amin RS, Fitton CM. Tracheostomy and

home ventilation in children. Semin

Neonatol. 2003;8(2):127–135

13. Overman AE, Liu M, Kurachek SC, et al.

Tracheostomy for infants requiring

prolonged mechanical ventilation:

10 years’ experience. Pediatrics.

2013;131(5). Available at: www.

pediatrics. org/ cgi/ content/ full/ 131/ 5/

e1491

14. Edwards EA, O’Toole M, Wallis

C. Sending children home on

tracheostomy dependent ventilation:

pitfalls and outcomes. Arch Dis Child.

2004;89(3):251–255

15. Edwards JD, Kun SS, Keens TG.

Outcomes and causes of death

in children on home mechanical

ventilation via tracheostomy: an

institutional and literature review. J

Pediatr. 2010;157(6):955–959.e2

16. Frates RC Jr, Splaingard ML, Smith

EO, Harrison GM. Outcome of home

mechanical ventilation in children. J

Pediatr. 1985;106(5):850–856

17. Edwards JD, Rivanis C, Kun SS, Caughey

AB, Keens TG. Costs of hospitalized

ventilator-dependent children:

differences between a ventilator

ward and intensive care unit. Pediatr

Pulmonol. 2011;46(4):356–361

18. Seneff MG, Wagner D, Thompson D,

Honeycutt C, Silver MR. The impact

of long-term acute-care facilities

on the outcome and cost of care

for patients undergoing prolonged

mechanical ventilation. Crit Care Med.

2000;28(2):342–350

19. Gien J, Kinsella JP, Grenolds A, Abman

SH, Baker CD. Improved Survival Using

a Multidisciplinary Care Team for

Infants with Tracheostomy-Dependent

Severe Bronchopulmonary Dysplasia.

E- PAS2014: 1534. 579

20. Dagher M, Lloyd RJ. Managing negative

outcome by reducing variances in the

emergency department. QRB Qual Rev

Bull. 1991;17(1):15–21

21. Hilton B. The benefi ts of business

process mapping. Admin Radiol.

1993;12(11):31–34

22. Tofi l NM, Rutledge C, Zinkan JL, et al.

Ventilator caregiver education through

the use of high-fi delity pediatric

simulators: a pilot study. Clin Pediatr

(Phila). 2013;52(11):1038–1043

23. Abman SH, Nelin LD. Management

of Severe BPD. In: Bancalari E, ed.

The Newborn Lung: Neonatology

Questions and Controversies,

2nd ed. Philadelphia, PA: Elsevier;

2012:21.21–21.29

24. Schreiner MS, Downes JJ, Kettrick

RG, Ise C, Voit R. Chronic respiratory

failure in infants with prolonged

ventilator dependency. JAMA.

1987;258(23):3398–3404

25. Amin R, Sayal P, Syed F, Chaves A,

Moraes TJ, MacLusky I. Pediatric long-

term home mechanical ventilation:

twenty years of follow-up from one

Canadian center. Pediatr Pulmonol.

2014;49(8):816–824

26. Gien J, Abman SH, Baker CD.

Interdisciplinary care for

ventilator-dependent infants with

chronic lung disease. J Pediatr.

2014;165(6):1274–1275

27. Guinane CS, Sikes JI, Wilson RK.

Using the PDSA cycle to standardize

a quality assurance program in

a quality improvement-driven

environment. Jt Comm J Qual Improv.

1994;20(12):696–705

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DOI: 10.1542/peds.2015-0637 originally published online March 10, 2016; 2016;137;Pediatrics 

Steven H. Abman and Jason GienChristopher D. Baker, Sara Martin, Jodi Thrasher, Heather M. Moore, Joyce Baker,

Ventilator-Dependent ChildrenA Standardized Discharge Process Decreases Length of Stay for

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