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Yildirim MI, Spaeder MC, Castro BA, Chamberlain R, Fuzy L, Howard S, McNaull P, Raphael J, Sharma R, Vizzini S, Wielar A, Frank DU. The Impact of Nasal Intubation on Feeding Outcomes in Neonates Requiring Cardiac Surgery: A Randomized Control Trial. Pediatr Cardiol 2024; 45:426-432. [PMID: 37853163 DOI: 10.1007/s00246-023-03322-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
Neonates who require surgery for congenital heart disease (CHD) frequently have difficulty with oral feeds post-operatively and may require a feeding tube at hospital discharge. The purpose of this study was to determine the effect of oral or nasal intubation route on feeding method at hospital discharge. This was a non-blinded randomized control trial of 62 neonates who underwent surgery for CHD between 2018 and 2021. Infants in the nasal (25 patients) and oral (37 patients) groups were similar in terms of pre-operative risk factors for feeding difficulties including completed weeks of gestational age at birth (39 vs 38 weeks), birthweight (3530 vs 3100 g), pre-operative PO intake (92% vs 81%), and rate of pre-operative intubation (22% vs 28%). Surgical risk factors were also similar including Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category (3.9 vs 4.1), shunt placement (32% vs 41%), cardiopulmonary bypass time (181 vs 177 min), and cross-clamp time (111 vs 105 min). 96% of nasally intubated patients took full oral feeds by discharge as compared with 78% of orally intubated infants (p = 0.05). Nasally intubated infants reach full oral feeds an average of 3 days earlier than their orally intubated peers. In this cohort of patients, nasally intubated infants reach oral feeds more quickly and are less likely to require supplemental tube feeding in comparison to orally intubated peers. Intubation route is a potential modifiable risk factor for oral aversion and appears safe in neonates. The study was approved by the University of Virginia Institutional Review Board for Health Sciences Research and was retrospectively registered on clinicaltrials.gov (NCT05378685) on May 18, 2022.
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Affiliation(s)
- Melissa I Yildirim
- Division of Pediatric Cardiology, Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, OH, USA.
| | - Michael C Spaeder
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Barbara A Castro
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Rebecca Chamberlain
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Lisa Fuzy
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Sarah Howard
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Peggy McNaull
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jacob Raphael
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ruchik Sharma
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Samantha Vizzini
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Amy Wielar
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Deborah U Frank
- Division of Pediatric Critical Care, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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Moss J, Maurer B, Howes C. Unplanned Extubation in the Pediatric Intensive Care Unit. Crit Care Nurs Clin North Am 2023; 35:295-301. [PMID: 37532383 DOI: 10.1016/j.cnc.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Unplanned extubations (UEs) are common, potentially avoidable complications of endotracheal intubation among pediatric patients. UE can be associated with adverse patient outcomes including increased length of stay, hospitalization cost, and cardiorespiratory decompensation. Inconsistency in the definition of UE has led to underreporting. Staff must be able to recognize and intervene appropriately when an UE occurs. Risk factors have been identified and quality improvement initiatives aimed at reducing UE have shown to be effective in reducing the incidence. The lack of consistent definition may lead to underreporting and may not lead to effective quality improvement initiatives.
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Affiliation(s)
- Julianne Moss
- Department of Pediatric Critical Care, University of Maryland Children's Hospital, 22 South Greene Street, Baltimore, MD 21201, USA; University of Maryland Children's Hospital, 110 South Paca Street, 8th Floor, Baltimore, MD 21201, USA.
| | - Brieann Maurer
- Department of Pediatric Critical Care, University of Maryland Children's Hospital, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Cynthia Howes
- Department of Pediatric Critical Care, University of Maryland Children's Hospital, 22 South Greene Street, Baltimore, MD 21201, USA
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Tasker RC. Editor's Choice Articles for July. Pediatr Crit Care Med 2023; 24:537-540. [PMID: 37409895 DOI: 10.1097/pcc.0000000000003302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
This is another excellent issue of Pediatric Critical Care Medicine (PCCM) for July; congratulations to our authors and many thanks to all reviewers. This month, my Editor's Choice articles cover three topics: clinical pathophysiology in pediatric patients supported using extracorporeal membrane oxygenation (ECMO); unplanned extubation of endotracheal tubes in pediatric cardiac ICU (CICU) patients; and sepsis biomarkers in the low-middle income (LMIC) resource setting. The PCCM Connections for Readers focuses on a novel pediatric theme in lung mechanics physiology, i.e., mechanical power in pediatric acute respiratory distress syndrome (PARDS).
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Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Harwayne-Gidansky I, Dominick C, Nishisaki A. Unplanned Extubations in the Cardiac ICU: Are We Missing the Beat? Pediatr Crit Care Med 2023; 24:617-619. [PMID: 37409898 PMCID: PMC10348451 DOI: 10.1097/pcc.0000000000003271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Ilana Harwayne-Gidansky
- Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical College, Albany, NY
| | - Cheryl Dominick
- Department of Respiratory Care, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Perry T, Klugman D, Schumacher K, Banerjee M, Zhang W, Bertrandt R, Wolovits JS, Murphy LD, Misfeldt AM, Alten J, Cooper DS. Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes. Pediatr Crit Care Med 2023; 24:551-562. [PMID: 37070818 DOI: 10.1097/pcc.0000000000003235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU). DESIGN Registry data (August 2014 to October 2020). SETTING Forty-five Pediatric Cardiac Critical Care Consortium hospitals. PATIENTS Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44-8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86-2.54; p = 0.15), but uncertainty remains. CONCLUSIONS UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.
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Affiliation(s)
- Tanya Perry
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Darren Klugman
- Department of Pediatrics, John's Hopkins Children's Hospital Medical Center, Baltimore, MD
| | - Kurt Schumacher
- Congenital Heart Center, University of Michigan, Ann Arbor, MI
| | | | - Wenying Zhang
- Congenital Heart Center, University of Michigan, Ann Arbor, MI
| | - Rebecca Bertrandt
- Division of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Joshua S Wolovits
- Department of Pediatrics, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX
| | - Lee D Murphy
- Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Andrew M Misfeldt
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jeffrey Alten
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Wollny K, McNeil D, Moss SJ, Sajobi T, Parsons SJ, Benzies K, Metcalfe A. Unplanned Extubations Requiring Reintubation in Pediatric Critical Care: An Epidemiological Study. Pediatr Crit Care Med 2023; 24:311-321. [PMID: 37026721 DOI: 10.1097/pcc.0000000000003167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
OBJECTIVES Unplanned extubations are an infrequent but life-threatening adverse event in pediatric critical care. Due to the rarity of these events, previous studies have been small, limiting the generalizability of findings and the ability to detect associations. Our objectives were to describe unplanned extubations and explore predictors of unplanned extubation requiring reintubation in PICUs. DESIGN Retrospective observational study and multilevel regression model. SETTING PICUs participating in Virtual Pediatric Systems (LLC). PATIENTS Patients (≤ 18 yr) who had an unplanned extubation in PICU (2012-2020). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We developed and trained a multilevel least absolute shrinkage and selection operator (LASSO) logistic regression model in the 2012-2016 sample that accounted for between-PICU variations as a random effect to predict reintubation after unplanned extubation. The remaining sample (2017-2020) was used to externally validate the model. Predictors included age, weight, sex, primary diagnosis, admission type, and readmission status. Model calibration and discriminatory performance were evaluated using Hosmer-Lemeshow goodness-of-fit (HL-GOF) and area under the receiver operating characteristic curve (AUROC), respectively. Of the 5,703 patients included, 1,661 (29.1%) required reintubation. Variables associated with increased risk of reintubation were age (< 2 yr; odds ratio [OR], 1.5; 95% CI, 1.1-1.9) and diagnosis (respiratory; OR, 1.3; 95% CI, 1.1-1.6). Scheduled admission was associated with decreased risk of reintubation (OR, 0.7; 95% CI, 0.6-0.9). With LASSO (lambda = 0.011), remaining variables were age, weight, diagnosis, and scheduled admission. The predictors resulted in AUROC of 0.59 (95% CI, 0.57-0.61); HL-GOF showed the model was well calibrated (p = 0.88). The model performed similarly in external validation (AUROC, 0.58; 95% CI, 0.56-0.61). CONCLUSIONS Predictors associated with increased risk of reintubation included age and respiratory primary diagnosis. Including clinical factors (e.g., oxygen and ventilatory requirements at the time of unplanned extubation) in the model may increase predictive ability.
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Affiliation(s)
- Krista Wollny
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
- Alberta Children's Hospital, PICU, Calgary, AB, Canada
- Maternal Newborn Child and Youth Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Deborah McNeil
- Maternal Newborn Child and Youth Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
| | - Stephana J Moss
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tolulope Sajobi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Karen Benzies
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Amy Metcalfe
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Liu K, Liu Z, Li LQ, Zhang M, Deng XX, Zhu H. Predictive value of the unplanned extubation risk assessment scale in hospitalized patients with tubes. World J Clin Cases 2022; 10:13274-13283. [PMID: 36683639 PMCID: PMC9851005 DOI: 10.12998/wjcc.v10.i36.13274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/21/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Critical patients often had various types of tubes, unplanned extubation of any kind of tube may cause serious injury to the patient, but previous reports mainly focused on endotracheal intubation. The limitations or incorrect use of the unplanned extubation risk assessment tool may lead to improper identification of patients at a high risk of unplanned extubation and cause delay or non-implementation of unplanned extubation prevention interventions. To effectively identify and manage the risk of unplanned extubation, a comprehensive and universal unplanned extubation risk assessment tool is needed.
AIM To assess the predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale in inpatients.
METHODS This was a retrospective validation study. In this study, medical records were extracted between October 2020 and September 2021 from a tertiary comprehensive hospital in southwest China. For patients with tubes during hospitalization, the following information was extracted from the hospital information system: age, sex, admission mode, education, marital status, number of tubes, discharge mode, unplanned extubation occurrence, and the Huaxi Unplanned Extubation Risk Assessment Scale (HUERAS) score. Only inpatients were included, and those with indwelling needles were excluded. The best cut-off value and the area under the curve (AUC) of the Huaxi Unplanned Extubation Risk Assessment Scale were been identified.
RESULTS A total of 76033 inpatients with indwelling tubes were included in this study, and 26 unplanned extubations occurred. The patients’ HUERAS scores were between 11 and 30, with an average score of 17.25 ± 3.73. The scores of patients with or without unplanned extubation were 22.85 ± 3.28 and 17.25 ± 3.73, respectively (P < 0.001). The results of the correlation analysis showed that the correlation coefficients between each characteristic and the total score ranged from 0.183 to 0.843. The best cut-off value was 21, and there were 14135 patients with a high risk of unplanned extubation, accounting for 18.59%. The Cronbach’s α, sensitivity, specificity, positive predictive value, and negative predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale were 0.815, 84.62%, 81.43%, 0.16%, and 99.99%, respectively. The AUC of HUERAS was 0.851 (95%CI: 0.783-0.919, P < 0.001).
CONCLUSION The HUERAS has good reliability and predictive validity. It can effectively identify inpatients at a high risk of unplanned extubation and help clinical nurses carry out risk screening and management.
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Affiliation(s)
- Kun Liu
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zheng Liu
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lin-Qian Li
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Meng Zhang
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xue-Xue Deng
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong Zhu
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
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Quality improvement interventions to prevent unplanned extubations in pediatric critical care: a systematic review. Syst Rev 2022; 11:259. [PMID: 36461126 PMCID: PMC9717500 DOI: 10.1186/s13643-022-02119-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 11/03/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND An unplanned extubation is the uncontrolled and accidental removal of a breathing tube and is an important quality indicator in pediatric critical care. The objective of this review was to comprehensively synthesize literature published on quality improvement (QI) practices implemented to reduce the rate of unplanned extubations in critically ill children. METHODS We included original, primary research on quality improvement interventions to reduce the rate of unplanned extubations in pediatric critical care. A search was conducted in MEDLINE (Ovid), Embase, and CINAHL from inception through April 29, 2021. Two reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data from included studies were abstracted using a tool created by the authors, and QI interventions were categorized using the Behavior Change Wheel. Vote counting based on the direct of effect was used to describe the effectiveness of quality improvement interventions. Study quality was assessed using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Results were presented as descriptive statistics and narrative syntheses. RESULTS Thirteen studies were included in the final review. Eleven described primary QI projects; two were sustainability studies that followed up on previously described QI interventions. Under half of the included studies were rated as high-quality. The median number of QI interventions described by each study was 5 [IQR 4-5], with a focus on guidelines, environmental restructuring, education, training, and communication. Ten studies reported decreased unplanned extubation rates after the QI intervention; of these, seven had statistically significant reductions. Both sustainability studies observed increased rates that were not statistically significant. CONCLUSIONS This review provides a comprehensive synthesis of QI interventions to reduce unplanned extubation. With only half the studies achieving a high-quality rating, there is room for improvement when conducting and reporting research in this area. Findings from this review can be used to support clinical recommendations to prevent unplanned extubations, and support patient safety in pediatric critical care. SYSTEMATIC REVIEW REGISTRATION This review was registered on PROSPERO (CRD42021252233) prior to data extraction.
