Improving the Process of Trialing Pediatric Patients with Chronic Respiratory Failure Off Ventilatory Support In A Pediatric Pulmonology Clinic Setting

Background: There is a paucity of studies or protocols specifically designed for the initial wean off ventilatory support in pediatric patients with chronic respiratory failure during an outpatient follow-up visit. Most of the published protocols are in the inpatient setting. This quality improvement (QI) project will evaluate the preparedness and safety of pediatric patients with chronic respiratory failure during pulmonology appointments, streamline the trial off ventilatory support in the clinic, and ensure safe and adequate attempts.
The QI project will focus on the population of pediatric patients dependent on ventilatory support. The intervention is a newly developed clinical pathway for the initial wean off ventilatory support at the outpatient clinic setting. We will collect baseline data related to the safety and preparedness of the visits before the implementation. As an extra layer of safety precaution, our clinical team will also assess the tracheostomy go-bags that families are instructed to carry. Our team will evaluate all their safety equipment with them as part of their clinic appointment. We developed an appointment checklist to ensure access to the necessary items.
Before the visit: The clinical team would notify the durable medical equipment (DME) company that the patient will come in for an initial wean off ventilatory support and ask if their respiratory therapist (RRT) will be present at the appointment and bring the necessary equipment. Next, the nurse (RN) would round with the medical team at the beginning of the week to review if any patients would be doing a ventilator wean during any upcoming appointments. Then, the RN would call the families the day before the scheduled appointment. They will review the equipment checklist over the phone to ensure the tracheostomy go-bag and other necessary equipment were safely stocked.
During the visit: The pulmonologist, RN, and RRT would be present during the initial wean off ventilatory support. The RN/RRT would review and compare the equipment checklist before starting the appointment. Safety parameters would be discussed and followed throughout the wean, including frequency of vital sign monitoring, oxygen saturations, end-tidal CO2s, amount of oxygen supplementation to be used, and specific signs of respiratory distress to monitor. The team will discuss the parameters to abort the trial. These include low pulse oximetry, end-tidal CO2 elevation, or any other evidence of respiratory distress.
Conclusion of the visit: At the end of the study, the patient should be placed back on the ventilator in the original setting.
Outcome: The expected outcome is to improve the number of successful initial weans off ventilatory support and their safety. We anticipate that the intervention will benefit children on ventilatory support by decreasing the number of clinic appointments required to wean ventilation. We will provide re-education for our families on the importance of always having their tracheostomy go-bags. We aim to improve their familiarity with all the equipment and have the necessary knowledge to use it effectively during an emergency. We will achieve this by re-educating our families on the safety checks to improve outcomes for their patients with chronic respiratory failure.