Doctor of Nursing Practice Program

• Committee Chair Name & Credentials:
  Ken Nelson, DNP, RN, NE-BC, CPHQ
• Committee Member Name & Credentials:
  Kathie Krause,MSN, RN, NNP-BC, NEA-BC

DNP Project Abstract

Pediatric Post-Operative Tracheostomy Care: Improving Quality

Purpose
To implement a standardized evidence-based pediatric tracheostomy post-operative plan of care and revised order set in the electronic medical record to reduce tracheostomy related adverse events and to reduce the average length of stay (LOS) by 10%, from current ALOS of 66 days to <60 days.

Methods
Using the plan, do, study, act methodology this prospective quality improvement project developed and implemented a new pediatric tracheostomy post-operative plan of care and revised order set in the electronic medical record with feedback from more than ten clinical and interprofessional groups. Routine rounding monitored compliance with operational measures. Chart audits were performed and data for descriptive statistics and clinical outcomes were collected from December 14, 2022-March 14, 2023. Due to the small sample size clinical outcome data for each patient is described individually. Average LOS for the study sample, was measured in days from date of the tracheostomy insertion to discharge. Average LOS data are compared with previous average LOS data to assess for any change following the intervention.

Results
Of the seven patients, two were discharged during the data collection period with ALOS of 46 days. All seven patients studied have multiple co-morbidities that increase risk for complications, long length of stay and mortality including prematurity, pulmonary vascular and congenital heart disease. The five patients who remain hospitalized require additional surgical interventions for unrepaired heart disease, thoracic duct ligation, or chronic feeding intolerance. Three of the five patients have social/economic circumstances preventing discharge including identifying caregivers with a home setting capable of supporting long term mechanical ventilation. A longer period of study is necessary to draw additional conclusions.

Implications for Practice
Although there are factors beyond clinical and operational control, given the high resource utilization and high length of stay for this vulnerable patient population, it is prudent to minimize variation in care when possible to improve quality and decreases costs. At Monroe Carell approximately 24 new tracheostomies are placed annually and with a cost per day of $4000, a reduction in length of stay by 10%, could result in approximately $600,000 in savings annually. Future efforts will focus on implementing additional strategies to improve outcomes for this population and may be applicable to improving care for other complex pediatric patient populations.