DOI: 10.25549/usctheses-c40-349573
title: Post-tracheostomy outcomes in pediatric patients

description: Study 1: Bacterial respiratory tract infection hospital readmissions within 12 months of hospital discharge following tracheostomy ❧ Objective: Identify risk factors for readmission due to a bacterial tracheostomy-associated respiratory tract infection (bTARTI) within 12 months of discharge after tracheostomy. ❧ Methods: We performed a retrospective cohort study of 240 children who underwent tracheostomy at Children’s Hospital Los Angeles and were discharged with tracheostomy in place between 1/1/2005 and 6/30/2013. Children with prolonged total or post-tracheostomy length of stay (LOS), less than 12 months of follow-up, or who died during the index hospitalization were excluded. Readmission for a bTARTI (e.g. pneumonia, tracheitis) treated with antibiotics, as ascertained by manual chart review, was the outcome variable. We used multivariate logistic regression to identify the independent association between risk factors and hospital readmission for bTARTI within 12 months. ❧ Results: At index hospitalizations for tracheostomy, the median admission age was 5 months [interquartile range (IQR) 2-43 months] and median LOS was 73 days (IQR 43-121 days). Most patients were of Hispanic ethnicity (n=162, 68%) and were publicly insured (n=213, 89%). Nearly half (n=112, 47%) were discharged on positive pressure mechanical ventilation. Many (n=103, 43%) were admitted for bTARTI within 12 months of discharge. Only Hispanic ethnicity [adjusted odds ratio (aOR) 2.0; 95% confidence interval (CI): 1.1-3.9; p=0.03)] and acquisition of Pseudomonas aeruginosa between tracheostomy and discharge from index hospitalization (aOR 3.2; 95% CI: 1.2-8.3; p=0.02) were independently associated with increased odds of bTARTI readmission within 12 months of discharge. Discharge on gastrointestinal pro-motility agents was protective (aOR=0.4; 95% CI: 0.2-0.8; p=0.01). ❧ Conclusion: Modifiable factors associated with bTARTI risk suggest future targets for prevention. ❧ Study 2: Predictors of post-tracheostomy hospital discharge on home mechanical ventilation in pediatric patients ❧ Objective: Identify risk factors known prior to tracheostomy that predict discharge on home mechanical ventilation (MV) after tracheostomy. ❧ Methods: Retrospective cohort study of patients ≤18 years old who underwent tracheostomy at Children’s Hospital Los Angeles (CHLA) and were discharged between 1/1/2005 and 6/30/2014 with tracheostomy in place. We linked data obtained from manual chart review to administrative data obtained from the Pediatric Health Information System database. We included covariates with p12 months of age. We report adjusted odds ratios (aOR) with 95% confidence intervals (CI). ❧ Results: Of the 292 patients included, median admission age for the entire cohort was 6 months [interquartile range (IQR): 1-54] and median length of stay (LOS) 75 days (IQR: 43-126). The cohort was 60% (n=175) male and 65% (n=190) Hispanic. Over 87% (n=255) were on public insurance. Nearly half (n=141) were discharged from the acute care hospital on MV. For patients ≤12 months of age at admission, factors independently associated with MV discharge included increasing LOS prior to tracheostomy (per day; aOR: 1.01 95% CI: 1.00-1.02), prematurity (aOR: 2.4; 95% CI:1.1-5.1), chronic lung disease (aOR: 2.3; 95% CI: 1.1-4.6) and pre-tracheostomy Pseudomonas-positive respiratory culture (aOR: 3.4; 95% CI: 1.3-9.1); upper airway obstruction/ vascular anomaly was associated with decreased odds (aOR: 0.4; 95% CI: 0.2-0.9). For patients &gt;12 months of age at admission, factors independently associated with MV discharge included admission age (per year; aOR: 1.2; 95% CI: 1.1-1.3), increasing LOS prior to tracheostomy (per day; aOR: 1.05 95% CI: 1.03-1.08) and chronic lung disease (aOR: 2.9; 95% CI: 1.2-7.2). ❧ Conclusion: Regardless of age, pediatric patients with chronic lung disease and long pre-tracheostomy LOS are at the highest risk for post-tracheostomy hospital discharge on MV. These findings, combined with other identified predictor variables for specific age cohorts (prematurity, age) may help physicians participate in shared medical-decision making with families and identify patients that may need intensive care coordination while hospitalized and post-discharge.