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Melton K, Ryan C, Saunders A, Zix J. Reducing Pediatric Unplanned Extubation Across Multiple ICUs Using Quality Improvement. Pediatrics 2022; 149:186762. [PMID: 35490283 DOI: 10.1542/peds.2021-052259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Unplanned extubation (UE) in pediatric patients can result in significant harm or mortality. In our institution, efforts to reduce UE in the ICU were siloed and learnings were not shared. Our goal was to implement shared initiatives across ICUs in a pediatric institution using quality improvement methodology, with the global aim of reducing serious harm caused by UEs. METHODS The study was conducted as a single-center prospective quality improvement initiative in the pediatric, neonatal, and cardiac ICUs of a large, freestanding academic pediatric hospital. Using the model for improvement and plan-do-study-act cycles, our multidisciplinary team implemented multiple interventions to reduce UEs. The primary measure monitored was the monthly UE rate, defined as the number of UEs per 100 ventilator days, which was tracked over time using statistical control charts. RESULTS The overall monthly institutional UE rate was reduced from 1.22 UE per 100 ventilator days to 0.2 UE per 100 ventilator days, representing an 84% improvement in rate and reduction of harm. Sixteen percent to 21% of UEs required additional resources because of a difficult airway, and 10% to 22% of UEs resulted in cardiovascular collapse requiring resuscitation. CONCLUSIONS Significant harm is associated with UEs in pediatric patients. We implemented a bundle for UE reduction across all ICU populations in a pediatric hospital and significantly reduced the rate of UE within our institution and within each individual unit. Allowing variation for implementation of interventions by unit, although targeting a common goal, contributed to overall success and sustainability.
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Affiliation(s)
- Kristin Melton
- Department of Pediatrics, Division of Neonatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Caitlin Ryan
- James M. Anderson Center for Health Systems Excellence
| | | | - Julie Zix
- Newborn ICU, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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10
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da Silva PSL, Reis ME, Farah D, Andrade TRM, Fonseca MCM. Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis. Arch Dis Child 2022; 107:271-276. [PMID: 34284999 DOI: 10.1136/archdischild-2021-321996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/05/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children. DESIGN Systematic review according to the Cochrane guidelines and meta-analysis using random-effects modelling. METHODS We searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Cochrane and SciELO databases from inception until April 2021. We conducted a quality appraisal for each study using the Newcastle-Ottawa Scale and Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0 checklist. MAIN OUTCOME The primary outcome measure was UE rates per 100 intubation days. RESULTS We screened 10 091 records and finally included 11 studies. Six studies were pre/post-intervention studies, and five were interrupted time-series studies. The methodological quality was 'good' in 70%, and the remaining as 'fair' (30%). The most frequently used implementation strategies were staff education (100%), root cause analysis (100%), and audit and feedback (82%). Key bundle care components comprised identification of high-risk patients, endotracheal tube care and sedation protocol. Not all studies fully completed the SQUIRE V.2.0 checklist. Meta-analysis revealed a reduction in UE rate following the introduction of care bundles (rate ratio: 0.40 (95% CI: 0.19 to 0.84); p=0.02), which equates to a 60% reduction in UE rates. CONCLUSIONS We found that identifying high-risk patients, endotracheal tube care and protocol-directed sedation are core elements in care bundles for preventing UEs. However, there are several methodological gaps in the literature, including poor evaluation of adherence to bundle components. Future studies should address these gaps to strengthen their validity.
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Affiliation(s)
| | - Maria Eunice Reis
- Division of Neonatology, Santa Joana Hospital and Maternity, Sao Paulo, Brazil
| | - Daniela Farah
- Health Technologies Assessment Center, Federal University of Sao Paulo Paulista School of Medicine, Sao Paulo, Brazil
| | - Teresa Raquel M Andrade
- Health Technologies Assessment Center, Federal University of Sao Paulo Paulista School of Medicine, Sao Paulo, Brazil
| | - Marcelo Cunio Machado Fonseca
- Health Technologies Assessment Center, Federal University of Sao Paulo Paulista School of Medicine, Sao Paulo, Brazil
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11
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Pollak U, Feinstein Y, Mannarino CN, McBride ME, Mendonca M, Keizman E, Mishaly D, van Leeuwen G, Roeleveld PP, Koers L, Klugman D. The horizon of pediatric cardiac critical care. Front Pediatr 2022; 10:863868. [PMID: 36186624 PMCID: PMC9523119 DOI: 10.3389/fped.2022.863868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Candace N Mannarino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Grace van Leeuwen
- Pediatric Cardiac Intensive Care Unit, Sidra Medicine, Ar-Rayyan, Qatar.,Department of Pediatrics, Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Peter P Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Lena Koers
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Darren Klugman
- Pediatrics Cardiac Critical Care Unit, Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins Medicine, Baltimore, MD, United States
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Houska N, Twite MD, Ing RJ. The Importance of the Airway in Children Undergoing Surgery for Congenital Heart Disease. J Cardiothorac Vasc Anesth 2020; 35:145-147. [PMID: 33004270 DOI: 10.1053/j.jvca.2020.09.089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Nicholas Houska
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mark D Twite
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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Stone M, Ing RJ, Schwartz L. Risk Stratification for Prolonged Mechanical Ventilation After Cardiac Surgery in Children. J Cardiothorac Vasc Anesth 2020; 34:949-950. [PMID: 31937480 DOI: 10.1053/j.jvca.2019.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Matthew Stone
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Richard J Ing
- University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Lawrence Schwartz
- University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
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