Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations

Sustainable improvement in upstream and downstream outcomes for intubated patients three years after an airway-based educational intervention in a low-resource pediatric intensive care unit

OBJECTIVE

To determine whether implementation of an education-based intervention can sustainably improve upstream and downstream outcomes in intubated patients in a pediatric intensive care unit (PICU) in a low-resource country.

DESIGN

Quality improvement study comparing airway-related morbidity in two previously studied patient cohorts pre-intervention (Epoch 1) and immediately post-intervention (Epoch 2) with a third cohort thirty-six months post-intervention (Epoch 3).

SETTING

PICU of the largest public children's hospital in El Salvador.

PATIENTS

147 patients under 18 years requiring intubation and mechanical ventilation (MV) met inclusion criteria in the long-term follow-up period and were consecutively sampled without exclusion (Epoch 3) (compared to 98 previously studied patients in the short-term follow-up period (Epoch 2)).

INTERVENTION

A low-cost, education-based intervention to close knowledge gaps, improve communication among PICU doctors, nurses, and respiratory therapists, and optimize patient outcomes.

MEASUREMENTS AND MAIN RESULTS

The primary outcome measure was change in unplanned extubation (UE) between Epochs 2 and 3. Other outcomes included use of cuffed endotracheal tubes (ETT), rate of elective ETT change and days of MV. The 17 % decrease in UE previously reported for Epoch 2 was sustained in Epoch 3. There was a statistically significant increase in use of cuffed ETT from 35.7 % in Epoch 2-55.1 % in Epoch 3 (p = 0.003, z-score -2.99). There was also a statistically significant mean difference in rate of elective ETT change per 100 MV days from Epoch 2 to Epoch 3 of 1.7 (p = 0.007; 95 % CI 0.15-0.84). There was no change in MV days from Epoch 2 to Epoch 3 (p-value 0.764; 95 % CI -1.48-2.02). Beyond these quantifiable results, many unanticipated practice changes were observed three years after the initial intervention.

CONCLUSIONS

Sustained improvement in upstream and downstream outcomes (UE, cuffed ETT use, elective ETT change) for intubated patients in a low-resource PICU were observed three years after a low-cost, low-touch, education-based intervention.

Practical quality improvement changes for a low-resourced pediatric unit

Background

This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative.

Methods

This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions.

Results

147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components.

Conclusion

Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.

Impact of Collaborative Nursing Care Delivery on Patient Safety Events in an Emergency Intensive Care Unit: A Retrospective Observational Study

OBJECTIVES

Patient safety events (PSEs) have detrimental consequences for patients and healthcare staff, highlighting the importance of prevention. Although evidence shows that nurse staffing affects PSEs, the role of an appropriate nursing care delivery system remains unclear. The current study aimed to investigate whether nursing care delivery systems could prevent PSEs.

METHODS

This retrospective study was conducted in Japan. The study examined the collaborative 4:2 nursing care delivery system in which 2 nurses are assigned to care for 4 patients, collaborating to perform tasks, and provide care. The cohort receiving care from a collaborative 4:2 nursing care delivery system was labeled the postintervention, whereas the cohort receiving care from a conventional individualized system, in which one nurse provides care for 2 patients, was labeled the preintervention. The primary outcome was the occurrence of PSEs.

RESULTS

The preintervention and postintervention comprised 561 and 401 patients, respectively, with the latter consisting of a younger and more critically ill population. The number of PSEs per 1000 patient-days was not significantly different between the 2 groups (10.3 [95% confidence interval, 7.1-13.5] versus 6.0 [95% confidence interval, 3.2-8.9], P = 0.058). Multiple logistic regression analysis showed that the collaborative 4:2 nursing care delivery system was significantly associated with PSEs (adjusted odds ratio, 0.53; 95% confidence interval, 0.29-0.95; P = 0.037).

