Interdisciplinary Scoring Tool for Assessment for Tracheostomy in Severe Bronchopulmonary Dysplasia

Abstract

Background:

The Comprehensive Center for Bronchopulmonary Dysplasia (CCBPD) at Nationwide Children’s Hospital is a referral center for term and post-term patients with severe BPD. The CCBPD strongly promotes family centered care. There is very little data regarding the optimal criteria and timing for the decision of a tracheostomy in this patient population. Risks of tracheostomy long-term are poorly understood and followed. An objective scoring tool of important factors were created for infants with severe BPD with need for mechanical ventilation and prolonged positive pressure in 2015.

Methods:

Infants at 44 weeks corrected gestational age and beyond were scored monthly by the interdisciplinary team. Identified 16 clinical triggers based on disease physiology and past clinical decision making developed an objective scoring tool that assigned numerical values within each category. The total score was evaluated by zones: green for low risk, yellow for caution for need for tracheostomy and red reflecting likely need unless progress occurs soon. Infants scoring high in the high yellow zone or low red zone, triggered a care conference with family to discuss the score. We reviewed the percentage of parents with resistance to accept and consent to tracheotomy for 2 years before implementing the scoring tool and for 2 years after, as measured by the number of repeat care conferences. Also, rates and scores of tracheostomies before and after implementation were reviewed.

Results:

Parental resistance to tracheostomy placement decreased from 62% to 10%. Scoring resulted in high reliability separately amongst disciplines and within 2 points. All patients scored higher than 15 on scoring tool and all but 1 scored >20 at time of trach insertion. Tracheostomy rates remained stable before and after scoring tool implementation. 6 patients received a trach out of 13 scored in 2016. 4 patients received a trach out of 11 scored in 2017. 6 patients received a trach out of 15 scored in 2018.

Conclusions:

The tool provides an objective assessment determining the best timing for the decision of tracheostomy placement that provides a standardized approach to help parents understand why a tracheostomy might be recommended. Utilization of this scoring tool has helped decrease variability of decision making, anticipate discussions with family, and follow our outcomes over time for the severe BPD population.