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An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment

Abu-Sultaneh, Samer MD1; Hole, Acrista J. BSRT, RRT2; Tori, Alvaro J. MD1; Benneyworth, Brian D. MD1; Lutfi, Riad MD1; Mastropietro, Christopher W. MD1

Pediatric Critical Care Medicine: October 2017 - Volume 18 - Issue 10 - p e463–e471
doi: 10.1097/PCC.0000000000001285
Online Clinical Investigations

Objectives: Establishing protocols to wean mechanical ventilation and assess readiness for extubation, with the goal of minimizing morbidity associated with extubation failure and prolonged mechanical ventilation, have become increasingly important in contemporary PICUs. The aim of this quality improvement initiative is to establish a respiratory therapist–led daily spontaneous breathing trial protocol to standardize extubation readiness assessment and documentation in our PICU.

Design: A quality improvement project.

Setting: Single center, tertiary care Children’s Hospital PICU.

Patients: All intubated patients admitted to PICU requiring conventional mechanical ventilation between February 2013 and January 2016.

Interventions: A working group of pediatric intensivists, respiratory therapists, nurses, and information technology specialists established the protocol, standardized documentation via the electronic medical record, and planned education. Daily spontaneous breathing trial protocol implementation began in February 2015. All patients on mechanical ventilation were screened daily at approximately 4 AM by a respiratory therapist to determine daily spontaneous breathing trial eligibility. If all screening criteria were met, patients were placed on continuous positive airway pressure of 5 cm H2O with pressure support of 8 cm H2O for up to 2 hours. If tolerated, patients would be extubated to supplemental oxygen delivered via nasal cannula in the morning, after intensivist approval. Daily audits were done to assess screening compliance and accuracy of documentation.

Measurements and Main Results: We analyzed data from 398 mechanically ventilated patients during daily spontaneous breathing trial period (February 2015–January 2016), compared with 833 patients from the pre–daily spontaneous breathing trial period (February 2013–January 2015). During the daily spontaneous breathing trial period, daily screening occurred in 92% of patients. Extubation failure decreased from 7.8% in the pre–daily spontaneous breathing trial period to 4.5% in daily spontaneous breathing trial period. The use of high-flow nasal cannula slightly increased during the project, while there was no change in duration of mechanical ventilation or the use of noninvasive ventilation.

Conclusions: An interprofessionally developed respiratory therapist–led extubation readiness protocol can be successfully implemented in a busy tertiary care PICU without adverse events.

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1Section of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN.

2Department of Respiratory Care Services, Riley Hospital for Children at Indiana University Health, Indianapolis, IN.

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The authors have disclosed that they do not have any potential conflicts of interest.

Dr. Abu-Sultaneh was the leader of this project and was involved in the conception and design of the project, reviewing the available pertinent literature, data collection, drafting the initial draft of the article, and final approval of the article. Drs. Hole, Tori, Benneyworth, Lutfi, and Mastropietro were involved in the conception and design of the project, met regularly with the project leader to review preliminary data and plan reeducation efforts, performed critical revisions of the article, and granted final approval of the article.

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©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies