Pediatric Pulmonology 50:691–697 (2015)

Examining Pediatric Emergency Home

Ventilation Practices in Home Health Nurses:
Opportunities for Improved Care
1
Sheila S. Kun, * Virginia N. Beas, MS,2 Thomas G. Keens, MD,3
RN, BSN, BA, MS, CPN,
Sally S.L. Ward, MD,3 and Jeffrey I. Gold, PhD2
Summary. Objectives: To assess the pediatric home health nurses’ knowledge in tracheostomy
and ventilator emergency care on home mechanical ventilation (HMV). Background: Emergencies
are frightening experiences for solo home health nurses and require advanced skills in emergency
response and care, especially in pediatric patients who pose unique challenges. Working
Hypothesis: Nurses with greater years of nursing experience would perform better on emergency
HMV case-based scenarios than nurses with less years of experience. Study Design: An
exploratory online survey was used to evaluate emergency case-based pediatric scenarios.
Demographic and professional experiences were profiled. Patient-subject Selection: Seventy-
nine nurses had an average of 6.73 (SD ¼ 1.41) years in pediatric nursing. Over 70% received their
HMV training in their agency, 41% had less than 4 years of experience, and 30.4% had
encountered at least one emergency situation at home. Methodology: The online survey was
distributed by managers of 22 home health agencies to nurses providing pediatric HMV care.
Results: Nurses scored an average of 4.87 out of 10 possible points. There were no significant
differences between nurses with <4 years of experience versus those with more experience on
ventilator alarms knowledge or total knowledge. Ninety-seven percent of the nurses favored more
training in HMV from a variety of settings (e.g., agency, on-line training). Conclusions: Nurses did
not perform well in case-based ventilator alarm scenarios. Length of nursing experience did not
differentiate greater knowledge. It is clear that nurses require and want more training in
emergency-based HMV. Recommendations for an enhanced curriculum are suggested. Pediatr
Pulmonol. 2015;50:691–697. ß 2014 Wiley Periodicals, Inc.

Key words: home mechanical ventilation; tracheostomy; pediatric.

INTRODUCTION
Since the 1960s, programs of home mechanical
ventilation (HMV) via tracheostomy in the United States
have demonstrated their efficacy and relatively safety in 1
Division of Pediatric Pulmonary, Children’s Hospital Los Angeles, Los
supporting children with chronic respiratory failure Angeles, California.
outside the intensive care settings.1,2,3 It is estimated 2
that there are 8,000 children with chronic respiratory Anesthesia Critical Care Medicine, Children’s Hospital Los Angeles, Los
Angeles, California.
failure currently being managed at home by mechanical
ventilation.4 Even with the advances in newer ventilators 3
Keck School of Medicine, University of Southern California, Los Angeles,
and modern monitoring devices, pediatric HMV remains California.
to be a complex and risky population to care for at home.
Mortality varies among 19 institutions with reported Conflict of interest: None.
studies as much as43%.5 Studies suggest that the survival 
Correspondence to: Sheila S. Kun, RN, BSN, BA, MS, CPN, Children’s
of these children is dependent on the clinical course of Hospital’s Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027.
their underlying disease.6–8 However, a retrospective E-mail: skun@chla.usc.edu
observational cohort analysis of 228 children at our
institution noted only 34% of deaths were related to the Received 27 September 2013; Accepted 20 January 2014.
progression of their underlying condition. Forty-nine DOI 10.1002/ppul.23040
percent of deaths were unexpected.8 The Ventilator Assisted Published online 7 April 2014 in Wiley Online Library
Children’s Home Program (VACHP) in Pennsylvania (wileyonlinelibrary.com).

ß 2014 Wiley Periodicals, Inc.

