Outcome of home care for technology-dependent children: success of an independent, community-based case management model

Ventilatory support at home for children: A joint position paper from the Thoracic Society of Australia and New Zealand/Australasian Sleep Association

The goal of this position paper on ventilatory support at home for children is to provide expert consensus from Australia and New Zealand on optimal care for children requiring ventilatory support at home, both non-invasive and invasive. It was compiled by members of the Thoracic Society of Australia and New Zealand (TSANZ) and the Australasian Sleep Association (ASA). This document provides recommendations to support the development of improved services for Australian and New Zealand children who require long-term ventilatory support. Issues relevant to providers of equipment and areas of research need are highlighted.

Liberation and mortality outcomes in pediatric long-term ventilation: A qualitative systematic review

OBJECTIVE

To provide a systematic review of liberation from positive pressure ventilation and mortality of children with chronic respiratory failure who used long-term invasive and noninvasive ventilation (LTV).

METHODS

Papers published from 1980 to 2018 were identified using Pubmed MEDLINE, Ovid MEDLINE, Embase, and Cochrane databases. Search results were limited to English-language papers with (a) patients less than 22 years at initiation, (b) patients who used invasive ventilation (IV) via tracheostomy or noninvasive ventilation (NIV), and (c) data on mortality or liberation from LTV. Data were presented using descriptive statistics; changes in outcomes over time were explored using linear regression. Follow-up variability, cohort heterogeneity, and insufficient data precluded combining data to estimate incidences or rates.

RESULTS

One hundred and thirty papers with 12 704 patients were included. The median number of patients was 37 (interquartile range [IQR] 17-74, range 6-3802). Twenty-five percent of patients were initiated on IV; 75% on NIV. The maximum follow-up ranged from 0.5 to 31.8 years (median 8.8 years). The median proportion of patients liberated in these papers was 3% (IQR 0%-21%). The median proportion of mortality was 18% (IQR 8%-27%). Proportions of liberation and mortality did not significantly change over time. Progression of underlying disease (44%), respiratory illness (19%), and LTV accident (11%) were the most common causes of death.

CONCLUSIONS

These papers collectively show most patients survive for many years using LTV; in many subgroups, death is a more common outcome than liberation. However, the limitations of these papers preclude robust prognostication.

Factors for Hospitalization in a Medically Complex Population of Pediatric Home Care Patients

Research has identified demographic, clinical, and technological characteristics that are associated with recurrent pediatric hospital admissions. However, research focusing on risk factors for hospitalization among pediatric home care patients is lacking. The purpose of this study was to identify characteristics associated with 60-day hospitalization among pediatric home care patients. To address this objective, we used information collected from pediatric home care patients, age 6 months to 17 years, who were served by a large not-for-profit home care agency in New York City between 2008 and 2012 ( N = 6,187). Results showed that 5.4% of patients in our study population were hospitalized. Specific characteristics that were significantly associated with hospitalization are described in detail.

Outcomes of children with severe bronchopulmonary dysplasia who were ventilator dependent at home

OBJECTIVE

To describe the incidence and outcomes of children with chronic respiratory failure secondary to severe bronchopulmonary dysplasia (BPD) on chronic positive pressure ventilation (PPV) via tracheostomy at home.

METHODS

We retrospectively reviewed medical charts of patients with severe BPD who were PPV dependent at home and who were enrolled in a university-affiliated home ventilator program between 1984 and 2010. We excluded patients with other comorbidities that could contribute to the development of chronic respiratory failure. We reported the incidence of these children in Indiana and cumulative incidences of survival, liberation from PPV, and decannulation.

RESULTS

Over 27 years, 628 children were cared for in our home ventilator program. Of these, 102 patients met inclusion criteria: 83 (81.4%) were alive and 19 (18.6%) were deceased. Sixty-nine patients (67.6%) were liberated from PPV, and 97.1% of them were weaned before their fifth birthday, with a median age at liberation of 24 months (interquartile range, 19-33). Similarly, 60 patients (58.8%) were decannulated, of which 96.7% completed this process before their sixth birthday, with a median age at decannulation of 37.5 months (interquartile range, 31.5-45). The incidence of children with chronic respiratory failure secondary to BPD who were PPV-dependent at home in Indiana was 1.23 per 100 000 live births in 1984 and increased to 4.77 per 100 000 live births in 2010.

CONCLUSIONS

Although extreme prematurity associated with severe BPD necessitating PPV at home carries significant risks of morbidity and mortality, successful liberation from mechanical ventilation and decannulation are likely to occur.

