Gaudreau Philip A, Greenlick Hannah, Dong Tiffany, Levy Michelle, Hackett Alyssa, Preciado Diego, Zalzal George, Reilly Brian K
Department of Otolaryngology, Naval Medical Center, San Diego, California.
Division of Otolaryngology, Children's National Medical Center, Washington, DC.
JAMA Otolaryngol Head Neck Surg. 2016 Oct 1;142(10):966-971. doi: 10.1001/jamaoto.2016.1803.
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.
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.
A postoperative tracheostomy care and education protocol.
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).
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).
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.
小儿气管造口术常用于上呼吸道梗阻和长期机械通气。接受气管造口术的儿童通常有多种慢性医疗问题，这使他们再次入院和出现其他并发症的风险很高。
确定实施针对家长教育和伤口护理的术后方案（由接受过气管造口护理培训的护士执行）是否能降低再次入院率和其他并发症的发生率。
设计、地点和参与者：对2009年1月1日至2014年12月31日在一家三级儿科医疗中心接受气管造口术的18岁及以下儿童进行了病例系列研究和病历回顾。
术后气管造口护理和教育方案。
总体30天再入院率、30天气管造口相关再入院率、气管造口伤口并发症以及可能影响再入院率和伤口并发症的其他因素（气管造口时的年龄、出院地点、气管造口的指征）。
共纳入191名儿童（118名男孩和73名女孩）；其中，112名参与了教育方案培训，79名儿童未参与。实施教育方案后，总体再入院率没有下降（方案实施前为26.8%，方案实施后为26.6%；差值为0.2%；95%CI为-12.5%至13.0%），气管造口相关再入院率也没有下降（方案实施前为10.1%，方案实施后为7.1%；差值为3.0%；95%CI为-5.0%至11.0%）。总体而言，68.6%的再入院与合并症有关（95%CI为55.9%至81.3%）。方案实施后，气管造口相关伤口并发症显著减少（从31.6%降至17.9%；差值为13.7%；95%CI为1.6%至26.0%）。多因素logistic回归分析显示，与出院至高级护理机构的患者相比，出院回家的儿童因气管造口相关并发症再次入院的可能性显著更高（比值比为14.47；95%CI为3.08至67.92）。
气管造口护理需要所有护理人员具备专业知识，对于未经专门培训的人员来说具有挑战性。专门的护理和教育方案与气管造口伤口并发症的减少有关。与出院至高级护理机构的儿童相比，直接出院回家的儿童再次入院的风险更高。有必要进一步制定护理人员教育方案，以持续降低再入院率和气管造口相关并发症的发生率。