692 Kun et al.
retrospectively studied patients and noted, despite
technological advances in home monitoring, the acciden-
tal death rate of patients enrolled in the VACHP has
remained nearly the same (27.5%).4 The preventable
death statistic of patients enrolled in VACHP echoed a
similar trend in our own institution showing that the HMV
carries a 20% on a 5-year mortality rate, and that these
deaths are often due to unexpected events.8
In addition to unpredictable mortality, the children on
HMV are at risk for acute illness and repeated hospital-
izations. Our recent report noted the 12-month incidence
of non-elective readmission was 40%. Pneumonia and
tracheitis were the most common reasons for readmissions
accounting for 64% of the reasons for readmissions.9
While these studies demonstrate the inevitable morbidity
of children on HMV as the natural consequence of their
medical conditions, data support that employing evi-
denced-based nursing interventions improves mortality,
decreases frequency and length of stay in intensive care
unit, and decreases cost and complications for the 1.5
million ventilator-dependent people in the United States.10
Dougherty et al.7 administered an assessment survey of
21 home care nurses (16 RNs and 5 LPNs) who were
providing home care for patients enrolled in the VACHP.
Knowledge deficits were noted in many areas: tracheos-
tomy emergencies (86%), ventilator care and manage-
ment (86%) and troubleshooting ventilator alarms
(100%). Kun et al.11 surveyed 108 parents and 44 nurses
about unexpected situations with tracheostomies or their
ventilators in the home. While their average knowledge
score was 81%, 63% did not know about alarms related to
accidental dislodgement of the tracheostomy tube and
52% failed to understand high-pressure alarms and
mucous plugging.11 Findings from this study highlight
the need for education on the technical aspects of
ventilator alarms and tracheal mucous plugging. Given
that this study was primarily aimed at parents, a study
focused on home health nurses was the next logical step.
TABLE 1— Demographics of Home Health Nurses (N ¼ 79)
Percentage
Age
20–29 20.9
30–39 16.4
40–49 16.4
50–59 34.3
Over 60 11.9
Gender
Female 73.4
Male 17.7
Education
LVN 79.5
AA 1.4
RN 13.7
BSN 5.5
Pediatric Pulmonology
The aim of the current study was to (1) identify home
health nurses’ knowledge of emergency HMV, (2)
evaluate how home health nurses got their training on
HMV, (3) assess specific technical knowledge on how
ventilators alarms work in emergency HMV, and (4)
identify preferred learning methods for ongoing educa-
tion. It was hypothesized that home health nurses with
greater years of nursing experience would preform better
on emergency HMV case-based scenarios than home
health nurses with less years of experience.
MATERIALS AND METHODS
Participants
Seventy-nine home health nurses (Mage ¼ 44.24; SD
¼ 13.07), females (75.3%) with an average of 5.63 years
(range 0–30 years) of pediatric experience in a home
health-nursing agency with an average of 12 years of total
nursing experience (range 1–43 years) participated in the
study (see Table 1). Forty-one percent of the home health
nurses reported having less than 3 years of nursing
experience. The home health nurse educational back-
ground is comprised of 61 Licensed Vocational Nurses
(LVN)/Licensed Practical Nurses (LPN), 11 Registered
Nurses (RN), and 4 reported having a Bachelor of Science
in Nursing (BSN) degree. Seventy-four percent received a
high school diploma, 1 had an Associate of Arts (AA)
degree. Two of the nurses did not include their education
background in the survey. Seventy percent of the home
health nurses reported receiving their HMV training from
their agency during their orientation, 72.2% have cared
for children on HMV, and 30.4% of them had encountered
an emergency situation at home.
Materials
An investigator-developed measure was created using
an expert panel of medical professionals (e.g., home
health nurses, physicians, psychologists, social workers)
and consisted of 10 pediatric emergency case-based
scenarios with 4–5 corresponding answers. For example,
an emergency situation related to the triggering of a
ventilator alarm with a disconnected circuit in the
ventilator tubing. Specifically, the respondents were
asked, “Select the alarm that would sound, which would
then prompt the nurse to act appropriately to maintain
adequate ventilation,” (a) High pressure alarm, (b) Low
pressure alarm, (c) Both high and low pressure alarms, or
(d) Neither high pressure nor low pressure alarms. Other
emergency scenarios included how to manage a clinical
situation, for example, mucous plugging in the tracheos-
tomy tube and how the home health nurse should respond
to the clinical situation (see Table 2). The authors limited
the choice of only one correct answer to each of the 10
questions. The home health nurses were also asked to
 Pediatric Emergency Home Ventilation in Home Nurses 693
TABLE 2— The 10 Emergency Scenarios

