OBJECTIVE 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.

Simulation training can be incorporated into discharge training for families of children requiring LTMV. Rehearsal of emergency management in a simulated clinical setting increases caregiver confidence to assume care for their ventilator-dependent child.

Summary Introduction Children with chronic respiratory failure and upper airway disorders may require tracheostomy placement and long-term mechanical ventilation, yet many improve to permit ventilator weaning and decannulation. Methods As a quality improvement project, we conducted a chart review of patients followed by our Ventilator Care Program who underwent evaluation for weaning nocturnal ventilation (NV) and/or decannulation from 2007–2014. We collected patient demographics and characterized location, monitoring techniques, and outcomes for patients undergoing weaning NV or decannulation. We attempted to implement end tidal carbon dioxide (ETCO2) monitoring and used linear regression to compare ETCO2 with morning pCO2. Results Weaning NV was successful in 20/21 patients. Decannulation was successful in 18/21 attempts. Once implemented, ETCO2 was piloted and successfully performed in 12 attempts (29%). Blood testing was performed in 24/42 trials (57%). When measured, the final ETCO2 result partially correlated with morning pCO2 (R2 = 0.53, P < 0.02). Neither blood testing nor ETCO2 was performed for the four patients with unsuccessful attempts. Conclusions Inpatient observation for weaning NV and decannulation is safe and, in most cases, successful. With close observation, weaning NV at home may also be safe. Blood testing and ETCO2 monitoring were frequently utilized, but rarely affected decision-making since signs of respiratory distress were observed clinically prior to testing. ETCO2 monitoring may provide reassurance without venipuncture. With our experience, we propose an algorithm for weaning NV and decannulation.

The I'M SAFE tool identifies patients at increased risk for falls. When linked to a multidisciplinary fall prevention program, the incidence of preventable falls can be reduced. The program's impact has persisted across two facilities.