CONCLUSIONS

These findings suggest that in an emergency intensive care unit, a collaborative nursing care delivery system was associated with a decrease in PSEs.

Reducing paediatric unintended extubation: A standardized bundle approach

BACKGROUND

Unintended extubation (UE) is a serious risk associated with endotracheal intubation. In the paediatric population, UE can lead to significant patient harm. On average, each UE increases ICU and hospital length of stay by 5.5 and 6.5 days respectively and costs an additional $36 000. The international benchmark rate of UE for quality analysis cited in the literature is <1 per 100 ventilator days. The United States organization Solutions for Patient Safety (SPS) developed and introduced a bundle to reduce UE with a goal of ≤0.95 per 100 ventilator days.

AIM

The aim of this quality improvement project was to determine the baseline rate of UE in a 20-bed mixed medical/surgical PICU in the Pacific Northwest of the United States, implement the SPS bundle for UE prevention, and assess adherence to the bundle, and subsequent rate of UE.

STUDY DESIGN

The IHI Model for Improvement Plan-Do-Study-Act (PDSA) was used to guide the development, implementation, and assessment of the SPS UE Bundle standardizing the management of endotracheal tubes. Adherence to the bundle was measured through peer-to-peer audits. Rates of adherence and UE were monitored on line charts.

RESULTS

Baseline rate of UE was 1.83 per 100 ventilator days; 23 weeks post implementation of the bundle the rate of UE was reduced to 0.38 UE per 100 ventilator days, F(7, 9) = 4.685, p = 0.027. The mean bundle adherence was 92%.

CONCLUSIONS

This quality improvement initiative confirms that high adherence to the SPS UE Bundle may significantly reduce rates of UE in PICU settings.

RELEVANCE TO CLINICAL PRACTICE

Use of the SPS evidence-based discrete UE bundle and high adherence to the bundle can standardize practise and may reduce unintended extubation in the paediatric population.

Unplanned Extubations Requiring Reintubation in Pediatric Critical Care: An Epidemiological Study

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.

Quality improvement project to reduce unplanned extubations in a paediatric intensive care unit

BACKGROUND

Unplanned extubations are recurrent adverse events in mechanically ventilated children and have been the focus of quality and safety improvement in paediatric intensive care units (ICUs).

LOCAL PROBLEM

To reduce the rate of unplanned extubation in the paediatric ICU by 66% (from 2.02 to 0.7).

METHODS

This is a quality improvement project that was conducted in a paediatric ICU of a private hospital at the quaternary level. All hospitalised patients who used invasive mechanical ventilation between October 2018 and August 2019 were included.

INTERVENTIONS

The project was based on the Improvement Model methodology of the Institute for Healthcare Improvement to implement change strategies. The main ideas of change were innovation in the endotracheal tube fixation model, evaluation of the endotracheal tube positioning, good practices of physical restraint, sedation monitoring, family education and engagement and checklist for prevention of unplanned extubation, with Plan-Do-Study-Act, the tool chosen to test and implement ideas for change.

RESULTS

The actions reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 2 years, totalling 743 days without any event. An estimate was made comparing cases with unplanned extubation and controls without the occurrence of this adverse event, which resulted in savings of R$955 096.65 (US$179 540.41) during the 2 years after the implementation of the improvement actions.

CONCLUSION

The improvement project conducted in the 11-month period reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 743 days. Adherence to the new fixation model and the creation of a new restrictor model, which enabled the implementation of good practices of physical restraint were the ideas of change that had the greatest impact in achieving this result.

Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews

AIMS

This study was performed to identify and summarize systematic reviews focusing on the prevention of unplanned endotracheal extubation in the intensive care unit.

DESIGN

Overview of systematic reviews.

METHODS

This overview was conducted according to the Preferred Reporting Items for Overviews of Systematic Reviews, including the harms checklist. A literature search of PubMed, the Cochrane Library, CINAH, Embase, Web of Science, SINOMED and PROSPERO was performed from January 1, 2005-June 1, 2021. A systematic review focusing on unplanned extubation was included, resulting in an evidence summary.

