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Original Investigation
September 19, 2019

Association of a Multidisciplinary Care Approach With the Quality of Care After Pediatric Tracheostomy

Author Affiliations
  • 1Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital, Boston, Massachusetts
  • 2Department of Respiratory Care, Boston Children’s Hospital, Boston, Massachusetts
  • 3Department of Complex Care Service, Boston Children’s Hospital, Boston, Massachusetts
  • 4Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
  • 5Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. Published online September 19, 2019. doi:10.1001/jamaoto.2019.2500
Key Points

Question  Is a multidisciplinary tracheostomy program associated with the quality of care after pediatric tracheostomy?

Findings  In this cohort study that included 700 children who received a tracheostomy, implementation of a multidisciplinary tracheostomy program was associated with a reduction in tracheostomy-related adverse events by 43%, improved tracheostomy education, and achievement of a continuum of care from an inpatient to outpatient setting.

Meaning  This study suggests that a multidisciplinary tracheostomy program may be associated with quality-driven care for children who have received a tracheostomy.

Abstract

Importance  Incidence of tracheostomy placement in children is increasing, and these children continue to have high incidences of morbidity and mortality. A multidisciplinary tracheostomy program may help improve the quality of care received by these patients.

Objective  To determine whether implementation of a multidisciplinary tracheostomy program can improve the care of children who received a tracheostomy through reduction in tracheostomy-related adverse events (TRAEs), improved tracheostomy education, and caregiver preparedness.

Design, Setting, and Participants  A prospective cohort study was conducted from January 2015 to June 2018 at a pediatric tertiary referral center in Boston, Massachusetts. The participants included 700 children who had received a tracheostomy, most of whom were aged birth to 18 years, but some patients with congenital disorders were much older.

Exposures  Institution of a multidisciplinary tracheostomy team (MDT) whose activities included conducting staff meetings, organizing outpatient clinics, conducting inpatient tracheostomy ward rounds, and conducting inpatient tracheostomy rounds at a local rehabilitation hospital. Quality improvement initiatives included monitoring standardized TRAEs and distributing standardized tracheostomy “go-bags.”

Main Outcomes and Measures  Reduction of TRAEs and improved caregiver preparedness through distribution of tracheostomy go-bags were assessed following the establishment of a multidisciplinary tracheostomy program.

Results  In total, 700 children who had received a tracheostomy during the study period were actively followed up by the MDT. Of these children, 378 (54.0%) were males and 322 (46.0%) were females; mean (SD) age was 4.1 (6.1) years. More than 60 new pediatric tracheostomies were performed annually at the referral center. Reported TRAEs were reduced by 43.0% from the first to the third year after the implementation of a standardized, closed-loop monitoring system (from a mean [SD] of 6.1 [5.2] TRAEs per 1000 inpatient tracheostomy-days in 2015 to a mean [SD] of 4.0 [2.5] in 2018). The most common TRAE was unplanned decannulation, which occurred 64 times during the study period. On average, 10 patients were seen in each monthly multidisciplinary tracheostomy clinic. Clinic interventions included continuing care (146 [52.5%]), communication enhancement (67 [23.6%]), plans for decannulation (52 [18.6%]), and referrals for comorbidities (13 [4.6%]). Approximately 19 inpatients were seen during biweekly rounds and 8 during monthly rounds at a local rehabilitation hospital. A total of 297 patients received standardized tracheostomy go-bags, and more than 70 positive bag checks were performed in the monthly MDT clinics. A positive bag check refers to the incidence when a family is given a go-bag and also uses it. In contrast, a negative bag check refers to when a family is given a go-bag but neither brings it to the clinic nor acknowledges that they use it.

Conclusions and Relevance  This study’s findings suggest that a multidisciplinary tracheostomy program may be a powerful tool for enhancing patient safety and quality improvement. Ongoing studies will develop measurable pediatric tracheostomy outcome metrics and assess long-term outcomes.

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