Abstract
Pediatric in-patients with tracheostomy (PIT) are at high risk for clinical deterioration. Medical emergency teams (MET) have been developed to identify high-risk patients. This study compared MET activation rates between PITs and the general ward population. This was a retrospective cohort study conducted at a tertiary pediatric hospital. The primary outcome (MET activation) was obtained from a database. Between 2008 and 2014, the MET activation rate was significantly higher in the PIT group than the general ward population (14 vs. 2.9 per 100 admissions, p < 0.001). PITs are at significantly higher risk for MET activation. Strategies should be developed to reduce their risk on the wards.
Keywords: tracheostomy, medical emergency team, rapid response system
Introduction
The requirement for a tracheostomy in pediatric patients has significant implications. Reviewing long-term outcomes in these patients revealed a mortality rate between 13 and 16%. 1 2 3 4 5 6 7 8 9 Children with tracheostomies are also at high risk for morbidity, with 75% experiencing a tracheostomy-related complication, and the majority of those being serious in nature. 7 These patients also have significant healthcare utilization. During admission when the tracheostomy is placed, the length of stay (LOS) averages from 46 to 107 days. 3 9 10 11 12 After discharge, patients with tracheostomies are also at high rates of readmission (1). This results in significant healthcare expenses with one American study estimating hospital costs to be 1.3 billion dollars per year. 13 Given that patients with tracheostomies have significant mortality, morbidity, and healthcare utilization, there is interest in novel strategies to improve their outcomes and reduce resource use.
Medical emergency teams (MET) have been implemented as part of a rapid response system (RRS) to improve the identification and treatment of patients at risk for clinical deterioration. 14 Recently, several adult and pediatric studies have focused on individual patient outcomes following MET review (16–19). These studies showed that patients receiving an MET review had higher mortality rates and longer LOS than patients who were never seen by the MET (16–19). These findings suggest that patients reviewed by the MET are high-risk, and determining specific risk factors associated with an MET activation may be helpful in understanding this population and improving short- and long-term health outcomes. 15 16 17 18 As well, understanding the risk factors for MET activation may be useful in determining how best to use the MET and whether the role of the MET could be tailored to specific patient populations.
There is currently no literature examining MET utilization in pediatric in-patients with tracheostomies (PITs). We hypothesize that these patients are at significant risk for clinical deterioration on the wards. The objective of this study was to calculate the MET activation rate in PITs and compare it with other ward patients. Our secondary objectives were to describe the characteristics of MET activations within this group and to determine the adjusted risk of MET activation after controlling for covariates, including age, nature of admission (elective vs. urgent), and chronic comorbidities. Finally, we compared resource utilization between the two groups, including readmission rates, average LOS in hospital, and rates of pediatric intensive care unit (PICU) admission.
Methods
Study Design and Setting
This is a retrospective cohort study of pediatric patients who were admitted to the general inpatient ward at a tertiary care pediatric hospital in Canada between January 1, 2008 and December 31, 2014. The hospital is university-affiliated and is accredited for training by the Royal College of Physicians and Surgeons of Canada. It has 166 inpatient beds, approximately 6,000 admissions per year, and a pediatric cardiac surgical program. Research ethics board (REB) approval was obtained from the Research Institute.
Tracheostomy Management at Our Hospital
Tracheostomies are inserted by otolaryngologists in the operating room, with patients admitted to the PICU postoperatively where they remain until their first tracheostomy change (5–7 days). Patients requiring chronic ventilation remain in the PICU until stable ventilator settings are achieved for at least 48 hours. Patients are then transferred to the inpatient ward and are admitted under general pediatrics, otolaryngology, or complex care pediatrics.
Once patients with tracheostomies are discharged, if they require readmission, they are admitted to the general wards and have the same PICU admission criteria as patients without tracheostomies. If they are on home ventilators, they can be admitted to the general wards as long as they are on stable ventilator settings. If they require any change in settings, they must be admitted to the PICU. Our institution currently does not have a step-down unit.
