Discharging a Pediatric Patient on a Home Mechanical Ventilator Delilah Dees, BSN, RN, PHN, CCM Children’s Hospital Los Angeles
Background
Results of the HMV – MAP
Children’s Hospital Los Angeles (CHLA) is a high-acuity, high-volume medical center that treats the most vulnerable children in Southern California in need of specialty care. We also care for the largest group of home mechanical ventilator (HMV) patients in the Western United States, averaging more than 200 patients per year. CHLA Newborn and Infant Critical Care unit (NICCU) has served 2000 of the 8000 reported nationally. Despite rapid advancements in medicine, the manner of our discharges has become increasingly challenging for the entire interprofessional team, given the high mortality rate of 27%, and readmission rate of 40% within 3 months of discharge. Sending home a complex patient on a home mechanical ventilator has created many challenges for physicians, nurses, clinical care coordinators, social workers, insurance companies, venders, and ultimately the parents and family members. As Clinical Care Coordinators, we strive to improve the consistency of discharge planning while engaging patients and families to ensure a seamless transition to the home environment. In order to address inconsistencies with the discharge planning processes, we assisted in the development of a Multidisciplinary Action Plan (MAP) model to standardize complex discharge planning for first-time home transition of HMV patients, helping to improve efficiency, quality of training, and fewer discharge failures. An interprofessional team was formed to formulate an improved discharge planning process. The HMV-MAP program has guided the practice and is proven to be successful with interdisciplinary ongoing conferences, improved communication, training, independent care, defining stability, emergency scenario teaching and the garden walk.
Literature Research Authors Kun et al., 2011
Edwards et al., 2012
Kun et al., 2010
Kun et al., 2015
Title
Findings
Hospital readmissions for newly discharged pediatric home mechanical ventilation patients
Very high readmission rate within 3 months of discharge with a common factor of a medical change made one week prior to discharge Mortality rate remains high at 27 %
Decreasing accidental mortality of ventilator dependent children at home, a call to action How much do primary caregivers know about tracheostomy and home ventilator emergency care?
Examining pediatric emergency home ventilator practices in home health nurses: opportunities for improves care
Parents and In-home nurses of children on a home mechanical ventilator were knowledgeable except for interpreting ventilator alarms and emergency procedures In-home nurses of children on a home mechanical ventilator had poor knowledge of what to do in an emergency
Measured Outcomes Identify barriers, improvement, delays Re-admissions for respiratory associated complications ( within 30 days post hospital discharge)
Pre-HMV Baseline Data N=109 HMV pediatric patients from 2003-2009 (Kun et al., 2011) 46% Pneumonia, tracheitis, tracheostomy decannulation, obstruction, and other respiratory causes
Post HMV MAP Pilot Study N=26 HMV Develop pediatric patients from Improve process July 2013- January 2015 re-evaluate
0%
7.7 % Electrolytes imbalance, sepsis and Ileus
Emergency room visits within 24-48 hours post hospital discharge
No benchmark data
15% Aspiration pneumonia, dehydration, emesis, accidental GT removal
Length of stay
No benchmark data
7 weeks or less
Ongoing Research for the HMV Program HMV-MAP Model Daily bedside rounding with interprofessional team Collaboration with the Social Worker Collaboration with community resources
Challenges NICCU is the highest co-morbidity population Parents overwhelmed with new diagnosis High length of stay due to intense expected training Starting new insurance policy on a newborn and/or insurance change Limited home health nurses with experience caring for children with a mechanical ventilator in home setting Ongoing break down in communication Limited vendor options
Increase knowledge of the Healthcare system and resources for this population Improve caregiver knowledge and confidence caring for a child at home on a home mechanical ventilator Improve collaboration with the community, including home health agencies
Physicians, Pulmonary, Critical Care, Hospitalist, General Pediatrician
Clinical Care Coordinator, Care Manager, Nurses, RCP, Dietician
Strengths
Improve collaboration and communication with entire interdisciplinary HMV team across the continuum, improving the care from a systems approach
Multidisciplinary Action Plan (MAP) Model
31% Abdominal pain, infectious, gastrointestinal, tracheostomy bleeding, failure to thrive, feeding intolerance, neurosurgical, dehydration/electrolyte imbalance, seizures, and ophthalmologic causes
Readmissions for nonrespiratory associated complications (within 30 days post hospital discharge)
Future Goals
Patient & Family
Social work, Child Life Specialist, Spiritual Care
OT/PT, Speech and Dysphagia Team
Acknowledgements I would like to acknowledge and thank the following authors and colleagues for their time and contributions: Sheila Kun, BA, BSN, MS, FCCP Jiffy Ellashek, MSN, RN, CPN Sandy Hall, MSN, MBA, RN-BC, NE-BC
References Kun, S.S, J.D. Edwards, S.L Davidson Ward, and T.G Keens. Hospital readmissions for newly discharged pediatric home mechanical ventilation patients. Pediatric Pulmonology, 47:409-414, 2011 Kun, S.S, Edwards, J. D. , Ward, S.L D, Hulse, L.M., and Keens, T.G. How much do primary caregivers know about tracheostomy and home ventilator emergency care? Pediatric Pulmonology, 45:270274, 2010. PMID: 20146395 Kun, S.S, Beas, V.N., Gold, J.I., Keens, T.G., Ward, S.L.D. Examining pediatric emergency home ventilator practices in home health nurses: opportunities for improves care. Pediatric Pulmonology, 50:691-697, 2015. PMID: 24706404 Boroughs, D. & Dougherty, J.A. (February, 2012). Decreasing accidental mortality of ventilator dependent children at home, a call to action. Home Healthcare Nurse, 30 (2) 103-111
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