Outcomes of children treated with tracheostomy and positive-pressure ventilation at home

BACKGROUND

Long-term outcomes for children who survive on tracheostomy and positive-pressure ventilation (TPPV) at home are not well known.

METHODS

A retrospective review of 20 years of clinical data at a single institution was performed. Outcome measures included 5-year survival, decannulation rate, and neurocognition.

RESULTS

A total of 91 children were categorized under neuromotor dysfunction (52%), chronic lung disease (29%), and congenital anomalies (20%). The 5-year survival rates for these categories were 89% (95% confidence interval [CI] = 80%-99%), 76% (95% CI = 57%-100%), and 94% (95% CI = 83%-100%), respectively. Overall, the 5-year decannulation rate was 25% (95% CI = 14%-35%), with children with chronic lung disease having the highest rate (51%). It was found that 14% were extremely delayed in neurocognition.

CONCLUSION

Most children on TPPV at home survive beyond 5 years, and a significant number are decannulated. Primary care physicians and communities should be prepared to accommodate the increasing number of children on TPPV at home.

[Chronic dependence on mechanical pulmonary ventilation in pediatric care: a necessary debate for Brazil's Unified Health System]

People with prolonged dependence on mechanical ventilation require permanent care and the use of equipment that can result in longer term hospital internment. This can lead to difficulty of access for patients with acute injuries, as well as personal difficulties and stress with reduced quality of life for their families or caregivers due to such longer hospital internment. This critical review of publications dealing with dependence on mechanical ventilation among children and adolescents aimed at making information organized in a systematic manner available in order to support discussion on the subject. It should be borne in mind that changes in epidemiological profile and growing technological access determine needs such as intensive therapy hospital beds and complex home care for chronic patients, which still have limits of supply and regulatory restrictions in the Brazilian public health system.

Outcomes and causes of death in children on home mechanical ventilation via tracheostomy: an institutional and literature review

OBJECTIVE

To describe outcomes and causes of death in children on chronic positive-pressure ventilation via tracheostomy.

STUDY DESIGN

We conducted a retrospective observational cohort analysis of 228 children enrolled in an university-affiliated home mechanical ventilation (HMV) program over 22 years (990 person-years). Cumulative incidences of survival and liberation from HMV are presented. Time-to-events were compared by reason for chronic respiratory failure (CRF) and age and date of HMV initiation with Kaplan-Meier and Cox regression analyses. Circumstances of death are described.

RESULTS

Of our cohort, 47 of 228 children died, and 41 children were liberated from HMV. The 5-year cumulative incidences of survival and liberation were 80% and 24%, respectively. Being placed on HMV for chronic pulmonary disease was independently associated with liberation from HMV (hazard ratio, 7.38; 95% CI, 3.0-18.2; P < .001). Neither age nor reasons for CRF were associated with shortened survival. Progression of underlying condition accounted for only 34% of deaths; 49% of deaths were unexpected.

CONCLUSION

Most children on HMV survive or were weaned off. However, a sizable number of children in our cohort died, and many deaths were unexpected and from causes not directly related to their primary reason for CRF.

A home respiratory support programme for children by parents and layperson carers

AIM

To describe a respiratory support programme for children at home by parents and layperson carers.

METHODS

Analysis of records of children with long-term mechanical respiratory support at home.

RESULTS

From 1979 to 2008 the programme managed 168 children (median age 7 years, range 3 weeks-19 years) with obstructive sleep apnoea (55, 32%), neuromuscular conditions (42, 25%), tracheo-bronchomalacia (23, 14%), kyphoscoliosis-cerebral palsy (20, 12%), acquired central hypoventilation (8, 5%), congenital central hypoventilation (7, 4%), chronic lung disease or pulmonary hypoplasia (8, 5%), traumatic quadriplegia (3, 2%) and tumour-related quadriplegia (2, 1%). One hundred and sixty-one (96%) were discharged: 73 (46%) remain in the programme; 27 (16%) transferred to adult services, 25 (15%) recovered and 36 (23%) died. Principal modes of therapy were mask continuous positive airway pressure (CPAP) 35%, mask bilevel positive airway pressure 30%, tracheostomy CPAP 20%, tracheostomy mechanical ventilation 8%, phrenic nerve pacing 3%, negative pressure chamber ventilation 2% and nasal tube CPAP 2%. Two unexpected deaths occurred at home: one from accidental tracheostomy decannulation and another unrelated to respiratory support. Average time in the programme was 3.3 years. Parents of 69 children were provided with trained carers. Successful discharge resulted from early recognition of potential to discharge, parental training, recruitment and training of carers, purchase of equipment and secure funding. Seven children were not discharged, two of whom died in the hospital and five are subject to discharge planning.

