Pediatrics · Medical Literature
The DECIDE-T protocol: adoption and enhancement of a care pathway for children with medical complexity - an implementation evaluation project for paediatric tracheostomy
Abstract
Introduction Medical advancements have led to increased survival for critically ill children, many of whom require tracheostomy. Standardised protocols in paediatric tracheostomy have been associated with reduced hospital length of stay, lower readmission rates and reduced acute healthcare costs, without compromising safety. DECIDE-T (Digital hEalth pathway for ChIldren with meDical complExity requiring Tracheostomy) is a novel initiative that moves beyond single-site quality-improvement efforts to deliver a provincially coordinated, multicentre digital care pathway integrated into the electronic health record system. The initiative spans the full care continuum—from decision-making and acute care to home transition and decannulation—with the goal of improving clinical outcomes, efficiency and caregiver experience. Methods and analysis DECIDE-T is a multicentre single-arm pre–post implementation study that applies multiple theory-based frameworks for implementation and evaluation. It incorporates both quantitative and qualitative research methods to assess the implementation and impact of the intervention. Guided by the Quality Implementation Framework and the Interactive Systems Framework, the study includes four phases: (1) Site assessments to identify implementation barriers and facilitators using the Consolidated Framework for Implementation Research (CFIR); (2) Developing a comprehensive plan and implementation strategies using the CFIR-Expert Recommendations for Implementing Change Matching Tool; (3) Pathway roll-out and evaluation of clinical, process and economic outcomes guided by the RE-AIM framework (reach, effectiveness, adoption, implementation and maintenance); and (4) Dissemination of lessons learnt from the implementation experience. Data collection will involve surveys, interviews, focus groups, care pathway audits, patients’ clinical and administrative data, analysed using thematic content analysis and interrupted time seri
Clinical relevance
DECIDE-T addresses a critical gap in paediatric tracheostomy care: the absence of provincially coordinated, multicentre standardised pathways that span the full continuum from surgical decision-making through acute hospitalisation, home transition, and decannulation. The target population is children with medical complexity (CMC) who survive critical illness and require tracheostomy — a growing cohort given advances in neonatal and paediatric critical care. Clinicians should engage with this initiative because prior single-site quality-improvement protocols have already demonstrated reductions in hospital length of stay, readmission rates, and acute healthcare costs without compromising safety, and DECIDE-T seeks to scale and sustain these gains through EHR-integrated digital pathways.
Key findings
NOTE: DECIDE-T is a prospectively registered multicentre single-arm pre–post implementation study; primary outcome data are not yet available. The following findings are drawn from the study rationale and design as reported in the published protocol abstract: 1. Prior standardised paediatric tracheostomy protocols are associated with reduced hospital length of stay (effect size not yet reported for DECIDE-T; cited as established background evidence). 2. Existing protocols are associated with lower readmission rates (quantitative data pending DECIDE-T analysis). 3. Prior protocols are associated with reduced acute healthcare costs without compromising patient safety (DECIDE-T will formally assess economic outcomes). 4. The study will employ interrupted time series analysis to evaluate pre–post changes in clinical, process, and economic outcomes across multiple sites (statistical estimates unavailable at protocol stage). 5. Implementation fidelity will be assessed using the RE-AIM framework dimensions (Reach, Effectiveness, Adoption, Implementation, Maintenance), with both quantitative audits and qualitative methods (surveys, interviews, focus groups). 6. Barriers and facilitators to implementation will be systematically characterised using the Consolidated Framework for Implementation Research (CFIR) and matched to strategies via the CFIR-ERIC Matching Tool (site-specific data pending).
Practice implications
Paediatric intensivists, otolaryngologists, and complex care teams at institutions without a standardised tracheostomy care pathway should proactively assess their current practices using validated implementation frameworks (e.g., CFIR) to identify modifiable barriers before pathway adoption. Clinicians involved in tracheostomy care should anticipate integration of digital care pathways into the EHR as a scalable mechanism to standardise decision-making, caregiver education, and post-discharge follow-up, including decannulation readiness assessment. Centres planning to adopt DECIDE-T or analogous pathways should engage multidisciplinary stakeholders — including surgeons, intensivists, respiratory therapists, and caregivers — from the outset, and plan for outcome tracking across all RE-AIM domains to ensure both implementation fidelity and sustained clinical benefit.