ABSTRACT  

Between 2021 and 2022, 22 children received tracheostomies at UCSF, with an average length of stay (LOS) of ~180 days. Discharge for this population is a complex process, including arranging for medical equipment, home care nursing, and training caregivers, which can all lead to delays in discharge and prolong hospital stays. While it's not always possible to control the lack of medical equipment and nursing, we can have an impact on caregiver training. Children who have undergone a tracheostomy require intensive caregiver education, and despite multidisciplinary team efforts, home caregivers may experience fragmented care and communication during the transition from hospital to home^1,2,3,4. A study found that the second most common cause of discharge delays were due to caregiver training delays, with a median range of discharge 41 days after they were deemed medically stable². Other studies have reported similar findings highlighting the challenges of the transition from actively supporting a critically ill patient to physically providing primary care, which can be emotionally complex and involve a steep learning curve ^3,4,5.  An early caregiver training program has the potential to reduce inpatient LOS and healthcare costs^5,6. The primary aim of this project is to reduce LOS by enacting a high fidelity simulation training program integrated with bedside education for caregivers with the secondary goal of reducing readmission rates and improving caregiver competency. 

TEAM 

• Department of Pediatric Pulmonology: Kelly Kim (project lead), Sanaz Vaziri (project lead), Ngoc Ly (Executive sponsor) 

• Inpatient Respiratory therapist lead: David Woolsey 

• Outpatient Respiratory therapist leads: Minh Huynh, Crystal Diaz, Phyllis Moore 

• Clinical Nursing Coordinators: Jeannie Chan (ICN), Shelley Diane (PICU)

• ENT: Pamela Chan  

PROBLEM – Delays in caregiver education lead to delays in discharge. 

Although the number of patients who are trach/vent dependent may not be substantial, their intricate care needs and extended hospital stays create a considerable burden on the healthcare system. A study has shown that the average cost to the hospital for caring for a single child requiring a tracheostomy and prolonged mechanical ventilation is > $600,000 for the initial admission⁷. Previous studies, and most intensive care providers’ anecdotal experience, take note of the lengthy admissions and slow progress of this patient population toward discharge^1-3. These patients also have high rates of complications and hospital readmissions, and the financial costs and resources utilized that are associated with caring for them can be a large burden to the health care system^7,8. 

 Per hospital policy, tracheostomy and ventilator patients can only be housed in the intensive care units (PICU, CICU, ICN). During high-census periods, the lack of available inpatient beds can lead to the diversion of critically ill patients, canceled surgical procedures, or postponement of scheduled admissions. As a result, reducing the length of stay in a safe manner has become even more crucial. We can effectively alleviate some of the strain on hospital resources and make more beds available for those who need them. This will ultimately benefit both patients, families, and the hospital system.

 As soon as the need for chronic ventilation has been established, a family care conference is held with the multidisciplinary team and caregivers to discuss the intricacies of a tracheostomy. Approximately 1-2 weeks later, the tracheostomy is performed and the first tracheostomy tube change is completed 7 days post-surgery. Caregivers have a checklist of skills they need to complete prior to discharge. Typically, the teaching process begins 2-3 weeks after the first tracheostomy tube change due to various factors including scheduling difficulties, learning difficulties, language barriers or lack of familiarity/apprehension with tracheostomies; reasons commonly seen at other institutions. Teaching can also be interrupted due to medical instability, which usually occurs at multiple points during admission.  Teaching also takes place using a low fidelity simulation doll. Many caregivers feel that the doll does not simulate a real tracheostomy or provide a realistic understanding of tracheostomy care. Many caregivers continue to feel discomfort with teachings prior to discharge and require re-education and additional support which often leads to discharge delays. 

 The transition from hospital to home can also be very stressful for families resulting in 26%–30% of tracheostomy-dependent children readmitted within 30 days post discharge, with a subset of these readmissions seen in patients with caregiver delays in teaching. Furthermore, we found that a significant number of readmissions might have been avoidable with quality care at home. Caregivers frequently report feeling unprepared and uncomfortable caring for their children and their medical devices at home despite receiving training in the hospital. As a result, they have a low threshold to seek care for their children through the ED or hospital, with subsequent impact on their children’s health outcomes.

 In patients with tracheostomy and ventilators, standardizing discharge processes has been shown to decrease overall length of stay and readmission rates without jeopardizing patient safety. Baker et. al reduced mean overall length of stay by 42% after interventions including education materials, chronic ventilation road map for caregivers, team-based care coordination, and high-fidelity simulation trainings. While our institution has some of these in place, we have identified certain areas in caregiver education and documentation of discharge readiness which can contribute to reducing length of stay. 

