A Standardized Discharge Process Decreases Length of Stay for Ventilator-Dependent Children

Abstract

Objective: Children who require chronic mechanical ventilation via tracheostomy are medically complex and require prolonged hospitalization, placing a heavy burden on caregivers and hospital systems. We developed an interdisciplinary Ventilator Care Program to relieve this burden, through improved communication and standardized care. We hypothesized that a standardized team approach to the discharge of tracheostomy- and ventilator-dependent children would decrease length of stay (LOS), reduce patient costs, and improve safety.

Methods: We used process mapping to standardize the discharge process for children requiring chronic ventilation. Interventions included developing education materials, a Chronic Ventilation Road Map for caregivers, utilization of the electronic medical record to track discharge readiness, team-based care coordination, and timely case management to arrange home nursing. We aimed to decrease overall and pediatric respiratory care unit LOS as the primary outcomes. We also analyzed secondary outcomes (mortality, emergency department visits, unplanned readmissions), and per-patient hospital costs during 2-year "preintervention" and "postintervention" periods (n = 18 and 30, respectively).

Results: Patient demographics were not different between groups. As compared with the preintervention cohort, the overall LOS decreased 42% (P = .002). Pediatric respiratory care unit LOS decreased 56% (P = .001). As a result, unplanned readmissions, emergency department visits, and mortality were not increased. Direct costs per hospitalization were decreased by an average of 43% (P = .01).

Conclusions: Although LOS remained high, a standardized discharge process for chronically ventilated children by an interdisciplinary Ventilator Care Program team resulted in decreased LOS and costs without a negative impact on patient safety.

FIGURE 1

A, Process map. VCP team members participated in process mapping sessions to determine the necessary steps for a safe discharge. In the figure, color-coding indicates the provider responsible for completing each task. ENT, Ear Nose Throat specialist (otolaryngologist); PT, physical therapy; OT, occupational therapy; RT, respiratory therapy; SW, social work; DME, durable medical equipment; CM, case management; Ox, oximetry; WOB, work of breathing. B, Chronic ventilation road map. The road map outlines the discharge process in a “family friendly” manner. The map emphasizes the collaborative team approach to care and the focus on caregiver education.

FIGURE 2

Statistical process control I-charts demonstrate LOS and PRCU LOS for all patients. Each dot represents an individual hospital admission. The primary intervention involved implementation of the new standardized process with road map and education handouts. Red dots indicate failed tests for special cause. A, Mean overall LOS was significantly reduced after the intervention (Table 2), but LOS remained elevated for some patients after the intervention. B, The intervention resulted in a sustained reduction in PRCU LOS as demonstrated by the centerline shift. UCL, upper control limit.