RESULTS

Thirteen systematic reviews were included. A summary of evidence on unplanned endotracheal extubation was developed, and the main contents were risk factors, preventive measures and prognosis. The most important nursing measures were restraint, fixation of the tracheal tube, continuous quality improvement, psychological care and use of a root cause analysis for the occurrence of unplanned endotracheal extubation.

CONCLUSIONS

This overview re-evaluated risk factors and preventive measures for unplanned endotracheal extubation in the intensive care unit, resulting in a summary of evidence for preventing unplanned endotracheal extubation and providing direction for future research.

TRIAL REGISTRATION DETAILS

The study was registered on the PROSPERO website.

Effect of ICU quality control indicators on VAP incidence rate and mortality: a retrospective study of 1267 hospitals in China

PURPOSE

To investigate the effects of ICU quality control indicators on the VAP incidence rate and mortality in China throughout 2019.

METHODS

This was a retrospective study. A total of 1267 ICUs from 30 provinces in mainland China were included. Data were collected using the National Clinical Improvement System Data that report ICU information. Ten related quality control indicators were analyzed, including 5 structural factors (patient-to-bed ratio, physician-to-bed ratio, nurse-to-bed ratio, patient-to-physician ratio, and patient-to-nurse ratio), 3 process factors (unplanned endotracheal extubation rate, reintubation rate within 48 h, and microbiology detection rate before antibiotic use), and 2 outcome factors (VAP incidence rate and mortality). The information on the most common infectious pathogens and the most commonly used antibiotics in ICU was also collected. The Poisson regression model was used to identify the impact of factors on the incidence rate and mortality of VAP.

RESULTS

The incidence rate of VAP in these hospitals in 2019 was 5.03 (2.38, 10.25) per 1000 ventilator days, and the mortality of VAP was 11.11 (0.32, 26.00) %. The most common causative pathogen was Acinetobacter baumannii (in 39.98% of hospitals), followed by Klebsiella pneumoniae (38.26%), Pseudomonas aeruginosa, and Escherichia coli. In 26.90% of hospitals, third-generation cephalosporin was the most used antibiotic, followed by carbapenem (24.22%), penicillin and beta-lactamase inhibitor combination (20.09%), cephalosporin with beta-lactamase inhibitor (17.93%). All the structural factors were significantly associated with VAP incidence rate, but not with the mortality, although the trend was inconsistent. Process factors including unplanned endotracheal extubation rate, reintubation rate in 48 h, and microbiology detection rate before antibiotic use were associated with higher VAP mortality, while unplanned endotracheal extubation rate and reintubation rate in 48 h were associated with higher VAP mortality. Furthermore, K. pneumoniae as the most common pathogen was associated with higher VAP mortality, and carbapenems as the most used antibiotics were associated with lower VAP mortality.

CONCLUSION

This study highlights the association between the ICU quality control (QC) factors and VAP incidence rate and mortality. The process factors rather than the structural factors need to be further improved for the QC of VAP in the ICU.

Unplanned Extubations in Pediatric Critical Care: A Case–Control Study

The aim of this study was to quantify associations between the risk of unplanned extubation and patient-, environment-, and care-related factors in pediatric critical care and to compare outcomes between children who did and did not experience an unplanned extubation. This is a retrospective case–control analysis including patients <18 years who experienced an unplanned extubation during intensive care unit (ICU) admission (2004–2014). Cases were matched by age, duration of mechanical ventilation, and date to control patients (4:1) who were intubated but did not experience an unplanned extubation. Conditional logistic regression was used to evaluate associations between unplanned extubations and the abstracted characteristics. We identified 1,601 eligible controls matched to 458 case patients. When adjusted for confounders, eight variables were associated with unplanned extubation: three patient-related factors (previous ICU admission, previous intubation, and the volume of secretions); one environment-related factor (patient room setup); and four care-related factors (intubation route, and the use of sedation, muscle relaxation, and restraints). Patients who had an unplanned extubation had longer length of stay, but lower rate of mortality. This is the largest case–control study identifying variables associated with unplanned extubation in pediatric critical care. Several are potentially modifiable and may provide opportunities to improve quality of care in controlled ICU environments.