TARGET: reduce length of stay in the ICU by minimum of 7-10 days. Secondary target: improve caregiver confidence, reduce readmission rates 

The primary aim of this initiative is to reduce the length of stay in the ICU by a minimum of 1 week by enacting a high fidelity simulation training program which will start even prior to insertion of a tracheostomy. Our secondary aims are to reduce readmission rates and improve caregiver competence in tracheostomy care through simulation training both inpatient and outpatient which we also predict will have an impact on reducing length of stay and readmission rates.

There are many discrepancies in standard discharge education for parents of pediatric tracheostomy patients which lead to lack of caregiver knowledge, and variations in quality of life in the home environment. Caregiver anxiety related to the tracheostomy can also lead to improper care and increased risk of complications which can also lead to increased readmission rates. While caregivers receive training on emergency scenarios, it's important to acknowledge that such situations may not be as common in a hospital setting. This can limit their exposure to true emergency management, which may make them feel less confident or capable. In studies where simulation training was enacted, it resulted in increased caregiver competence in routine tracheostomy care and emergency scenarios⁹. A high fidelity simulation doll has the ability to control the stoma size so that learners can practice on realistic tracheal tube insertion and emergency scenarios such as simulate a false passage, mucus plugs, abnormal breathing patterns, and cardiopulmonary arrest. With high fidelity simulations, caregivers were also able to attain proficiency in the necessary skills without having to repeatedly practice on their child and had the flexibility to practice on the simulator at their own convenience⁶. Providing realistic experiential learning introduced families to the stress they will face at home and unmasks false confidence, allowing for review and targeted re-education prior to discharge. Research has confirmed that repetitive caregiver education improves survival rates, decreases frequency and lengths of hospital stays, readmission rates, and decreases complications and costs for these children^4,5,6,10. 

Beyond just financial benefits, providing care for these patients at home can have important psychological and developmental benefits. Long hospital stays can disrupt the family unit and impede a child's development. 

Once these children are home, there is a high risk for mortality and readmissions. Ensuring close follow-up care and giving caregivers the opportunity to continue education and training while outpatient can also be instrumental in helping families re-learn skills and reducing readmissions⁸. 

GAPS

Traditionally, home tracheostomy and ventilator management is taught via a combination of didactic instruction and bedside skills demonstration. However, the current approach to teaching these skills is inconsistent and highly dependent on the caregivers' schedules, as well as the availability of nursing and respiratory therapists. Typically, most of the tracheostomy care occurs during the day. If caregivers are unable to be at the bedside due to work commitments, childcare, or long distances from home, this becomes a missed opportunity. On preliminary chart review, about 20% of our tracheostomy/ventilator patients in 2021-2022 were noted to have training delays identified in their notes (in line with similar studies). In a subset of these patients, the third caregiver did not start training until 1-2 weeks prior to discharge which may not provide sufficient time for them to become fully comfortable with the teachings and care. 

Caregivers receive education on how to care for the stoma, detect signs of infection, suction secretions, change the tracheostomy tube, and manage potential airway emergencies. For some pediatric patients, home mechanical ventilation is also required, necessitating additional education. At times, teaching is carried out using a low fidelity simulation doll. While using this type of doll for training may be useful, it may not always provide a comprehensive and accurate representation of the intricacies involved in tracheostomy change or care. This could pose challenges for many families, as they may not be able to fully achieve the desired, life-like effects they aim for, potentially limiting the value of the training. As a result, they may struggle to apply the knowledge and skills they have gained to actual situations, underscoring the importance of using effective training tools to enhance patient care.

INTERVENTION 

 By adding a high-fidelity simulation mannequin to interventions that are already implemented, start training even prior to insertion of the tracheostomy, and implement an outpatient re-education on emergency scenarios, we hope to optimize tracheostomy education. 

 Typically, there is a 3-4 week period between the initial discussions surrounding tracheostomy and the first post-surgical tracheostomy tube change. This presents an ideal opportunity to start making an impact through training. By starting an early tracheostomy education program using a high-fidelity mannequin, caregivers will have a better understanding of the intricacies of the tracheostomy, which can speed up the learning and education process. This, in turn, can have a positive impact on both the length of stay and caregiver confidence which in turn can reduce readmission rates. The NICU, PICU and CICU are homes to many of our patients with tracheostomies.  The mannequin has the benefits of being portable and will be able to move between the units. The simulation tracheostomy dolls offer an opportunity for caregivers to practice the skills they have learned during the pre and early post-operative weeks when they are unable or hesitant to practice on their child. They also have the opportunity to practice these scenarios throughout their child’s stay and have the ability to work on specific areas they are uncomfortable with at their own pace.