CONCLUSION

Respiratory support of children at home by trained parents and layperson carers is safe and efficient. All modes of respiratory support may be used.

Service integration and co-ordination: a framework of approaches for the delivery of co-ordinated care to children with disabilities and their families

This article clarifies the nature of 'service integration' and 'service co-ordination' and discusses how these aspects relate to the fundamental goal of providing co-ordinated care for children with disabilities and their families. Based on a review of the service delivery literatures in the fields of health, social services and rehabilitation, a framework is presented that outlines the scope of the co-ordination-related functions and activities encompassed in three common types of approaches to the delivery of co-ordinated care. These are a system/sector-based service integration approach, an agency-based service integration approach and a client/family-based service co-ordination approach. The functions outlined in the framework include aggregate-level planning of services (designed to map out the scope and plan for service provision in a community or geographical area), administrative functions (designed to ensure wise and equitable access to resources) and client-specific service delivery functions (designed to link clients/families to needed services). The framework is a tool that can be used to support policy making and decision making with respect to the design of efforts to provide co-ordinated care. It provides information about commonly used approaches and the essential elements of these approaches, which can be used in making choices about the scope and nature of an approach towards service integration/co-ordination.

Care coordination in the medical home: integrating health and related systems of care for children with special health care needs

Care coordination is a process that facilitates the linkage of children and their families with appropriate services and resources in a coordinated effort to achieve good health. Care coordination for children with special health care needs often is complicated because there is no single point of entry into the multiple systems of care, and complex criteria frequently determine the availability of funding and services among public and private payers. Economic and sociocultural barriers to coordination of care exist and affect families and health care professionals. In their important role of providing a medical home for all children, primary care physicians have a vital role in the process of care coordination, in concert with the family.

Economic and psychologic costs for maternal caregivers of gastrostomy-dependent children

OBJECTIVE

To examine the economic and psychologic costs of care provided by maternal caregivers to children with gastrostomy tube (GT) feedings.

STUDY DESIGN

We conducted a 3-site study of primary maternal caregivers of 101 chronically ill children, with (n = 50) and without (n = 51) enteral nutrition support by GT to determine the time spent providing technical care, nontechnical care, and health care management and to assess depressive mood and quality of life. Associated costs were determined.

RESULTS

Caregivers spent 339.7 +/- 34.1 (SEM) min/d to provide all care. Children with a GT required more than twice as much care time as children without a GT: 484.5 +/- 54.6 versus 197.8 +/- 30.6 min/d ( P < .0001). The mean annual total value of home care by the primary caregiver for a child with a GT was 37,232 dollars, compared with 15,004 dollars for the child without a GT. Caregivers of children with GT were no more depressed or less satisfied with their lives than caregivers of children without GT.

CONCLUSIONS

Use of a GT for enteral nutrition support is associated with significant increased care time by the primary caregiver but not at additional psychologic cost compared with caring for chronically ill children.

Health care policy for medically fragile children

Medically fragile children are part of a growing population of children with special health care needs (CSHCN) who are dependent on technology for survival. Despite the extensive care needs characteristic of this population, many medically fragile children are cared for in their homes. Caregivers for these children are faced with numerous tasks, including the daily care of their child as well as the coordination of vital services. Inadequate access to health care, little service availability, limited insurance, and financial restraints may further complicate caring for a medically fragile child in the home. Although federally funded programs such as Supplemental Security Income (SSI) and State Title V CSHCN programs may be beneficial for these children and their families, current policies may limit access to these necessary services. As patient advocates, nurses may be instrumental in assisting medically fragile children and their families to obtain much-needed programs and vital services.

Long-term follow-up of home mechanical ventilation in young children with spinal cord injury and neuromuscular conditions

OBJECTIVES

To provide outcomes of two decades of experience in home ventilation of children with spinal cord injury and neuromuscular conditions.

STUDY DESIGN

Data were collected through chart review and interviews on 39 children who had become ventilator-dependent before their 6th birthday; 23 children had neuromuscular diseases and 16 had spinal cord injuries.

RESULTS

Patients required an average of 0.7 rehospitalizations per year. There were 8 deaths. Survival rates were 97% at 1 year, 97% at 3 years, 84% at 5 years, and 71% at 10 years. Thirty children attended school, 13 were in regular school (1 at university level), 5 were home-schooled, 5 were in special education schools, and 5 were in regular school with some special education classes. One graduated high school, and another graduated university and received a graduate degree. Three children had progressive weakness. Two gained significant muscle strength.

CONCLUSIONS

Our experience showed that these patients can be discharged to home with low morbidity and mortality rates and successful reintegration into the community.

