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Original Investigation |

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

Philip A. Gaudreau, MD1; Hannah Greenlick, RN2; Tiffany Dong, BA3; Michelle Levy, PA-C2; Alyssa Hackett, MD4; Diego Preciado, MD, PhD2; George Zalzal, MD2; Brian K. Reilly, MD2
[+] Author Affiliations
1Department of Otolaryngology, Naval Medical Center, San Diego, California
2Division of Otolaryngology, Children’s National Medical Center, Washington, DC
3George Washington University School of Medicine and Health Sciences, Washington, DC
4Department of Otolaryngology, New York Eye and Ear Infirmary, New York
JAMA Otolaryngol Head Neck Surg. Published online July 28, 2016. doi:10.1001/jamaoto.2016.1803
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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.

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“Trach Me Home” Protocol

Protocol for perioperative care followed by tracheostomy care specialist. Ambu bag indicates bag valve mask; Consult, consultation; CPR, cardiopulmonary resuscitation; ENT, otolaryngologst; Preop, preoperative; PPS, professional practice specialist or clinical nurse specialist; PT, patient; RN, registered nurse; Trach, tracheostomy. This form is reproduced with permission from the Children’s National Medical Center Pediatric Intensive Care Unit Practice Council.

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