Clinical Challenges in Pediatric Ventilation Liberation: A Meta-Narrative Review

OBJECTIVES

To map the evidence for ventilation liberation practices in pediatric respiratory failure using the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards.

DATA SOURCES

CINAHL, MEDLINE, COCHRANE, and EMBASE. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register.

STUDY SELECTION

Abstracts were screened followed by review of full text. Articles published in English language incorporating a heterogeneous population of both infants and older children were assessed.

DATA EXTRACTION

None.

DATA SYNTHESIS

Weaning can be considered as the process by which positive pressure is decreased and the patient becomes increasingly responsible for generating the energy necessary for effective gas exchange. With the growing use of noninvasive respiratory support, extubation can lie in the middle of the weaning process if some additional positive pressure is used after extubation, while for some extubation may constitute the end of weaning. Testing for extubation readiness is a key component of the weaning process as it allows the critical care practitioner to assess the capability and endurance of the patient's respiratory system to resume unassisted ventilation. Spontaneous breathing trials (SBTs) are often seen as extubation readiness testing (ERT), but the SBT is used to determine if the patient can maintain adequate spontaneous ventilation with minimal ventilatory support, whereas ERT implies the patient is ready for extubation.

CONCLUSIONS

Current literature suggests using a structured approach that includes a daily assessment of patient's readiness to extubate may reduce total ventilation time. Increasing evidence indicates that such daily assessments needs to include SBTs without added pressure support. Measures of elevated load as well as measures of impaired respiratory muscle capacity are independently associated with extubation failure in children, indicating that these should also be assessed as part of ERT.

Intraoperative Accidental Extubation during Thyroidectomy in a Known Difficult-Airway Patient: An Adult Simulation Case for Anesthesiology Residents

Intraoperative accidental extubation on a known difficult-airway patient requires prompt attention. A good understanding of the steps to re-establish the airway is critical, especially when the patient is known to have a difficult airway documented or discovered on induction or acquires a difficult airway secondary to intraoperative events. The situation becomes even more complicated if the case has been handed off to another anesthesiologist, where specific and detailed information may not have been conveyed. This simulation was designed to train first-year clinical anesthesia residents. It was a 50 min encounter that focused on the management of complete loss of an airway during a thyroidectomy on a known difficult-airway patient. The endotracheal tube dislodgement was simulated by deliberate tube manipulation through the cervical access window of the mannequin. Learners received a formative assessment of their performance during the debrief, and most of the residents met the educational objectives. Learners were asked to complete a survey of their experience, and the feedback was positive and constructive. The response rate was 68% (17/25). Our simulation program helped anesthesiology residents develop intraoperative emergency airway management skills in a safe environment, as well as foster communication skills among anesthesiologists and the surgery team.

Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis

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.

Quality of clinical practice guidelines and recommendations for the management of pain, sedation, delirium and iatrogenic withdrawal in pediatric intensive care: a systematic review protocol

INTRODUCTION

Inadequate management of pain and sedation in critically ill children can cause unnecessary suffering and agitation, but also delirium and iatrogenic withdrawal. It is, therefore, important to address these four interrelated conditions together. Some clinical practice guidelines (CPGs) are available for the management of pain and sedation, and a few for delirium and iatrogenic withdrawal in the paediatric intensive care unit; none address the four conditions altogether. Critical appraisal of the quality of CPGs is necessary for their recommendations to be adopted into clinical practice. The aim of this systematic review is to identify and appraise the quality of CPGs and recommendations for management of either pain, sedation, delirium and iatrogenic withdrawal.