Caring for medically fragile children in the home: an alternative theoretical approach

Medically fragile children require extensive, ongoing care that is typically provided in the home environment. The phenomenon of "caregiver burden" has been the topic of many studies in which the hardships and everyday life stressors of families with medically fragile children are examined. These studies are limited in that they focus merely on the difficulties of care, which represent only one dimension of the larger phenomenon of caregiving. It is the purpose of this article to review the literature from an alternative perspective in an attempt to provide a more thorough understanding of the dynamic of caregiving for a medically fragile child.

Advanced practice nurses as faculty

This article details a program through which two child health faculty members who are advanced practice nurses (APNs) combined practice with teaching undergraduate students in a community-based clinical experience on nursing case management. A collaborative agreement between a university-based Children's Special Services Team (CSST) and school of nursing faculty was developed to extend services into the home communities of children with special healthcare needs. Senior students made visits to the homes of the team's clients, conducted assessments, interacted with families, and provided additional care. The team, which included physicians, nurses, a social worker, and therapists (occupational and physical) identified children and families who would benefit from home visits by students nurses who were directed by APNs. Both service and educational goals were accomplished by this community-based case-management experience. The children and their families received additional care from multiple healthcare providers. Students practiced components of community-based case management, and the CSST obtained vital information about their clients' living environments.

Core guidelines for the discharge home of the child on long-term assisted ventilation in the United Kingdom. UK Working Party on Paediatric Long Term Ventilation

Paediatric home ventilation is a feasible option and can be successful in a wide range of conditions and ages. Advances in ventilator technology and an ethos of optimism for home care has increased the possibilities for discharging chronically ventilated children from intensive care units and acute medical beds. With careful planning the process can succeed, but difficulties often thwart the responsible team, especially when attempting discharge for the first time. These core guidelines aim to assist a smooth, swift and successful transfer. They were developed by a working party of interested professionals spanning a wide range of health care disciplines and represent a synthesis of views accumulated from the experiences of individual teams throughout the UK. Three case scenarios provide further illustrative detail and guidance.

Discharging ventilator-dependent children: a continuing challenge

Preparation of ventilator-dependent children, their families, the health care system, and communities for community-based care has presented many challenges over the past two decades. This article reviews some of the challenges that have been resolved by interdisciplinary discharge planning, discharge protocols, case management approaches, and collaborative care. Unresolved challenges continue to prevent children with special health care needs (CSHCN) from being served adequately by the health care system, the legal system and the community in this era of cost containment. Current literature, existing research and clinical observation were used to develop nursing implications and recommendations for continued research.

The impact of care coordination on children with special health care needs

Families of children with special health care needs face challenges in securing comprehensive health, educational, and social services. As a result, care may be fragmented, duplicative, confusing, and unnecessarily costly. Case management or care coordination is a method of overcoming some of the obstacles experienced by these children and their families. This article describes the Automated Case Management System/Community Based Care Coordination Project for California Children Services Children and Their Families in Los Angeles County (grant number MCJ 065020), a grant project funded by the Maternal Child Health Bureau from October 1987 to December 1990 in which family-centered, community-based care coordination services were provided to a select group of clients and the effectiveness of the interventions was evaluated. Care coordination was readily accepted by families and resulted in increased services, but the evaluation proved to be challenging.

Prolonged mechanical ventilation in children

Improvements in neonatal and pediatric intensive care have produced a growing population of children dependent on mechanical ventilation for survival. Long-term mechanical ventilation has become a realistic alternative to death from progressive respiratory failure for many children with chronic respiratory illness. This article reviews the pathophysiology, etiology, and management of chronic respiratory failure in childhood.

Morbidity and mortality patterns of ventilator-dependent children in a home care program

We evaluated the effectiveness of the Home Care Program of Children's Hospital of Winnipeg for ventilator-dependent children by retrospectively examining morbidity and mortality from February 1, 1979, to July 31, 1992. For the 22 study subjects, the cause of chronic respiratory failure was neurologic disorders for 14 (64%) (group A) and pulmonary disorders for eight (36%) (group B). There were no significant differences between groups A and B in the average number of hospital days, readmission rate, or length of stay per admission. Eleven patients have remained ventilator-dependent at home, four no longer require mechanical ventilation, and seven died. Factors such as diagnosis, type of family, home location, age at initiation of mechanical ventilation, and initial duration of hospital stay did not influence morbidity or mortality in either group. Within the overall mortality rate of 32% is a higher rate among patients whose disorders initially carried a poor prognosis. Ventilator-dependent children can be successfully managed at home, with few nonelective hospital readmissions, through a well-organized home care program.