131
TECHNOLOGY-DEPENDENT CHILDREN IN NEW YORK STATE BERNARD N. MILLNER, M.D. Medical Director Physically Handicapped Children's Program New York State Department of Health Albany, New York
YORK STATE HOSPITALS WERE SURVEYED to determine the number and characteristics of technology-dependent children who remained in acute-care hospitals although considered medically stable enough for care at home or in skilled nursing facilities. More than 200 such children were identified in 47 hospitals. The chief obstacles to discharge were lack of skilled home nursing services in local communities, social problems that made it impossible for families to care for their children at home, and lack of beds in appropriate skilled nursing facilities. Half of the children suffered from neurological conditions and one quarter from pulmonary problems. Thirty-seven percent needed ventilator support, 56% cardiopulmonary monitoring, and 59% suctioning. Twenty-two percent depended on parenteral nutrition. Most of these children were dependent on skilled nursing care, the average child needing 13.7 hours per day. Forty-one percent needed 24-hour-a-day nursing care. N EW
BACKGROUND The use of mechanical equipment to support life is not new, and management of patients in their homes with such equipment dates back at least 40 years. Following the epidemics of poliomyelitis during the 1940s and 1950s, hundreds of patients were maintained in "iron-lungs" in special nursing homes and in their own homes. Since then, life-support equipment has proliferated. New patients have emerged who need the new technologies. The largest group comprises infants who have survived premature birth through sophisticated respiratory support systems. Many of these children continue to depend on respiratory support well beyond the neonatal period. Address for reprint requests: New York State Department of Health, Room 772, Coming Tower
Building, Empire State Plaza, Albany NY, 12237
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132BERNARD 132 BERNARD N. MILLNER
As physicians became familiar with the new equipment and techniques, they began to use them for home care, even though this required great effort. The advantages of home care to patients and families are self-evident. This is especially true during the early years of life. "For most children with stable medical conditions and high-tech needs, home care is the best living arrangement, " reflects the current view.1 When new technologies first became available, few parents realized that care at home was an option for a child being kept alive by a medical support system. A pioneering few, however, after observing the techniques of care in intensive care units, were willing to undertake the problems associated with these treatment methods at home. With the help of understanding physicians, social workers, nurses, respiratory therapists, and equipment dealers, they made the necessary complicated arrangements. However, all but the most intrepid were discouraged from actually accomplishing this by the magnitude of the problems and sacrifices involved. During the 1980s increasing numbers of families attempted to care for technology-dependent children at home, and pressure was brought on public and private resources to provide the services needed to make this possible. In New York many families appealed to the state government for help in making the arrangements necessary to allow their technology-dependent children to move from acute care hospitals into their homes. These appeals brought the problem to the attention of the New York State Council on Children and Families, a policy, planning, and coordinating arm of the executive branch. The council investigated the problem, but its analysis was hampered by a dearth of reliable information on which to plan services .2 The number of such children who might safely be transferred from hospitals to homes was not known, nor was there accurate information about their health care needs. The present survey was carried out in January 1989 to collect this information. DEFINITION OF TECHNOLOGY-DEPENDENT CHILDREN As defined by the federal Office of Technology Assessment, "technologydependent" refers to children who use a medical technology (embodied in a medical device) that compensates for the loss of a vital body function, and who require substantial daily skilled nursing care to avert death or further disability.3 Dependence on a medical device is assumed to be prolonged. The definition, therefore, does not include such situations as a premature newborn who outgrows the need for mechanical ventilation after a few weeks. "Skilled nursing care" includes highly technical nursing skills, whether Bull. N.Y. Acad. Med.
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133
provided by professionals or nonprofessionals, such as parents trained in these skills.3 Technology-dependent children often have mental, behavioral, and emotional disabilities in addition to those specified in the general definition, but they are distinguished by the level and nature of care-both in terms of medical device support and skilled nursing care-required by their chronic physical disabilities.
CLASSIFICATION The Office of Technology Assessment identified four separate populations of technology-dependent children, distinguished from each other by their clinical characteristics:3 Group I children are dependent for at least part of each day on mechanical ventilators; Group II children require prolonged intravenous nutrition or drug treatment; Group III children have daily dependence on other device-based respiratory or nutritional support, including tracheostomy tube care, suctioning, oxygen support, or tube feeding; and Group IV includes children with prolonged dependence on other medical devices that compensate for vital functions and who require daily or nearly daily nursing care. This group includes infants who depend on cardiorespiratory monitoring, renal dialysis, or other medical devices, such as urinary catheters or colostomy bags, as well as substantial nursing care, in connection with their disabilities. METHOD
We surveyed 228 acute care hospitals in New York State to determine the number and clinical characteristics of hospitalized technology-dependent children medically stable enough to be cared for in skilled nursing facilities or in their homes. Information was collected about their medical conditions and medical care needs. Hospitals were asked about the number and types of such children at home under the supervision of their medical staffs. Questionnaires were sent initially to the chief executive officers of all acute care hospitals in New York State that had pediatric or newborn departments. We asked them to distribute these questionnaires to the directors of the departments of pediatrics and newborn services and to the directors of the neonatal, pediatric, and adult intensive care units and intermediate care units. We specified that our inquiry concerned only patients younger than 21 years old who depended on some type of medical device for life support and who were medically stable and therefore appropriate for care either in their homes Vol. 67, No. 2, March-April 1991
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BERNARD N. MILLNER
BERNARD N. MILLNER
134
or in extended care facilities rather than in acute care hospitals. Follow-up letters were sent to hospitals which had not responded six and 10 weeks after the original correspondence. If replies were inconsistent or omitted essential information, we communicated with the hospitals by phone and letter within a few days. As we reviewed returned questionnaires, it became clear that they did not contain as much information as we needed about the children's clinical problems and treatment needs. Therefore, we used a second report form to gather additional clinical information about each child. Copies were sent to the hospitals that reported the presence of one or more medically stable technology-dependent child. Information from the survey questionnaires and the individual patient reports was entered into a commercial database program, dBase III Plus. Accumulated totals of data items were generated by the database program. Diagnoses, comments, and other textual material were entered verbatim. RESULTS OF SURVEY
Responses were received from 224 (98%) of the 228 hospitals surveyed. Forty-seven hospitals (21%) identified 210 technology-dependent children considered medically stable by their physicians and ready for discharge home or to extended care nursing facilities. Ventilator support was the most important need of 59 patients (28%), and other respiratory system care was the most important need of 42 (20%). For 26 patients (12%) the primary need was parenteral nutrition; for 20 (10%), it was cardiorespiratory monitoring; and, for 15 (7%), intravenous drug therapy (Table I). Many patients needed more than one type of technological support. TABLE I. MOST IMPORTANT MEDICAL CARE NEEDS OF 210 MEDICALLY STABLE TECHNOLOGY-DEPENDENT CHILDREN IN HOSPITALS No. (%) 59 Ventilator support (28) 42 Other respiratory system care (20) 26 Parenteral nutrition (12) 20 (10) Cardio-respiratory monitoring 15 ( 7) Intravenous drugs 2 ( 1) Renal dialysis 15 Other (7) 31 Not given (15) Total
210
(100) Bull. N.Y. Acad. Med.
135 135
TECHNOLOGY-DEPENDENT TECHNOLOGY-DEPENDENT CHILDREN CHILDREN
The hospitals indicated that 140 (67%) of the children were ready to be transferred to their homes if adequate technological support and skilled nursing care could be arranged for them there. They reported, however, that essential nursing services were unavailable for 114 (8 1%) of these children. In addition, necessary technological support was unavailable for use at home for 55 (39%) of the children. Of those for whom nursing services could not be arranged, in 91 instances (80%) the nursing services they needed did not exist in the community; in 44 cases (39%) funds were not available to pay for them. Thus, for most technology-dependent children in the hospital, unavailability of home nursing services kept the children in acute care hospitals. Hospitals reported that 136 (65%) of 210 children could appropriately have been cared for in skilled nursing facilities. For 118 (87%), however, no appropriate facility was available. Discharge of 78 patients (37%) was prevented by problems other than lack of nursing services and technology support. In almost half of these cases, hospital staff believed that the child's family would be unable to care for him at home.
CHARACTERISTICS OF INDIVIDUAL CHILDREN Detailed reports about 108 children were received from 33 hospitals. Infants predominated: 64 patients were younger than one year old at the time of admission, 27 were between one and four years of age, and only 13 were over five. There were 53 boys and 31 girls. Twenty-one children were identified as of low birth weight. Neurological and pulmonary disorders predominated in 52 (48%) and 27 (25%) children, respectively (Table II). Nineteen children suffered from encephalopathy, most from perinatal anoxia or traumatic brain injury; 11 had hydrocephalus, and six had degenerative central nervous system disease. TABLE II. PRIMARY DISORDERS OF PATIENTS BY SYSTEMS No. (%) 52 Neurological (48) 27 Pulmonary (25) Musculoskeletal 9 ( 8) Gastrointestinal 6 ( 6) Cardiovascular 4 ( 4) Renal 4 ( 4) Drug withdrawal ( 3) 3 Other 2 ( 2) Not reported I Total
Vol. 67, No. 2, March-April 1991
108
(100)
136
BERNARD N. MILLNER
Among those with respiratory problems, 11 had respiratory distress syndrome and nine had bronchopulmonary dysplasia. The technological support needed was most often related to the respiratory system. Sixty-four patients (59%) needed suctioning, and 40 (37%) needed ventilator support. Sixty children (56%) required cardiorespiratory monitoring. Among the nonrespiratory needs, parenteral nutrition predominated in 24 children (22%). Other significant medical support needs included nutritional care, needed by 27 children, and other kinds of respiratory care, needed by 23 (Table III). Eighty-three (77%) of the 108 technology-dependent children were considered suitable for skilled nursing facility care and 73 (68%) for home care. Chief obstacles to discharge were social, reported in 50 cases (46%), absence of appropriate skilled nursing facilities, cited in 48 cases (44%), and lack of community nursing services in 28 cases (26%). Lack of funds was a major problem in 14 cases (13%), and the unavailability of medical equipment was a factor in only five (5%). NURSING CARE NEEDS
Need for skilled nursing care was a thread that ran through the fabric of all types of technology-dependent children. Hospitals estimated the needs for skilled nursing care in hours per day for 93 children (Table IV). Thirty-eight patients (41%) needed 24-hour nursing care, while only 17 needed four hours per day or less. The average need for nursing care was 13.7 hours per day. DURATION OF NEED FOR TECHNOLOGY SUPPORT
Clinicians were asked to estimate the expected duration of each patient's dependency on technological life support (Table V). This information reflected the severity and chronicity of the medical conditions. In almost every case the duration was estimated to be "lifetime," "indefinitely," or "unknown." In only 24 of 216 life support technologies for which an estimate was given was the duration less than 24 months. TECHNOLOGY-DEPENDENT CHILDREN AT HOME
Although the main purpose of the survey was to discover the number and medical care needs of medically stable technology-dependent children in hospitals, planning services for their home care also requires comparable information about children already at home. For this reason, several questions about patients at home under the care of the medical staffs of the hospitals were included in the initial survey questionnaire. Thirty hospitals Bull. N.Y. Acad. Med.
137
TECHNOLOGY-DEPENDENT CHILDREN
TABLE III. MEDICAL TECHNOLOGY AND OTHER NEEDS OF 108 CHILDREN IN HOSPITALS Major Suction Monitor Ventilator Parenteral nutrition Parenteral drugs Dialysis Other Nutritional Gastrostomy feeding Gastric tube feeding Other tube feedings "Skilled nurse feeding" Special diet Respiratory Oxygen Tracheostomy care Chest physical therapy Other respiratory care Colostomy care Bladder catheterization Intranasal medications Occupational and physical therapy
64 60 40 24 4 3
(59%) (56%)
27
(25%)
23
(21%)
2
( 2%) ( 1%)
(37%) (22%)
( 4%) ( 3%)
12 8 4 2 1 10 6 2 5
TABLE IV. ESTIMATED HOURS OF SKILLED NURSING CARE NEEDED PER DAY 11 (10%) None 6 ( 6%) 1-4 22 (20%) 5-8 15 (14%) 9-16 1 ( 1%) 17-23 38 (35%) 24 15 (14%) Not reported 13.7 hours per day Average
(13%) reported that their medical staffs were responsible for 219 children who required at least 10 hours per week of skilled nursing care. The major needs of the children at home were similar to those of the medically-stable hospitalized patients. Most needed respiratory system support: 72 (33%) needed ventilator support, 59 (27%) needed other types of respiratory system support, and 49 (22%) required cardiorespiratory monitoring. Twenty-five children (11%) depended on parenteral nourishment, and 20 (9%) required intravenous drug therapy. Thus, treatment needs of this group Vol. 67, No. 2, March-April 1991
MILLNER N. MILLNER BERNARD N. BERNARD
138 138
TABLE V. ESTIMATED DURATION OF NEED FOR TECHNOLOGY SUPPORT 12-23
TECHNOLOGY-DEPENDENT CHILDREN IN NEW YORK STATE BERNARD N. MILLNER, M.D. Medical Director Physically Handicapped Children's Program New York State Department of Health Albany, New York
YORK STATE HOSPITALS WERE SURVEYED to determine the number and characteristics of technology-dependent children who remained in acute-care hospitals although considered medically stable enough for care at home or in skilled nursing facilities. More than 200 such children were identified in 47 hospitals. The chief obstacles to discharge were lack of skilled home nursing services in local communities, social problems that made it impossible for families to care for their children at home, and lack of beds in appropriate skilled nursing facilities. Half of the children suffered from neurological conditions and one quarter from pulmonary problems. Thirty-seven percent needed ventilator support, 56% cardiopulmonary monitoring, and 59% suctioning. Twenty-two percent depended on parenteral nutrition. Most of these children were dependent on skilled nursing care, the average child needing 13.7 hours per day. Forty-one percent needed 24-hour-a-day nursing care. N EW
BACKGROUND The use of mechanical equipment to support life is not new, and management of patients in their homes with such equipment dates back at least 40 years. Following the epidemics of poliomyelitis during the 1940s and 1950s, hundreds of patients were maintained in "iron-lungs" in special nursing homes and in their own homes. Since then, life-support equipment has proliferated. New patients have emerged who need the new technologies. The largest group comprises infants who have survived premature birth through sophisticated respiratory support systems. Many of these children continue to depend on respiratory support well beyond the neonatal period. Address for reprint requests: New York State Department of Health, Room 772, Coming Tower
Building, Empire State Plaza, Albany NY, 12237
Vol. 67, No. 2, March-April 1991
132BERNARD 132 BERNARD N. MILLNER
As physicians became familiar with the new equipment and techniques, they began to use them for home care, even though this required great effort. The advantages of home care to patients and families are self-evident. This is especially true during the early years of life. "For most children with stable medical conditions and high-tech needs, home care is the best living arrangement, " reflects the current view.1 When new technologies first became available, few parents realized that care at home was an option for a child being kept alive by a medical support system. A pioneering few, however, after observing the techniques of care in intensive care units, were willing to undertake the problems associated with these treatment methods at home. With the help of understanding physicians, social workers, nurses, respiratory therapists, and equipment dealers, they made the necessary complicated arrangements. However, all but the most intrepid were discouraged from actually accomplishing this by the magnitude of the problems and sacrifices involved. During the 1980s increasing numbers of families attempted to care for technology-dependent children at home, and pressure was brought on public and private resources to provide the services needed to make this possible. In New York many families appealed to the state government for help in making the arrangements necessary to allow their technology-dependent children to move from acute care hospitals into their homes. These appeals brought the problem to the attention of the New York State Council on Children and Families, a policy, planning, and coordinating arm of the executive branch. The council investigated the problem, but its analysis was hampered by a dearth of reliable information on which to plan services .2 The number of such children who might safely be transferred from hospitals to homes was not known, nor was there accurate information about their health care needs. The present survey was carried out in January 1989 to collect this information. DEFINITION OF TECHNOLOGY-DEPENDENT CHILDREN As defined by the federal Office of Technology Assessment, "technologydependent" refers to children who use a medical technology (embodied in a medical device) that compensates for the loss of a vital body function, and who require substantial daily skilled nursing care to avert death or further disability.3 Dependence on a medical device is assumed to be prolonged. The definition, therefore, does not include such situations as a premature newborn who outgrows the need for mechanical ventilation after a few weeks. "Skilled nursing care" includes highly technical nursing skills, whether Bull. N.Y. Acad. Med.
TECHNOLOGY-DEPENDENT CHILDREN
133
provided by professionals or nonprofessionals, such as parents trained in these skills.3 Technology-dependent children often have mental, behavioral, and emotional disabilities in addition to those specified in the general definition, but they are distinguished by the level and nature of care-both in terms of medical device support and skilled nursing care-required by their chronic physical disabilities.