Emergency scenarios Correct Incorrect Missing

1. A 4-year old boy with Nemaline rod myopathy (a neuromuscular disease) uses 50 (63.3%) 12 (15.2%) 17 (21.5%)
positive pressure ventilation via tracheostomy at home, with the following settings:
pressure control; rate 20; peak inspiratory pressure 20 cm H2O; positive end
expiratory pressure 4 cm H2O; FIo2 0.21; high pressure alarm 30 cm H2O; and low
pressure alarm 10 cm H2O. If the ventilator becomes disconnected from the
tracheostomy, which ventilator alarm will sound?
2. A 3-year old girl with congenital myopathy uses positive pressure ventilation via 52 (65.8%) 10 (12.7%) 17 (21.5%)
tracheostomy at home, with the following settings: volume control; rate 20; tidal
volume setting 250 ml; positive end expiratory pressure 4 cm H2O; FIo2 0.21; high
pressure alarm 40 cm H2O; and low pressure alarm 15 cm H2O. If there is a mucous
plug occluding the tracheostomy, which ventilator alarm will sound?
3. A 5-year old boy with spinal muscular atrophy (a neuromuscular disease) uses 1 (1.3%) 61 (77.2%) 17 (21.5%)
positive pressure ventilation via tracheostomy at home, with the following settings:
pressure control; rate 20; peak inspiratory pressure 22 cm H2O; positive end
expiratory pressure 4 cm H2O; FIo2 0.21; high pressure alarm 30 cm H2O; and low
pressure alarm 10 cm H2O. If there is a mucous plug occluding the tracheostomy,
which ventilator alarm will sound?
4. A 6-year old boy with spinal muscular atrophy uses positive pressure ventilation via 3 (3.8%) 59 (74.7%) 17 (21.5%)
tracheostomy at home, with the following settings: pressure control; rate 20; peak
inspiratory pressure 20 cm H2O; positive end expiratory pressure 4 cm H2O; FIo2
0.21; high pressure alarm 30 cm H2O; and low pressure alarm 10 cm H2O. If there is a
mucous plug occluding the tracheostomy, which ventilator alarm will sound?
5. A 4-year old girl with chronic lung disease uses positive pressure ventilation via 51 (64.6%) 12 (15.2%) 16 (20.3%)
tracheostomy at home. In her home, she suddenly shows distress and becomes
cyanotic. You do not observe any chest rise with ventilator breaths, and you do not
hear any breath sounds. The suctioning catheter can only go down 4 cm in her
tracheostomy tube and bag-to-trach ventilation does not help. What should you do
next?
6. A 2-year old girl with Nemaline rod myopathy uses positive pressure ventilation via 53 (67.1%) 10 (12.7%) 16 (20.3%)
tracheostomy at home. In her home, she suddenly shows distress and becomes
cyanotic. You do not observe any chest rising. The ventilator shuts down suddenly.
What should you do next?
7. A 2-year old boy with chronic lung disease uses positive pressure ventilation via 14 (17.7%) 78 (60.8%) 17 (21.5%)
tracheostomy at home. In his home, his tracheostomy tube (size 3.5 mm) disconnects
from the stoma, with the ventilator circuit still attached to the tracheostomy tube. The
tip of the tracheostomy tube is against clothing. Which ventilator alarm will sound?
8. Common causes of low pressure alarm are 49 (62%) 13 (16.5%) 17 (21.5%)
9. A 3-year old boy with chronic lung disease uses positive pressure ventilation via 12 (15.2%) 47 (59.5%) 20 (25.3%)
tracheostomy at home with the following settings: pressure control; rate 26 peak
inspiratory pressure 24 cm H2O; positive end expiratory pressure 4 cm H2O; FIo2
0.21. His low VI (low inspiratory minute volume) alarms. The possible reason for the
alarm is
10. A 3-year old boy with chronic lung disease uses positive pressure ventilation via 18 (22.8%) 41 (51.9%) 20 (25.3%)
tracheostomy. He comes to the clinic for his first check up. While entering the clinic,
suddenly the lights on his ventilator panels (LED) are all dimmed. What should you
do next?

