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Abstract
BACKGROUND: There is currently no standardized way to determine suitability for extubation of pediatric ICU (PICU) patients, potentially resulting in prolonged duration of mechanical ventilation. We aimed to design and implement a protocol for screening all intubated PICU patients for extubation readiness.
METHODS: We adopted the quality improvement (QI) Model for Improvement with Plan-Do-Study-Act (PDSA) cycles to achieve this aim. This QI project was conducted over 11 months in a multidisciplinary PICU. Outcome measures included the (1) development of a standardized extubation readiness test (ERT) that was acceptable and safe; (2) performance of ERT on > 80% of all mechanically ventilated subjects; and (3) maintenance or reduction in mechanical ventilation duration, extubation failure (non-elective re-intubation within 48 h of extubation), and need for rescue noninvasive ventilation (NIV). Balancing measures were to ensure (1) no compromise of the subject's clinical status; and (2) acceptability of the ERT workflow by medical, nursing, and respiratory therapist (RT) teams.
RESULTS: Four PDSA cycles were necessary to achieve the aims of this study. During the QI period, 438 subjects were admitted to the PICU. The ERT was championed by the RTs who conducted the test during office hours. ERT performance increased from 0% (baseline) to 90% (fourth PDSA cycle). Extubation failure rate after implementing ERT was reduced compared to baseline (4/31 [12.9%] vs 3/127 [2.4%], P = .01), whereas need for rescue NIV (3/31 [9.7%] vs 10/127 [7.9%], P = .74) and duration of mechanical ventilation (2 [1–7] d vs 1 [1–3] d, P = .09) were unchanged. PICU length of stay was reduced after implementing ERT (5 [3–10] d vs 3 [1–6] d, P = .01). No subject was destabilized as a result of ERT, and PICU staff found the workflow acceptable.
CONCLUSIONS: An acceptable and safe ERT protocol was implemented and found to improve outcomes in PICU subjects on mechanical ventilation.
- ventilator liberation
- ventilator weaning
- spontaneous breathing trial
- mechanical ventilation
- airway extubation
- extubation failure
- respiratory therapy
Footnotes
- Correspondence: Herng Lee Tan MSc RRT RRT-ACCS RRT-NPS, Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899. E-mail: tanhernglee{at}yahoo.com
Supplementary material related to this paper is available at http://rc.rcjournal.com.
The authors have disclosed no conflicts of interest.
A version of this paper was presented by Mr Aguilan at the SingHealth Duke-NUS Scientific Congress held virtually September 17–18, 2021.
The study was performed at Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore.
- Copyright © 2022 by Daedalus Enterprises
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