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Schults JA, Charles KR, Harnischfeger J, Ware RS, Royle RH, Byrnes JM, Long DA, Ullman AJ, Raman S, Waak M, Lake A, Cooke M, Irwin A, Tume L, Hall L. Implementing paediatric appropriate use criteria for endotracheal suction to reduce complications in mechanically ventilated children with respiratory infections. Aust Crit Care 2024; 37:34-42. [PMID: 38142148 DOI: 10.1016/j.aucc.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Endotracheal suction is used to maintain endotracheal tube patency. There is limited guidance to inform clinical practice for children with respiratory infections. OBJECTIVE The objective of this study was to determine whether implementation of a paediatric endotracheal suction appropriate use guideline Paediatric AirWay Suction (PAWS) is associated with an increased use of appropriate and decreased use of inappropriate suction interventions. METHODS A mixed-method, pre-implementation-post-implementation study was conducted between September 2021 and April 2022. Suction episodes in mechanically ventilated children with a respiratory infection were eligible. Using a structured approach, we implemented the PAWS guideline in a single paediatric intensive care unit. Evaluation included clinical (e.g., suction intervention appropriateness), implementation (e.g., acceptability), and cost outcomes (implementation costs). Associations between implementation of the PAWS guideline and appropriateness of endotracheal suction intervention use were investigated using generalised linear models. RESULTS Data from 439 eligible suctions were included in the analysis. Following PAWS implementation, inappropriate endotracheal tube intervention use reduced from 99% to 58%, an absolute reduction (AR) of 41% (95% confidence interval [CI]: 25%, 56%). Reductions were most notable for open suction systems (AR: 48%; 95% CI: 30%, 65%), 0.9% sodium chloride use (AR: 23%; 95% CI: 8%, 38%) and presuction and postsuction manual bagging (38%; 95% CI: 16%, 60%, and 86%; 95% CI: 73%, 99%), respectively. Clinicians perceived PAWS as acceptable and suitable for use. CONCLUSIONS Implementation of endotracheal tube suction appropriate use guidelines in a mixed paediatric intensive care unit was associated with a large reduction in inappropriate suction intervention use in paediatric patients with respiratory infections.
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Affiliation(s)
- Jessica A Schults
- Metro North Health, Herston Infectious Disease Institute, Queensland, Australia; The University of Queensland, School of Nursing Midwifery and Social Work, Australia; The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Queensland, Australia.
| | - Karina R Charles
- The University of Queensland, School of Nursing Midwifery and Social Work, Australia; The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Jane Harnischfeger
- The University of Queensland, School of Nursing Midwifery and Social Work, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Ruth H Royle
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Joshua M Byrnes
- Menzies Health Institute Queensland, Griffith University, Queensland, Australia; Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Australia
| | - Debbie A Long
- The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia; School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Queensland, Australia
| | - Amanda J Ullman
- The University of Queensland, School of Nursing Midwifery and Social Work, Australia; The University of Queensland, Children's Health Research Centre, Australia; Menzies Health Institute Queensland, Griffith University, Queensland, Australia; Children's Health Queensland Hospital and Health Service, Queensland, Australia
| | - Sainath Raman
- The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Michaela Waak
- The University of Queensland, Children's Health Research Centre, Australia; Queensland Children's Hospital, Paediatric Intensive Care Unit, Queensland, Australia
| | - Anna Lake
- The University of Queensland, Children's Health Research Centre, Australia
| | - Marie Cooke
- School of Nursing & Midwifery, Griffith University, Australia
| | - Adam Irwin
- The University of Queensland, Centre for Clinical Research, The University of Queensland, Queensland, Australia; Infection Management and Prevention Service, Queensland Children's Hospital, Queensland, Australia
| | - Lyvonne Tume
- Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK; Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK
| | - Lisa Hall
- Metro North Health, Herston Infectious Disease Institute, Queensland, Australia; School of Public Health, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