Source of Data
The study cohort consisted of all patients who were admitted to one of the pediatric wards between January 1, 2008 and December 31, 2014. Admissions were excluded if the patient was above 18 years of age or spent their entire hospital stay in an ICU (neonatal or pediatric). The medical day unit, postanesthesia care unit, and diagnostic imaging were not considered inpatient units. Children with tracheostomies were identified using source lists from the Division of Respirology, Department of Otolaryngology, diagnostic imaging (DI), operating room (OR) database, decision support (DS), and critical care information systems. A chart review was conducted on all patients identified by the source lists to determine their tracheostomy status.
Demographic variables were collected including date of birth, gender, indication for the tracheostomy, date of insertion and decannulation (where applicable), requirement for ventilatory support, and comorbidities. For the indication for tracheostomy, we used the definitions described by Amin et al. 19 For complex chronic conditions (CCCs), we used the framework established by Feudtner and et al 20 which defined CCC as “any medical condition that can be reasonably expected to last at least 12 months (unless death intervenes) and to involve either several different organ systems or one organ system severely enough to require specialty pediatric care and some period of hospitalization in a tertiary care center.”
Description of Rapid Response System
In 2006, the Ministry of Health and Long-Term Care (MOHLTC) in Ontario, Canada, funded the implementation of a pediatric RRS using a physician-led MET at four academic pediatric hospitals. A full description of the RRS has been previously described. 21 At our hospital, the MET consists of a critical care physician, critical care nurse, and critical care-trained respiratory therapist. A dedicated PICU physician attends all daytime activations of the MET with overnight coverage provided by the in-house PICU house-staff, with PICU attending backup. Any healthcare provider or caregiver can activate the team for concerns of patient deterioration. The criteria for MET activation are based on the criteria by Tibballs. 22 The MET is activated using a dedicated pager, with the MET arriving within 10 minutes at the patient bedside. The MET does not respond to patients in the emergency department or neonatal intensive care unit.
Outcomes and Patient Characteristics
The primary outcome, rate of MET activation, was determined from an electronic list maintained by our hospital's RRS. MET activations were linked to admission data provided by DS through medical record number and date of activation. During the study period, patients admitted to PICU were followed by the MET for 48 hours post discharge. An MET assessment was considered a new MET activation if it occurred after the routine 48-hour follow-up period. DS also provided demographic and healthcare resource utilization data, including age, gender, admission diagnosis, nature of admission (urgent or elective), season, day of admission (weekday vs. weekend), number of hospital and PICU admissions, and hospital LOS.
As previously reported and described, 15 the Clinical Classifications Software (CCS) was used to present admission diagnoses using the International Classification of Diseases 10th Revision (ICD-10) coding system. The CCS approach uses ICD-10 codes to allocate patients into 33 groups to facilitate statistical analyses and has been used in similar adult 23 and pediatric studies. 15 24 ICD-10 codes were also used to identify patients with CCCs, using the framework established by Feudtner et al. 20 25 The CCC classification system uses ICD-10 codes to identify comorbidities involving 10 organ systems, and has been adapted for use in Canada. 26
Statistical Analysis
For bivariate analysis, the Chi-square test was used to compare MET activation rates between pediatric in-patients with and without tracheostomies. Demographic and patient characteristics were compared using the Mann–Whitney test for continuous variables and Chi-square test or Fisher's exact tests for categorical variables. To examine the relationship between PITs and MET activation, we used a marginal logistic regression with generalized estimating equations (GEE) estimator. We selected an exchangeable correlation structure to account for the correlations between admissions from the same patient. MET activation status is dichotomized as “No MET activation” or “One or more MET activation.”
Selection of a marginal logistic regression model also allowed us to account for and quantify the contributions of additional covariates/confounders in the relationship between MET utilization and tracheostomy status. Due to the limited number of PITs receiving an MET activation, only the most clinically pertinent confounders were included in the final multivariate model to avoid overfitting. The confounders considered most clinically relevant were age, nature of admissions (elective vs. urgent), and underlying disease process, and all three were treated as time-varying covariates. For the model age was treated as a continuous variable and nature of admission was dichotomous (elective vs. urgent/emergent). The Feudtner CCC system was utilized to adjust for and quantify the contribution of underlying disease processes leading to the tracheostomy and additional complex chronic conditions. Again, to avoid overfitting, we made the decision to not consider each CCC organ system (categorical variable) but to count the number of organ systems and treat CCC as a continuous variable. While adjusting for confounders, tracheostomy ICD-10 codes were removed from the Respiratory CCC category to avoid double-counting. All statistical analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, North Carolina).