 Current interventions already in place: 

• Weekly rounds with multidisciplinary team- ENT, Pulmonary, RT, and OT

• Trach/vent monthly meeting group 

• Outpatient monthly trach/vent clinic with ENT, OT, RT and Pulmonary- started March 2022

• Dedicated NP in place for inpatient and outpatient trach/vent patients

• Low fidelity simulation doll to practice trach care on 

 Phase 1: prior to placement of a tracheostomy

• Family meeting takes place with multidisciplinary team. Tracheostomy binder outlines the necessary information and a roadmap which contains a comprehensive checklist of competencies that caregivers must complete prior to their child's discharge 

• Learning at the bedside- caregiver becomes familiar with tracheostomy and supplies, introduction to the tracheostomy doll and trach teaching begins

• Identify upcoming training dates for teaching 

 Phase 2:  Post tracheostomy surgery, Prior to the first tube change (up to post op day 7)

• Caregivers continue to learn skills on high fidelity mannequin through demonstration and practice. The goal is for each caregiver to complete at least one trach change, change trach ties, and suctioning prior to phase 3

 Phase 3: after 1^st tracheostomy tube change- prior to discharge

• Learning at the bedside continues. Caregivers practice skills they acquired with the high fidelity simulation doll like tracheostomy tube changes and suctioning on patient. Simulation doll present to continue practicing skills caregivers feel they need more practice on.

• Practice emergency scenarios on high fidelity doll which allows for more realistic scenarios such as abnormal breathing patterns, cyanosis, cardiopulmonary arrest. Mannequin also allows simulation of difficult airway and changes in stoma size. Debriefs following each scenario allowing for questions, skill-building and emotional outlet

• Repeat scenarios monthly throughout stay promoting increased competency and confidence in skills 

Phase 4: Discharge readiness

• Demonstrate comfort and skills competency

• Evaluation of the caregivers ability to perform hands-on skill in 24 hour room in with observation from nursing and respiratory care staff.

 Phase 5: Post discharge

• Follow up in-person appointment in trach/vent clinic where caregivers will continue to practice emergency scenarios on high fidelity simulation dolls as a refresher. Usually seen every 3 months 

• Telehealth appointments with trach/vent NP within a month after discharge 

PROPOSED EHR MODIFICATIONS 

Currently our competency checklist is in our tracheostomy binder which sits by patient bedside. Integrating the tracheostomy binder into Apex would allow the team members to track progress on teaching and discharge readiness. 

COST 

 We anticipate a one time expense of ~$48,000 which will support the costs of a high fidelity simulation mannequin. 

The projected savings: 

• Traditional direct hospital charge cost associated with ICU admission is estimated to be around $5,500 daily. This is only focusing on direct costs. 

• Decreasing ICU stay by minimum of 7-10 days: $38,500-$55,000 in direct costs saved per patient

• If we anticipate that 20% of our tracheostomy patients will have caregiver delays (in accordance with the literature and chart review), by enacting this high fidelity simulation program with the other interventions already in place, we estimate that the total costs savings for reducing LOS by minimum of 7-10 days for 5 patients will result in a reduction of  $192,000-275,000 for the hospital system

• We are not counting  the substantial resources provided daily from respiratory therapists and nurses along with other costs from nebulized medications administered (at least 2-3 medications given twice a day), imaging, blood work, OT and PT therapies, and administering feeds 

• Availability of ICU beds prevents admission diversion and last minute cancellation of surgical cases reducing risks and downstream costs.

SUSTAINABILITY  

Currently we have multiple interventions in place already implemented that standardizes the discharge process and will help sustain this beyond the funding year. 

• Educational materials will be in place to help guide respiratory therapists regarding simulations. Respiratory therapists already provide the bulk of tracheostomy teaching and using a high fidelity simulation doll can be easily integrated

• Identifying days for training at the beginning of tracheostomy discussions will be incorporated in the skills checklist 

• There is a tracheostomy taskforce group that has been established who is already working on standardizing and improving the discharge process which decreasing variations in care practices

• Dedicated nurse practitioner who follows inpatient and outpatient tracheostomy/ventilator patients

• Tracheostomy rounds take place weekly with the multidisciplinary team

High fidelity simulators do not require a lot of maintenance and have the ability to move between units. High fidelity simulators can also be effective in providing training to other healthcare professionals including nurses, respiratory therapists and residents/fellows 

BUDGET: 

SimBaby: $41,000 (https://www.youtube.com/watch?v=iSTHQ0tXKJY) 
SimPad Plus: $1,000: operating device used to control Laerdal manikins and simulators enabling simulations to be run easily and effectively. 
LLEAP License $3,100 License Key providing access to Manual Mode, Automatic Mode, and Log Viewer Application
Laptop (patient monitor) $2150