specify how they reached their conclusion for each
emergency scenario. The options included the following:
(a) real life experience, (b) education, or (c) both-real
life experience and education. At the end of the survey,
the home health nurses were asked if they would be
interested in continuing their education in HMV, and to
select a learning modality preference (e.g., online
education, a workshop, and/or a practice session using
simulation technology). The home health nurse had the
option to skip any question(s) and to discontinue the
survey at any point. The survey took approximately 20–
30 min to complete.
Design and Procedures
The design is an exploratory web-based, online survey
designed to evaluate emergency case-based scenarios
surrounding pediatric home mechanical ventilation.
Twenty-two managers from home health agencies in
Southern California were asked to distribute the online
Pediatric Pulmonology
694 Kun et al.

Fig. 1. Total correct score on survey (N ¼ 79).

survey to their home health nurses who provide pediatric P ¼ 0.019, as well as in years of pediatric home
HMV care at their agency. The home health nurses had the experience and the total correct responses, r(52) ¼ 0.30,
opportunity to complete the survey online within a 4- P ¼ 0.032.
month period. Participation in the study was voluntary Four of the 10 scenarios were identified as having a low
and responses were anonymous. Confidentiality was correct response rate (see Fig. 2). A Pearson’s Correlation
maintained for each participating agency as well as for the was conducted to examine if age, education, or nursing
participating home health nurses. Children’s Hospital Los experience were associated with the low scoring scenari-
Angeles’s Institutional Review Board approved the os. No significant relationships were found (see Table 4).
current study. A total of 20 of the home health nurses correctly answered
at least one scenario out of the four scenarios with low
RESULTS correct response rate and 38 nurses incorrectly answered
all four of the scenarios. There was incomplete data on 21
The average number of correct responses was 4.87
of the home health nurses. A t-test analysis was conducted
(SD ¼ 1.41) out of 10 emergency scenarios (see Fig. 1). A
to examine if there were significant differences among
Pearson bivariate correlation was conducted and no
nurses who correctly answered the four scenarios across
significant relations were found among the demographic
age (M ¼ 44.29, SD ¼ 14.38), experience in nursing
variables, such as age, sex, and education (see Table 3).
(M ¼ 14.93, SD ¼ 14.94), experience in home nursing
However, there were significant relations between years in
(M ¼ 5.96, SD ¼ 7.65), and experience in pediatric
nursing experience and the total correct, r(54) ¼ 0.28,
nursing (M ¼ 5.29, SD ¼ 6.76). No significant differences
were found across age (t(51) ¼ 0.33, P ¼ 0.74), years in
TABLE 3— Person’s Correlational Table on Demographics
nursing (t(56) ¼ 0.75, P ¼ 0.46), years in home nursing
(N ¼ 62) (t(55) ¼ 0.90, P ¼ 0.37), or years in pediatric nursing
(t(54) ¼ 0.56, P ¼ 0.58). The percentage of home health
Total correct score nurses who had correct answered the 4 scenarios did not
Age 0.044 significantly differ by education, x2 (3, N ¼ 58) ¼ 4.29,
Sex 0.025 P ¼ 0.23 or on whether one had responded to an
Education 0.225 emergency situation for a child on home mechanical
Years in nursing 0.283 ventilation, x2 (1, N ¼ 57) ¼ 3.08, P ¼ 0.08.
Years in home nursing 0.214
Years in pediatric nursing 0.297
Further analyses examined the impact of years of
nursing experience between nurses with less than 4 years