Results
Cohort Identification
We identified 67 children with tracheostomies from the source lists. Of these, 11 were excluded because they no longer had tracheostomies, were over 18 years of age, or did not have at least one admission to the general wards during the study period. Therefore, there were 56 patients with tracheostomies who met inclusion criteria. During the study period, 24 (43%) were decannulated and 7 died (13%). As seen in Table 1 , the most common primary indication category for a tracheostomy was respiratory ( n = 40, 71%), with upper airway obstruction ( n = 36, 64%) as the most common specific respiratory condition. In addition to tracheostomy dependence, 21% ( n = 12) of the cohort required ventilatory support with an equal number requiring 24 hours ( n = 6, 11%) and nocturnal assistance ( n = 6, 11%).
Table 1. Characteristics of patients with tracheostomies.
| Characteristics | Patients with tracheostomies ( n = 56) |
|---|---|
| Age in years, median (IQR) | 1.1 (0.2, 2.8) |
| Gender, n (%) | |
| Female | 26 (46) |
| Primary indication for tracheostomy, n (%) | |
| Central nervous system conditions | 12 (21) |
| Birth injury and/or cerebral palsy | 1 (2) |
| Acquired central hypoventilation | 1 (2) |
| Congenital hypoventilation syndrome | 3 (5) |
| Other central causes | 7 (13) |
| MSK conditions | 4 (7) |
| Other myopathy | 1 (2) |
| Other MSK | 3 (5) |
| Respiratory conditions | 40 (71) |
| Upper airway obstruction | 36 (64) |
| Chronic lung disease | 1 (2) |
| Other respiratory conditions | 3 (5) |
| Level of ventilation, n (%) | |
| None | 44 (79) |
| Nocturnal only | 6 (11) |
| Continuous, greater than 20 hours | 6 (11) |
| Number of patients decannulated, n (%) | 24 (43) |
| Number of patients who died | 7 (13) |
Abbreviations: IQR, interquartile range; MSK, musculoskeletal.
Hospital and PICU Admission
Between 2008 and 2014, there were 42,041 admissions (29,229 unique patients) to the general pediatrics wards. Of these admissions, 264 (0.6%) involved PITs (some PITs had multiple admissions). Demographics for patients with and without tracheostomy are shown in Table 2 . Supplementary Table 1 (available in the online version) shows the top 20 admission diagnoses for the tracheostomy and non-tracheostomy cohorts, with the most common being lower respiratory tract infection and surgery.
Table 2. Demographics for admissions with and without a tracheostomy.
