NRNP 6831 Week 7 Technology Dependence Analysis Example

Technology Dependence Case Analysis: The First 90 Days at Home for a 2-Year-Old Who Uses a Tracheostomy and a Home Ventilator

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College of Nursing, Walden University

NRNP 6831: Management of Specialized and Complex Populations

Instructor Name

Month Day, Year

Technology Dependence Case Analysis: The First 90 Days at Home for a 2-Year-Old Who Uses a Tracheostomy and a Home Ventilator

The Child and the Household

Mason is a composite 2-year-old boy born at 26 weeks' gestation. Severe bronchopulmonary dysplasia left him unable to wean from mechanical ventilation, and he had a tracheostomy placed at 5 months. At discharge, at 23 months, he was ventilated during sleep and for about 2 hours in the afternoon, and he breathed on his own through a heat and moisture exchanger the rest of the day.

His household is where the equipment has to work. His mother is at home full time. His father works nights at a distribution center. His sister is 6. They rent an older house on a rural road where the power goes out in most summer storms. Home nursing was approved for 16 hours a day, mostly overnight, so that a trained caregiver would be awake while Mason slept on the ventilator.

This analysis records the equipment and training in place at discharge, follows the failures of the first 90 days in the order they happened, traces each one to its cause, and ranks them by how foreseeable they were.

Every Device, Its Vendor, and Its Backup

Table 1 lists what went home with Mason. The equipment came from one durable medical equipment company, which also provided a respiratory therapist for monthly home visits.

Table 1

Mason's Home Equipment and Supplies at Discharge

Training Before Discharge

The American Thoracic Society guideline for children on chronic invasive ventilation at home recommends that an awake, trained caregiver be present at all times and that at least two family caregivers be trained specifically in the child's care (Sterni et al., 2016). Mason's mother completed every skill before discharge: routine and emergency tracheostomy changes, suctioning, ventilator setup and alarm response, cardiopulmonary resuscitation, and manual ventilation with the bag.

His father's training was cut short. He completed suctioning, oxygen, and cardiopulmonary resuscitation, but not the emergency tracheostomy change or ventilator alarm response, because his night shifts conflicted with the training schedule and the discharge date was moved up by a week once a home nursing agency accepted the case. At discharge, the family had one fully trained caregiver, not two.

Ninety Days of Failures

Table 2 follows events in the order they happened. Each entry links back to a row in the equipment table or a gap in the training record.

Table 2

Failures in Mason's First 90 Days at Home and Their Causes

Only one entry involves a device doing something unexpected, and even that one, the oximeter, was working as set. Every other failure came from the system around the equipment: staffing, supply logistics, utilities, and training. Maynard et al. (2019) found that lack of home nursing was by far the most common cause of delayed discharge for children with medical complexity going home with nursing, which suggests that Mason's first week was predictable rather than unlucky. The same study found that more than half of the new patients were readmitted within 90 days.

What Was Foreseeable

Ranking the failures by whether a coordinated discharge plan could have anticipated them gives findings a discharge team could use.

Foreseeable and preventable at discharge: the second caregiver's training gap, which was known when the discharge date was moved; the power risk, since the house's outages were known, and registration with the utility and a written plan for outages are standard steps; and the nursing shortage, which was predictable enough that a plan for unfilled shifts should have existed, such as a relative trained as a backup or a shorter first week with a planned readmission for respite if shifts were not filled.

Foreseeable with better tracking: the supply lapse, which a calendar of reauthorization dates held by the equipment company or the medical home would have caught.

Partly foreseeable: alarm fatigue, which could have been reduced by a home visit in the first week to review probe fit and alarm limits.

Not foreseeable: the tracheitis itself, though the family's exhaustion by day 74 made it harder to manage at home.

The guideline's conclusion that care for these children works best when generalist and subspecialist clinicians manage it together through a medical home (Sterni et al., 2016) fits this case. Mason's pulmonologist managed his ventilator settings well. Nobody managed the household around them. The AAP clinical report on medical complexity places the family and home at the center of care for children like Mason and calls for care coordination that extends into the home (Kuo et al., 2016). His discharge plan stopped at the hospital door.

References

Kuo, D. Z., Houtrow, A. J., & Council on Children With Disabilities. (2016). Recognition and management of medical complexity. Pediatrics, 138(6), Article e20163021. https://doi.org/10.1542/peds.2016-3021

Maynard, R., Christensen, E., Cady, R., Jacob, A., Ouellette, Y., Podgorski, H., Schiltz, B., Schwantes, S., & Wheeler, W. (2019). Home health care availability and discharge delays in children with medical complexity. Pediatrics, 143(1), Article e20181951. https://doi.org/10.1542/peds.2018-1951

Sterni, L. M., Collaco, J. M., Baker, C. D., Carroll, J. L., Sharma, G. D., Brozek, J. L., Finder, J. D., Ackerman, V. L., Arens, R., Boroughs, D. S., Carter, J., Daigle, K. L., Dougherty, J., Gozal, D., Kevill, K., Kravitz, R. M., Kriseman, T., MacLusky, I., Rivera-Spoljaric, K., . . . Halbower, A. C. (2016). An official American Thoracic Society clinical practice guideline: Pediatric chronic home invasive ventilation. American Journal of Respiratory and Critical Care Medicine, 193(8), e16-e35. https://doi.org/10.1164/rccm.201602-0276ST