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The Paediatric AirWay Suction (PAWS) appropriateness guide for endotracheal suction interventions. Aust Crit Care 2021; 35:651-660. [PMID: 34953635 DOI: 10.1016/j.aucc.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/10/2021] [Accepted: 10/17/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND/OBJECTIVE Endotracheal suction is an invasive and potentially harmful technique used for airway clearance in mechanically ventilated children. Choice of suction intervention remains a complex and variable process. We sought to develop appropriate use criteria for endotracheal suction interventions used in paediatric populations. METHODS The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop the Paediatric AirWay Suction appropriateness guide. This included defining key terms, synthesising current evidence, engaging an expert multidisciplinary panel, case scenario development, and two rounds of appropriateness ratings (weighing harm with benefit). Indications (clinical scenarios) were developed from common applications or anticipated use, current practice guidelines, clinical trial results, and expert consultation. RESULTS Overall, 148 (19%) scenarios were rated as appropriate (benefit outweighs harm), 542 (67%) as uncertain, and 94 (11%) as inappropriate (harm outweighs benefit). Disagreement occurred in 24 (3%) clinical scenarios, namely presuction and postsuction bagging across populations and age groups. In general, the use of closed suction was rated as appropriate, particularly in the subspecialty population 'patients with highly infectious respiratory disease'. Routine application of 0.9% saline for nonrespiratory indications was more likely to be inappropriate/uncertain than appropriate. Panellists preferred clinically indicated suction versus routine suction in most circumstances. CONCLUSION Appropriate use criteria for endotracheal suction in the paediatric intensive care have the potential to impact clinical decision-making, reduce practice variability, and improve patient outcomes. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.
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Schults JA, Charles K, Long D, Erikson S, Brown G, Waak M, Tume L, Hall L, Ullman AJ. Appropriate use criteria for endotracheal suction interventions in mechanically ventilated children: The RAND/UCLA development process. Aust Crit Care 2021; 35:661-667. [PMID: 34924248 DOI: 10.1016/j.aucc.2021.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/10/2021] [Accepted: 10/17/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Endotracheal suction is an invasive airway clearance technique used in mechanically ventilated children. This article outlines the methods used to develop appropriate use criteria for endotracheal suction interventions in mechanically ventilated paediatric patients. METHODS The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop paediatric appropriate use criteria. This included the following sequential phases of defining scope and key terms, a literature review and synthesis, expert multidisciplinary panel selection, case scenario development, and appropriateness ratings by an interdisciplinary expert panel over two rounds. The panel comprised experts in the fields of paediatric and neonatal intensive care, respiratory medicine, infectious diseases, critical care nursing, implementation science, retrieval medicine, and education. Case scenarios were developed iteratively by interdisciplinary experts and derived from common applications or anticipated intervention uses, as well as from current clinical practice guidelines and results of studies examining interventions efficacy and safety. Scenarios were rated on a scale of 1 (harm outweighs benefit) to 9 (benefit outweighs harm), to define appropriate use (median: 7 to 9), uncertain use (median: 4 to 6), and inappropriate use (median: 1 to 3) of endotracheal suction interventions. Scenarios were than classified as a level of appropriateness. CONCLUSIONS The RAND Corporation/University of California, Los Angeles Appropriateness Method provides a thorough and transparent method to inform development of the first appropriate use criteria for endotracheal suction interventions in paediatric patients.
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Affiliation(s)
- Jessica A Schults
- Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Metro North Hospital and Health Service, Queensland, Australia; Child Health Research Centre, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia.
| | - Karina Charles
- Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia
| | - Debbie Long
- Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia; School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Simon Erikson
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Georgia Brown
- Royal Children's Hospital, Parkville, Victoria, Australia
| | - Michaela Waak
- Paediatric Intensive Care Unit Queensland Children's Hospital, South Brisbane, Queensland, Australia; Child Health Research Centre, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Lyvonne Tume
- School of Health & Society, University of Salford, Manchester UK; Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool UK
| | - Lisa Hall
- School of Public Health, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Amanda J Ullman
- School of Nursing, Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia; Child Health Research Centre, Faculty of Medicine, University of Queensland, St Lucia, Queensland, Australia; Queensland Children's Hospital, Queensland, Australia
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