CLASSIFICATION The Office of Technology Assessment identified four separate populations of technology-dependent children, distinguished from each other by their clinical characteristics:3 Group I children are dependent for at least part of each day on mechanical ventilators; Group II children require prolonged intravenous nutrition or drug treatment; Group III children have daily dependence on other device-based respiratory or nutritional support, including tracheostomy tube care, suctioning, oxygen support, or tube feeding; and Group IV includes children with prolonged dependence on other medical devices that compensate for vital functions and who require daily or nearly daily nursing care. This group includes infants who depend on cardiorespiratory monitoring, renal dialysis, or other medical devices, such as urinary catheters or colostomy bags, as well as substantial nursing care, in connection with their disabilities. METHOD
We surveyed 228 acute care hospitals in New York State to determine the number and clinical characteristics of hospitalized technology-dependent children medically stable enough to be cared for in skilled nursing facilities or in their homes. Information was collected about their medical conditions and medical care needs. Hospitals were asked about the number and types of such children at home under the supervision of their medical staffs. Questionnaires were sent initially to the chief executive officers of all acute care hospitals in New York State that had pediatric or newborn departments. We asked them to distribute these questionnaires to the directors of the departments of pediatrics and newborn services and to the directors of the neonatal, pediatric, and adult intensive care units and intermediate care units. We specified that our inquiry concerned only patients younger than 21 years old who depended on some type of medical device for life support and who were medically stable and therefore appropriate for care either in their homes Vol. 67, No. 2, March-April 1991
134
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or in extended care facilities rather than in acute care hospitals. Follow-up letters were sent to hospitals which had not responded six and 10 weeks after the original correspondence. If replies were inconsistent or omitted essential information, we communicated with the hospitals by phone and letter within a few days. As we reviewed returned questionnaires, it became clear that they did not contain as much information as we needed about the children's clinical problems and treatment needs. Therefore, we used a second report form to gather additional clinical information about each child. Copies were sent to the hospitals that reported the presence of one or more medically stable technology-dependent child. Information from the survey questionnaires and the individual patient reports was entered into a commercial database program, dBase III Plus. Accumulated totals of data items were generated by the database program. Diagnoses, comments, and other textual material were entered verbatim. RESULTS OF SURVEY
Responses were received from 224 (98%) of the 228 hospitals surveyed. Forty-seven hospitals (21%) identified 210 technology-dependent children considered medically stable by their physicians and ready for discharge home or to extended care nursing facilities. Ventilator support was the most important need of 59 patients (28%), and other respiratory system care was the most important need of 42 (20%). For 26 patients (12%) the primary need was parenteral nutrition; for 20 (10%), it was cardiorespiratory monitoring; and, for 15 (7%), intravenous drug therapy (Table I). Many patients needed more than one type of technological support. TABLE I. MOST IMPORTANT MEDICAL CARE NEEDS OF 210 MEDICALLY STABLE TECHNOLOGY-DEPENDENT CHILDREN IN HOSPITALS No. (%) 59 Ventilator support (28) 42 Other respiratory system care (20) 26 Parenteral nutrition (12) 20 (10) Cardio-respiratory monitoring 15 ( 7) Intravenous drugs 2 ( 1) Renal dialysis 15 Other (7) 31 Not given (15) Total
210
(100) Bull. N.Y. Acad. Med.
135 135
TECHNOLOGY-DEPENDENT TECHNOLOGY-DEPENDENT CHILDREN CHILDREN
The hospitals indicated that 140 (67%) of the children were ready to be transferred to their homes if adequate technological support and skilled nursing care could be arranged for them there. They reported, however, that essential nursing services were unavailable for 114 (8 1%) of these children. In addition, necessary technological support was unavailable for use at home for 55 (39%) of the children. Of those for whom nursing services could not be arranged, in 91 instances (80%) the nursing services they needed did not exist in the community; in 44 cases (39%) funds were not available to pay for them. Thus, for most technology-dependent children in the hospital, unavailability of home nursing services kept the children in acute care hospitals. Hospitals reported that 136 (65%) of 210 children could appropriately have been cared for in skilled nursing facilities. For 118 (87%), however, no appropriate facility was available. Discharge of 78 patients (37%) was prevented by problems other than lack of nursing services and technology support. In almost half of these cases, hospital staff believed that the child's family would be unable to care for him at home.
