Risk factors for return visits in children discharged with tracheostomy
Introduction
Tracheostomy is a vital procedure for many infants and children with chronic conditions, providing a secure airway for long-term mechanical ventilation in the outpatient setting. With approximately 4,800 pediatric tracheostomies placed each year, these patients account for a relatively small number of hospitalizations; however, they utilize a disproportionate amount of resources and are at high risk for morbidity and mortality. Pediatric patients with tracheostomy suffer from a mortality rate of 8% during initial hospitalization for tracheostomy placement and incur an initial hospitalization cost of nearly $250,000 each [1]. These patients are complex, often with multiple chronic conditions and use of at least one medical technology in addition to a ventilator [2]. Aided by technological advancements in neonatal and pediatric critical care, pediatric patients with tracheostomy are now routinely discharged to home care and are at high risk of readmission, with reports of over half of those discharged with tracheostomy returning within six months [[3], [4], [5], [6], [7], [8]].
In response, quality improvement programs have been established in institutions across the country in recent years to arrange closer follow-up and reduce readmission rates for this population. Enhanced inpatient tracheostomy training and establishment of multidisciplinary outpatient clinics have had notable success in providing support for home caregivers, who bear demanding responsibilities in the care of technology-dependent children [[9], [10], [11], [12], [13], [14], [15], [16], [17], [18]]. However, there is still marked variability in the surveillance and management of tracheostomy patients and a lack of standardized clinical guidelines that may improve outcomes [19]. Resources available to children discharged with tracheostomy vary widely by geographic region and insurance status, hindering the ability of practitioners to generalize best practices from one institution to another, and factors that may predict readmission have yet to be identified [20].
The objectives of this study are to describe patterns of unplanned returns to the system (RTS), either to Emergency Department (ED) or inpatient (IP) units, during the 180 days after initial discharge home with a tracheostomy; to identify associations between demographic and clinical factors and RTS; and to describe the characteristics of high-cost, high-need patients with multiple readmissions during this time period. Better understanding of the factors driving patients back to the healthcare system after discharge could lead to improvements in the discharge process or more tailored outpatient access to support, with the ultimate goal of proactive identification of patients who may require a more hands-on approach to outpatient care in order to decrease overall morbidity.
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Materials and methods
This study was approved by the Children's Healthcare of Atlanta Institutional Review Board. The authors have no conflicts of interest to disclose and the study did not receive financial support. Medical charts were reviewed to identify patients between birth and age 18 years of age who were discharged after tracheostomy placement between January 1, 2011 and December 31, 2015. Patients were excluded if they were not discharged with a tracheostomy, either because of death or decannulation prior
Results
During the 5-year study period, 158 patients underwent 159 tracheostomy placement procedures (one patient had tracheostomy replaced after a period of decannulation). Of these patients, 12 patients underwent decannulation before discharge, 11 patients did not survive to discharge, and 15 patients were lost to follow-up before 180 days post-discharge, leaving 121 eligible patients.
Demographic and clinical characteristics of all eligible patients are listed in Table 1. Median age for all patients
Discussion
Despite continued efforts to support home caregivers and schedule regular follow-up, RTS rates among pediatric patients with tracheostomy remain high. Estimates of the 30-day RTS rate range from 17 to 28 %, with even higher rates reported up to one year past the date of discharge [8,22,23]. With 30-day and 180-day RTS rates of 33.9 % and 66.1 %, respectively, our results are at the higher end of this range; however, the inclusion of ED visits in RTS rates varies among previous studies and
Conclusion
This study provides further evidence that pediatric patients discharged with tracheostomy are medically complex and at high risk of RTS, especially for respiratory and GI problems. Enteral feeding issues in particular drive a large proportion of RTS. This risk does not decrease after the initial post-discharge period and long-term follow-up is warranted. Younger patients and patients with history of early RTS are at highest risk for repeat RTS and should be identified for close outpatient
Acknowledgements
We would like to acknowledge Jessica L. Specht, MD for work in data acquisition.
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