P < 0.05. and more than 4 years, resulting in 22 home health nurses
Pediatric Pulmonology
 Pediatric Emergency Home Ventilation in Home Nurses 695

Fig. 2. Percentage of correct response on each emergency scenario (N ¼ 79). Indicates the
emergency scenarios that had a low number of correct responses. The differences are not
significantly.

with less than 4 years and 32 nurses were categorized as DISCUSSION

having 4 years or more of nursing experience (see Fig. 3).
Nurses with less than 4 years of nursing experience had an
average total correct score of 4.45 (SD ¼ 1.22). The
average total correct score for the nurses with 4 or more
years of nursing experience had an average of 5.16
(SD ¼ 1). The Wilcoxon signed-rank test was conducted
to determine if differences on total correct scenarios
differed between home health nurses with 4 or more years
of experience to home health nurses with less than 4 years
of experience. Results revealed no significant differences
between the two groups on total correct scenarios,
Z ¼ 1.77, P ¼ 0.077.
Although the home health nurses reported receiving the
majority of their emergency training from their agency of
employment, 97% of the home health nurses favored
more training. The nurses’ preference in the method of
training in mechanical ventilation ranged from taking an
online course (42%), agency-based training (37%), and
attending workshops at a local hospital (29%) (see
Table 5).
The current findings were a sobering reflection of
knowledge deficiencies among home health nurses who
provide critical healthcare to patients who are supported
by HMV. The aim of this study was to understand what
technical aspects of the ventilator seem to pose challenges
to home health nurses. The knowledge deficits in
managing emergency situations are inherent in the
working environment. Unlike working in an acute
hospital, the home environment is not conducive to
professional growth for many reasons. First and foremost,
on a daily basis, the exposure to the clinical presentation
of the patient is extremely limited: one patient, normally
in a fairly stable condition. Additionally, being a solo
practitioner is another major disadvantage. When
emergency situations arise in the home there is no code
blue team to rely on. The lack of exposure and experience
with emergency situations challenges the home health
nurses’ ability to remain proficient and skilled in the
management of emergency care. Routinely, in the hospital

TABLE 4— Low Scoring Emergency Scenarios Person’s Correlational Table (N ¼ 62).

Emergency scenario 3 Emergency scenario 4 Emergency scenario 7 Emergency scenario 9

Age 0.162 0.047 0.167 0.158
Education 0.064 0.112 0.113 0.059
Nursing experience 0.066 0.100 0.155 0.088
Home nursing experience 0.094 0.194 0.050 0.154
Pediatric home nursing 0.100 0.193 0.027 0.148

P < 0.05.