CHARACTERISTICS OF INDIVIDUAL CHILDREN Detailed reports about 108 children were received from 33 hospitals. Infants predominated: 64 patients were younger than one year old at the time of admission, 27 were between one and four years of age, and only 13 were over five. There were 53 boys and 31 girls. Twenty-one children were identified as of low birth weight. Neurological and pulmonary disorders predominated in 52 (48%) and 27 (25%) children, respectively (Table II). Nineteen children suffered from encephalopathy, most from perinatal anoxia or traumatic brain injury; 11 had hydrocephalus, and six had degenerative central nervous system disease. TABLE II. PRIMARY DISORDERS OF PATIENTS BY SYSTEMS No. (%) 52 Neurological (48) 27 Pulmonary (25) Musculoskeletal 9 ( 8) Gastrointestinal 6 ( 6) Cardiovascular 4 ( 4) Renal 4 ( 4) Drug withdrawal ( 3) 3 Other 2 ( 2) Not reported I Total
Vol. 67, No. 2, March-April 1991
108
(100)
136
BERNARD N. MILLNER
Among those with respiratory problems, 11 had respiratory distress syndrome and nine had bronchopulmonary dysplasia. The technological support needed was most often related to the respiratory system. Sixty-four patients (59%) needed suctioning, and 40 (37%) needed ventilator support. Sixty children (56%) required cardiorespiratory monitoring. Among the nonrespiratory needs, parenteral nutrition predominated in 24 children (22%). Other significant medical support needs included nutritional care, needed by 27 children, and other kinds of respiratory care, needed by 23 (Table III). Eighty-three (77%) of the 108 technology-dependent children were considered suitable for skilled nursing facility care and 73 (68%) for home care. Chief obstacles to discharge were social, reported in 50 cases (46%), absence of appropriate skilled nursing facilities, cited in 48 cases (44%), and lack of community nursing services in 28 cases (26%). Lack of funds was a major problem in 14 cases (13%), and the unavailability of medical equipment was a factor in only five (5%). NURSING CARE NEEDS
Need for skilled nursing care was a thread that ran through the fabric of all types of technology-dependent children. Hospitals estimated the needs for skilled nursing care in hours per day for 93 children (Table IV). Thirty-eight patients (41%) needed 24-hour nursing care, while only 17 needed four hours per day or less. The average need for nursing care was 13.7 hours per day. DURATION OF NEED FOR TECHNOLOGY SUPPORT
Clinicians were asked to estimate the expected duration of each patient's dependency on technological life support (Table V). This information reflected the severity and chronicity of the medical conditions. In almost every case the duration was estimated to be "lifetime," "indefinitely," or "unknown." In only 24 of 216 life support technologies for which an estimate was given was the duration less than 24 months. TECHNOLOGY-DEPENDENT CHILDREN AT HOME
Although the main purpose of the survey was to discover the number and medical care needs of medically stable technology-dependent children in hospitals, planning services for their home care also requires comparable information about children already at home. For this reason, several questions about patients at home under the care of the medical staffs of the hospitals were included in the initial survey questionnaire. Thirty hospitals Bull. N.Y. Acad. Med.
137
TECHNOLOGY-DEPENDENT CHILDREN
TABLE III. MEDICAL TECHNOLOGY AND OTHER NEEDS OF 108 CHILDREN IN HOSPITALS Major Suction Monitor Ventilator Parenteral nutrition Parenteral drugs Dialysis Other Nutritional Gastrostomy feeding Gastric tube feeding Other tube feedings "Skilled nurse feeding" Special diet Respiratory Oxygen Tracheostomy care Chest physical therapy Other respiratory care Colostomy care Bladder catheterization Intranasal medications Occupational and physical therapy
64 60 40 24 4 3
(59%) (56%)
27
(25%)
23
(21%)
2
( 2%) ( 1%)
(37%) (22%)
( 4%) ( 3%)
12 8 4 2 1 10 6 2 5
TABLE IV. ESTIMATED HOURS OF SKILLED NURSING CARE NEEDED PER DAY 11 (10%) None 6 ( 6%) 1-4 22 (20%) 5-8 15 (14%) 9-16 1 ( 1%) 17-23 38 (35%) 24 15 (14%) Not reported 13.7 hours per day Average
(13%) reported that their medical staffs were responsible for 219 children who required at least 10 hours per week of skilled nursing care. The major needs of the children at home were similar to those of the medically-stable hospitalized patients. Most needed respiratory system support: 72 (33%) needed ventilator support, 59 (27%) needed other types of respiratory system support, and 49 (22%) required cardiorespiratory monitoring. Twenty-five children (11%) depended on parenteral nourishment, and 20 (9%) required intravenous drug therapy. Thus, treatment needs of this group Vol. 67, No. 2, March-April 1991
MILLNER N. MILLNER BERNARD N. BERNARD
138 138
TABLE V. ESTIMATED DURATION OF NEED FOR TECHNOLOGY SUPPORT 12-23