| Tracheostomy | |||
|---|---|---|---|
| Variables (row % unless specified) | No ( n = 41,777) | Yes ( n = 264) | p -Value |
| Age (median, IQR) | 6.0 (1.2, 13.7) | 2.6 (1.4, 5.2) | <0.001 |
| Sex | 0.01 | ||
| Female | 19,209 (45.9) | 99 (37.5) | – |
| Male | 22,568 (54.0) | 165 (62.5) | – |
| Weekend admission ( n , %) | 0.89 | ||
| No | 33,570 (80.4) | 213 (80.7) | – |
| Yes | 8,207 (19.6) | 51 (19.3) | – |
| Admission location ( n , %) | <0.001 | ||
| Clinic | 2,378 (5.7) | 12 (4.6) | – |
| Day surgery department | 605 (1.4) | 6 (2.3) | – |
| Direct | 10,879 (26.0) | 125 (47.4) | – |
| Emergency department | 27,915 (66.8) | 121 (45.8) | – |
| Admission category ( n , %) | <0.001 | ||
| Elective | 8,644 (20.7) | 82 (31.1) | – |
| Urgent/emergent | 33,133 (79.3) | 182 (69) | – |
| CCC comorbidities ( n , %) | – | ||
| Neuromuscular | 2,033 (4.9) | 27 (10.2) | <0.001 |
| Cardiovascular | 2,126 (5.1) | 51 (19.3) | <0.001 |
| Respiratory | 833 (2.0) | 88 (33.3) | <0.001 |
| Renal | 1,370 (3.3) | 17 (6.4) | <0.01 |
| Gastrointestinal | 2,328 (5.6) | 160 (60.6) | <0.001 |
| Hematological | 2,312 (5.5) | 4 (1.5) | <0.01 |
| Metabolic | 797 (1.9) | 5 (1.9) | 1.00 |
| Congenital/genetic | 1,692 (4.1) | 41 (15.5) | <0.001 |
| Malignancy | 3,061 (7.3) | 5 (1.9) | <0.01 |
| Neonatal | 527 (1.3) | 17 (6.4) | <0.001 |
| Technological dependent | 2,210 (5.3) | 237 (89.8) | <0.001 |
| Transplant | 51 (0.1) | 0 | 1.0 |
| Number of CCC ( n , %) | <0.001 | ||
| 0 | 29,134 (69.7) | 42 (15.9) | – |
| 1 | 9,221 (22.1) | 90 (34.1) | – |
| 2 | 2,617 (6.3) | 84 (31.8) | – |
| 3 | 653 (1.6) | 35 (13.3) | – |
| 4 or more | 152 (0.4) | 13 (4.9) | – |
Abbreviations: IQR, interquartile range; CCC, complex chronic conditions.
PITs were significantly more likely to be younger, male patients, and with increasing numbers of CCCs. For example, 50% of tracheostomy admissions had two or more CCCs, versus only 8.4% of general ward admissions ( p < 0.001). PITs had a significantly longer LOS than general ward patients (6 days IQR: 3.0–16 vs. 3 days; IQR: 1.0–6.0; p < 0.001). The rate of hospital readmission within a year was also significantly higher among the tracheostomy group when compared with the general ward group (70.7 vs. 12.8%, p < 0.001). Finally, overall PICU admission rates were 35.2% for tracheostomy admissions, compared with 8.8% for admissions without tracheostomy ( p < 0.001).
MET Utilization
As seen in Table 3 , 1,277 out of 41,041 admissions (2.9%) in the general ward cohort had MET activations, while 37 out of 264 admissions (14%) in the tracheostomy cohort had MET activations. In the general ward cohort, 967 admissions had one MET activation (2.3%) and 269 admissions had more than one MET activation (0.6%). In the tracheostomy cohort, 28 (11%) admissions had one MET activation and 9 (3%) patients had more than one MET activation. The MET activations rates for both single and multiple MET activations were significantly higher in the tracheostomy group compared with the general ward group ( p < 0.001). Comparison of MET utilization rate by first or subsequent admission in the tracheostomy cohort demonstrated a significantly higher rate of activation on first admission (11/43, 25.5% vs. 26/221, 11.7%, p < 0.001).
Table 3. MET activation rates in patients with and without tracheostomies.
| Admissions | No tracheostomy | Tracheostomy | p -Value |
|---|---|---|---|
| Total | 41,777 | 264 | |
| Admissions with one MET activation | 967 (2.3%) | 28 (10.6%) | <0.001 |
| Admissions with > one MET activation | 260 (0.62%) | 9 (3.4%) | <0.001 |
Abbreviation: MET, medical emergency teams.
Characteristics of the initial MET activation for PITs are shown in Supplementary Table 2 (available in the online version). The majority of activations were triggered by physicians (60%) and the most common reason for activation was a respiratory concern such as respiratory distress or airway threat. During the MET review, 95% ( n = 35) of patients required intervention, with suctioning followed by repositioning/physiotherapy as the most common interventions. Of the 37 activations, 8 resulted in PICU admission (22%) and 29 stayed on the wards (78%).
