Pediatric Tracheostomy Care Simulation: Real-Life Scenarios in a Safe Learning Environment

Discussion

With limited health-care resources, much of the routine and emergency care falls on patients’ family or other non-medically trained caregivers. The idea of having to care for medically fragile children, especially by a non-medically trained caregiver, is anxiety provoking and can create a high-stress home environment. Ensuring that family and other non-medically trained caregivers are familiar with and able to provide appropriate care and response to certain life-threatening situations can decrease caregiver anxiety, improve the quality of home life, and result in better patient health. The overarching goal of creating and implementing the pediatric tracheostomy care simulation program was to decrease mortality and morbidity for pediatric patients with tracheostomy tube placement by increasing caregiver knowledge, confidence, and comfort levels of emergency tracheostomy care. This was the first study in the literature to our knowledge to provide an emergency care simulation program for caregivers of children with new tracheostomy tube placements and to prospectively follow up the children with tracheostomies during the global period of 90 d after discharge.

For evaluation of the simulation program, we administered the pre- and post-surveys to the caregivers and saw a 9.1% increase in total score knowledge, confidence, and comfort agreement on a Likert scale. However, most of the caregivers had high agreement in the subscales before the simulation program started. This may be attributed to the program taking place near the end of the child’s hospital stay with most of the children who were critically ill having lengthy stays (median, 190.5 d). During the child’s hospital stay, family members are encouraged to be highly involved and to practice tracheostomy tube changes on their child. The program assessed the self-perceived knowledge of caregivers because administering a “knowledge test” seemed inappropriate in this population, and the simulation team did not want the program to come across as a pass or fail class.

This study was also the first, to our knowledge, to assess prompt rates for the next step in each scenario. This part of the evaluation was important to understand where in each scenario the families were struggling most. The first scenario that was administered was tracheostomy tube plugging, and we saw a 40% prompt rate for replacing the tracheostomy tube. The caregivers were hesitant to physically remove the tracheostomy tube from the manikin and were unsure of how to proceed. In the following scenario, accidental dislodgement, none of the families needed prompting to replace the tracheostomy tube and performed the scenario steps an average of almost 3 minutes faster than when completing the first scenario. There also was a 13.8% decrease in average prompt rates from the first to the second scenario.

Overall, there was a slight decrease in the readmission rate within 90 d after discharge versus the 2015–2018 data from our hospital (44% vs 50%). Furthermore, there were no deaths during this time. Our sample size was small, and, over time and with a larger cohort, we expect the decrease in readmission to be significant. Not only does this reduction indicate improved patient care, but it also indicates reduced health-care costs, decreased family burdens, and potential improve quality of life. Additional studies to formally assess these outcomes are needed. Analysis of these data suggested that more prompting requires an increased time to completion and perhaps more hesitation in continuing with the next step in the scenario, along with increased discussion.

Despite the reduced readmission rate, our patient cohort had a high rate of return to the emergency department for tracheitis, which made up 75% (n = 3/4) of those readmitted. Tracheitis is a frequent complication of tracheostomy and can be defined as a tracheal bacterial infection.⁴ Due to the nature of the tracheostomy opening bypassing the nasal and oropharyngeal passages⁵ and that many of the children with a tracheostomy have a multitude of comorbidities, this population is more susceptible to respiratory infections.^6,7 Previous data from our institution indicated that tracheitis had a frequent cause for emergency department visits and hospital admissions for our tracheostomy population, which suggests better education on routine tracheostomy care and management of tracheitis through simulation may be a future tool to reduce hospital admissions and emergency department visits.⁸

This was the first simulation program in collaboration with WISER that targeted caregivers instead of health-care professionals within our health system. However, other tracheostomy simulation programs for caregivers^3,9-12 and for health professionals^13-16 exist globally and are becoming increasingly popular due to the interest, demand, and likelihood of evidenced-based improved outcomes after discharge.³ Thrasher et al⁹ implemented a simulation training for caregivers of children with a tracheostomy and who were ventilator-dependent. The participants completed both pre- and post-surveys, trained on a manikin for two emergency-based scenarios, and completed the debriefing process. Interestingly, the debriefing after simulation was perceived to be more beneficial than the actual scenarios.⁹ There is a plethora of recent literature that pertains to implementation of simulation programs and the importance of the debriefing process to reflect critically on what was learned.^17-20 Overall, it is important for each hospital with a simulation program to share its experiences and results to help other institutions create a program that fits their population and resources.

Debriefing is critical to learning and/or understanding that results from simulation. By using the cardiac arrest scenario as an example, the following notes and questions were reviewed with each caregiver:

• What about the clinical scenario makes cardiac arrest the obvious issue?

• Highlight the need for chest compressions as soon as possible

• Clinical signs that indicate impending decompensation (cyanosis, quick change in vitals)

Many moving parts went into designing and implementing the pediatric tracheostomy care simulation program at our hospital. Until recently, there was not a commercially available pediatric manikin that would accommodate a tracheostomy. The manikin required modifications and a custom-made trachea and tracheotomy. Simulation specialists were necessary as well to code each scenario criteria to make the scenarios come to life. During the coronavirus disease 2019 pandemic, we had to temporarily suspend the program due to hospital restrictions but have since implemented a research restart plan to safely conduct the program and in compliance with the hospital and university guidelines. Our sample size was also limited by the fact that not all families were a good fit for the program because some children with tracheostomy were not expected to be discharged home for some time due to being critically ill.

Another limitation of the research component was order bias of the scenarios. Although tracheostomy tube plugging had the longest time stamp, this scenario was presented first because we had to use a different prop tracheostomy that was plugged. Most of the children with tracheostomy were of the white race and a light-skinned manikin was used. However, we acknowledge that this possibly impedes the skill transfer of minority race caregivers because these learners may have a harder time perceiving the simulation as real. Conigliaro et al²¹ highlighted the limited diversity in simulation, which may result in the hindrance of exposure and training for clinical scenarios. In addition, it would be helpful to have caregiver data after their child’s discharge. Paper copies of a post-discharge survey were mailed out but not returned. For families in the future, it would be helpful for the researchers to obtain the post-discharge survey in-person at a routine follow-up otolaryngology appointment.

Caring for a child with a tracheostomy is a tremendous responsibility because a caregiver must be with the child 24 hours a day, 7 days a week. In helping caregivers prepare for taking care of their child at home when discharged, we successfully implemented a simulation program that reviewed 4 common emergency scenarios. Although disheartening for caregivers to even think that these scenarios could happen to their child, the program allowed caregivers to practice in a low-stress environment where questions were encouraged. Moving forward, we hope to include as many caregivers with a child with a new tracheostomy as possible, and to include additional scenarios that would be beneficial. It would be helpful to review tracheitis symptoms and care, and when to report to the emergency department as opposed to home care because this was a critical issue in our sample and hospital-wide. Furthermore, the implementation of the simulation program for emergency scenarios will be used on a larger scale to teach and train health-care providers at our hospital, specifically those who provide direct critical care to patients with tracheostomies (ie, neonatal ICU and emergency department personnel).