Pediatric Pulmonology
696 Kun et al.
Fig. 3. Home health nurse experience and correct response on four emergency scenarios.
setting, ventilators are managed by respiratory care
practitioners. Conversely, in the home setting, nurses are
expected to act as respiratory therapists without the same
level of expertise in ventilation management. Tradition-
ally, the home care environment does not provide ongoing
training, skill building, simulations, or other trainings that
would assist home-based nurses in knowing and deliver-
ing exemplary emergency-based ventilator services. It is
not surprising that during these last two decades, the
preventable death rate has not changed for children who
are ventilator dependent in the homeVACHP.9
A second aim of this study was to draw on expertise
from an interdisciplinary team (nurse, psychologist,
physician) to construct emergency scenarios that could
be used to conduct educational trainings including the use
of technology assisted simulation. Lastly, home health
TABLE 5— Home Health Nurses Preferred Method of
Learning About HMV (N ¼ 79)
Method Interested number
On-line education 25
Workshop offered at employment site 17
Workshop offered at nursing agency 22
Interactive session using scenarios 14
Practice session using a computer 14
Practice session using 11
simultaneous technology (simulated patients)
The number exceeds the total of home health nurses (N ¼ 79) because
they could have chosen more than one method of learning.
Pediatric Pulmonology
nurses were queried regarding their desired learning
preferences in order to determine the best way to deliver
current training about emergency ventilation manage-
ment. The current findings suggest that training/orienta-
tion opportunities of our home health colleagues
correspond with the reported study from the VACHP
research on home health nursing training. That the
preparation for home health nurses often rely on self-
reporting, group in-services and video or online instruc-
tion that does not require return demonstrations to
validate competency. The poor scores found in our survey
reflect that traditional training methods may not help to
prepare home health nurses for a real emergency. The
technical aspects of managing ventilator alarms require
hands on experience with “teach back” return demonstra-
tion techniques.
Furthermore, not all home health nurses have worked
with tracheostomies or ventilators in the hospital setting.7
With an influx of new graduates taking on home care as
their first job, the lack of exposure to a variety of
emergency settings pose a significant barrier to gaining
new knowledge. We speculate that the newer models and
types of home ventilators introduced to the market within
the last few years as well as the ability of these ventilators
to support increasingly more fragile patients add more
challenges to home health nurses.
The traditional teaching methods associated with
classroom or lecture/seminar settings are not conducive
to handling real-time emergencies. This educational and
skill management mismatch leaves a great variance in
delivering exemplary clinical services to children who are
 Pediatric Emergency Home Ventilation in Home Nurses
ventilator dependent at home. The current findings
illuminate a vital opportunity to deliver better-suited
educational paradigms to in-home healthcare professio-
nals, which include educational and simulator-based
trainings. One of the strengths of this scenario-based
study is to provide realistic situations based on the
author’s decades of expert experience. The scenarios that
we constructed could potentially become valuable
teaching tools for future emergency care training and
practice.
Our findings suggest that home health nurses who had
pediatric nursing experience scored better than non-
pediatric nurses. However, home health nurses with
4 years of experience or more did not significantly do
better than home health nurses with less than 4 years of
nursing experience. The results demonstrate that the
environment in which the nurses are functioning is related
to higher knowledge/performance, rather than years of
nursing experience. For example, a home health nurse
who has specific nursing experience in a pediatric nursing
home environment will be exposed to a diversity of
pediatric scenarios compared to someone who has all of
their nursing experience in general nursing.
One of the limitations of the study is that the home
health nurses had the option to skip questions. The nurses
could have accidently skipped questions or have skipped a
question because of difficulty. The missing data limited
our capacity to conduct additional analyses and examine
the predictive relationship of specific nursing character-
istics on performance. Future studies would benefit from a
larger sample and predictive analyses. Given that
scenarios were based on one specific ventilation system,
the author’s limited the “correct response” to one item per
question. Future studies may include multiple ventilation
systems, which would allow for more than one correct
response. The current participants might not have been
exposed to the technical differences in the ventilation
system referenced, the differences between volume versus
pressure control, nor the monitoring methodology of the
specific ventilator.
The ability to care for pediatric patients on HMV in an
acute setting is a critical responsibility. Therefore,
training of LVN colleagues in the home care setting for
home mechanical ventilation is vital. The current results
indicate that nurses in pediatric home care environments
are woefully inadequate and remediation and enhanced
training is of paramount importance. Although there are
designated groups of health professionals employed in
pediatric home care settings, the need for ongoing training
or advanced training for managing emergency HMV
services is necessary. The current study lends support to
enhancing healthcare professional training in pediatric
HMV in the traditional didactic nature as well as an
opportunity for computer-based training for ongoing
697
maintenance of critical skills that are required for
managing complex cases.
CONCLUSION
Home health nurses scored poorly on tracheostomy and
ventilator emergency care, especially on four scenarios
that include technical questions about alarm and what to
do with the ventilator emergency. The home environment
did not allow for accruement of sufficient experiences in
emergency care. We hope that the ten emergency
scenarios that we constructed would be a good resource
for future programs. Strategies for more hands on
experience, with return demonstrations and simulations
in the actual home setting would help to gain more
knowledge in home emergency care. Greater emphasis
should be placed on the use of simulation and “teach
back” methods to allow vigorous practice and raining. A
strong, collaborative partnership for innovative training of
our home health professionals promises to be the future
model for improving home healthcare delivery.
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