In a bivariate analysis, the calculated MET activation rate of 14.0 per 100 admissions in the tracheostomy cohort was significantly higher than the MET activation rate of 2.9 per 100 admissions for the general ward population ( p < 0.001). As shown in Table 4 , PITs had a 5.7 (95% CI: 3.6–9.2) times greater odds of MET utilization when compared with the general ward population. This difference did not change when we added age and nature of admission to the model (OR: 5.7, 95% CI: 3.6–9.1; Supplementary Table 3 , available in the online version). Addition of the CCC variable to the model allowed for an estimate of the relative contribution of the underlying disease process and other chronic conditions, and the tracheostomy. Each additional CCC was determined to significantly increase the odds of MET utilization (OR: 2.17, 95% CI: 2.06–2.29). After including the CCC, the presence of a tracheostomy remained independently associated with a significantly increased risk of MET utilization (OR: 2.2, 95% CI: 1.3–3.6; Supplementary Table 4 , available in the online version).
Table 4. Marginal logistic regression model examining the association between tracheostomy and MET activation (exchangeable working correlation = 0.09).
| OR | Upper 95% CI | Lower 95% CI | p -Value | |
|---|---|---|---|---|
| Tracheotomy (yes) | 5.7 | 3.6 | 9.2 | <0.001 |
Abbreviations: CI, confidence interval; MET, medical emergency teams; OR, odds ratio.
In an effort to control for LOS as a potential confounder, we compared the first day MET activation rates between the two groups and found that PITs still had significantly higher MET activation rates (5.7 per 100 admissions vs. 1.4 per 100 admissions; Table 5 ).
Table 5. Rate of first MET activation on the first 14 days by tracheotomy status.
| Rate of first MET activation on the first 14 days (%) | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Tracheotomy | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 |
| Yes | 5.7 | 0.5 | 1.6 | 0.0 | 1.4 | 2.4 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 0.0 | 1.5 | 0.0 |
| No | 1.4 | 0.5 | 0.4 | 0.3 | 0.2 | 0.3 | 0.2 | 0.2 | 0.2 | 0.4 | 0.3 | 0.3 | 0.3 | 0.2 |
Abbreviation: MET, medical emergency teams.
Discussion
In this study, we found that PITs had 5.7 times increased odds of receiving an MET activation than other ward patients. Furthermore, after controlling for CCCs, twice the greater risk of MET activation persisted, suggesting that the technology (tracheostomy tube) is a risk factor in and of itself for clinical deterioration on the wards.
Previous adult and pediatric studies have shown that patients who required one MET review had greater odds of in-hospital death compared with patients not reviewed by the MET (16–19). Furthermore, these studies showed that patients with multiple MET reviews had an even higher mortality risk. 15 16 17 In our study, we showed that PITs are at higher risk of receiving not just one, but multiple MET activations. Combining the literature regarding patient outcomes following MET activations and the studies reviewing long-term outcomes in patients with tracheostomies (1, 2, 10, and 12–14), PITs are at high risk for poor outcomes and increased health resource utilization.
This study examines the risk of an MET activation in a particular patient population and adds to the existing literature regarding at-risk ward patients and their characteristics. Other pediatric studies have examined patient-related risk factors for deterioration on the wards and have shown that age < 1 year, preexisting chronic disease, male gender, a diagnosis of epilepsy or congenital/genetic conditions, and a history of transplant are patient-related risk factors for deterioration. 27 28 29 PITs have many of these identified risk factors, with our study also demonstrating a significantly higher rate of CCCs in these patients compared with the general ward population (84 vs. 31%). Having a CCC confers significant risk for patients, with increased risk of hospital admissions, PICU admissions, LOS, and mortality 30 31
In addition, consistent with the literature suggesting that children with tracheostomies are at high risk for complications (1–11), our study also found that a tracheostomy alone increased the risk of MET activation. For example, Carr et al found that the majority of pediatric patients with tracheostomies experienced a postoperative tracheostomy-related complication such as accidental decannulation. 7 Of these complications, 48% of them occurred as an inpatient, with equal frequency in the ICU and on the wards, which is consistent with the adult literature. 32 Unfortunately, studies have suggested that healthcare providers do not feel comfortable managing these acute complications on the ward and some are uncomfortable with routine tracheostomy care. 33 This has led to an increase in mortality associated with transferring PITs from the ICU to noncritical care areas. 34 35 While some might suggest that PITs should remain in the PICU, it may not be feasible due to resource constraints, including bed availability. Given the potential discomfort with tracheostomy care on the ward, ward health care providers may use the critical-care trained MET providers as a resource for support. The findings of our study support this as the MET is activated almost 6 times more often for PITs than for those without one.
A recent systematic review showed a reduction in pediatric and adult cardiorespiratory arrest and mortality after the implementation of an MET suggesting that RRS can detect and manage deteriorating ward patients (15). Our study shows that the MET can successfully address the reasons for activation and deterioration in a high-risk population—PITs. Almost all these patients required intervention by the MET (95%), most commonly suctioning, repositioning, and administration of nebulized medications. Interestingly, 78.4% of these patients remained on the inpatient ward after the activation, which is comparable to other ward patients receiving MET activations (78.4 vs. 78.2%). 15 Overall, our study confirms and quantifies an increased rate of MET activation in PITs. Further, as the rate of PICU admission per MET activation remained comparable to what has been reported for the general inpatient population at our site, this work suggests that despite greater illness severity in this high-risk population, the MET is often able to address the clinical deterioration adequately. However, our retrospective study design does not allow us to make any strong statements on the effectiveness of the MET for resolving clinical deterioration or preventing PICU admission.
This study highlights the need for further quality improvement (QI) strategies to reduce this population's risk. One important component may be adherence to evidence-based standards to enhance care before emergencies occur. There is evidence that a tracheostomy care protocol reduces morbidity, mortality, and time to decannulation. 36 37 38 39 For example, the American Academy of Otolaryngology Head-Neck Surgery Foundation has developed a clinical consensus statement for tracheostomy care. 40 As well, the Global Tracheostomy Collaborative has identified five key drivers to improve the quality of care in tracheostomy patients. 41 These statements may help inform how to focus QI initiatives for PITs.
Another option to improve outcomes is routine MET involvement in high-risk patients, with some previous studies describing the protective effect of being followed by the MET, including a decreased risk of early PICU readmission (37) and a reduction in mortality on readmission. 21 42 PITs may benefit from a specialized MET approach, such as a lower threshold for MET activation and/or a longer follow-up period after the initial MET activation. In addition, other interventions could improve the care of these high-risk patients on the wards. For example, simulation has been successful in improving participants' airway management skills, 43 44 and specifically with regards to tracheostomies, simulation-based education, and skills sessions have been shown to improve nurses' and physicians' knowledge and skills in managing patients with tracheostomies. 45 46 47 48 Future studies are required to determine if enhancing the role of the MET and providing additional targeted education can further enhance the model of care in these patients. As well, considering that hospitals have competing priorities for resource allocation to QI initiatives, future studies are also needed to determine if other risk factors (e.g., younger age, CCCs) can be used to help prioritize QI interventions for high-risk PITs.
Our study had several limitations including its retrospective design and single-center representation resulting in a relatively small number of PIT MET activations. Because of this, we could only compare the MET activation rates between PITs and general ward patients, but we could not compare them to other patients with similar complexity and morbidity. We did attempt to address the contribution of underlying CCCs by controlling for them in our analyses; however, because of the retrospective nature it is possible that additional factors contributed to their risk on the wards that we did not control for in our study. Finally, the management of PITs and the criteria for MET activation at our institution may differ from others.
Conclusion
PITs have significantly higher MET activation rates than other ward patients, indicating they are at higher risk of clinical deterioration. MET is an important QI initiative to support and manage these patients on the wards. Identifying risk factors for clinical deterioration provides an opportunity for QI interventions targeting improved care for pediatric tracheostomy patients on the wards. Future studies are required to determine if enhancing the role of the MET and providing additional targeted education can further enhance the model of care in these patients.
Funding Statement
Funding There was no funding secured for this study.
Footnotes
Conflict of Interest None declared.
Supplementary Material
References
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