METHODS AND ANALYSIS

Researchers will conduct a systematic review in electronic databases (Medline ALL (Ovid), Embase.com, CINAHL with Full Text (EBSCO), JBI EBP Database (Ovid)), guideline repositories and websites of professional societies to identify CPGs published from 2010 to date. They will then combine index and free terms describing CPGs with pain, sedation, delirium and withdrawal. The researchers will include CPGs if they can be applied in the paediatric intensive care population (newborns to 18 years old) and include recommendation(s) for assessment of at least one of the four conditions. Two independent reviewers will screen for eligibility, complete data extraction and quality assessments using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence instruments. Researchers will report characteristics, content and recommendations from CPGs in tabulated forms.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. Results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021274364.

Caring for patients displaying agitated behaviours in the intensive care unit - A mixed-methods systematic review

BACKGROUND

Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role.

OBJECTIVES

The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU.

METHODS

A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715.

RESULTS

Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues.

CONCLUSIONS

This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.

Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit: The Elusive Benchmark

Unplanned extubation (UE) is a common adverse event in the neonatal intensive care unit (NICU). At our level IV NICU, we initiated a quality improvement project in 2012 to reduce UE rates from 7.47 to below 100 intubated days. We describe the strategies used.

ADVERSE EVENTS RELATED TO MECHANICAL VENTILATION IN A PEDIATRIC INTENSIVE CARE UNIT

OBJECTIVE

To identify the prevalence and factors associated with adverse events (AE) related to invasive mechanical ventilation in patients admitted to the Pediatric Intensive Care Unit (PICU) of a tertiary public hospital.

METHODS

This is a cross-sectional study from July 2016 to June 2018, with data collected throughout patients' routine care in the unit by the care team. Demographic, clinical and ventilatory characteristics and adverse events were analysed. The logistic regression model was used for multivariate analysis regarding the factors associated with AE.

RESULTS

Three hundred and six patients were included, with a total ventilation time of 2,155 days. Adverse events occurred in 66 patients (21.6%), and in 11 of those (16.7%) two AE occurred, totalling 77 events (36 AE per 1000 days of ventilation). The most common AE was post-extubation stridor (25.9%), followed by unplanned extubation (16.9%). Episodes occurred predominantly in the afternoon shift (49.3%) and associated with mild damage (54.6%). Multivariate analysis showed a higher occurrence of AE associated with length of stay of 7 days or more (Odds Ratio [OR]=2.6; 95% confidence interval [95%CI] 1.49-4.66; p=0.001).

CONCLUSIONS

The results of the present study show a significant number of preventable adverse events, especially stridor after extubation and accidental extubation. The higher frequency of these events is associated with longer hospitalization.

Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children

IMPORTANCE

Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events.

OBJECTIVE

To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children's hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study.

INTERVENTIONS

Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses.

MAIN OUTCOMES AND MEASURES

The main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level.

RESULTS

Among the 43 children's hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days.

CONCLUSIONS AND RELEVANCE

This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.

Achieving Sustainability in Reducing Unplanned Extubations in a Pediatric Cardiac ICU

OBJECTIVES

To determine the incidence of unplanned extubations in a pediatric cardiac ICU in order to prove sustainability of our previously implemented quality improvement initiative. Additionally, we sought to identify risk factors associated with unplanned extubations as well as review the overall outcome of this patient population.

DESIGN

Retrospective chart review.

SETTING

Pediatric cardiac ICU at Children's Hospital of Colorado on the Anschutz Medical Center of the University of Colorado.

PATIENTS

Intubated and mechanically ventilated patients in the cardiac ICU from July 2011 to December 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2,612 hospitalizations for 2,067 patients were supported with mechanical ventilation. Forty-five patients had 49 episodes of unplanned extubations (four patients > 1 unplanned extubation). The average unplanned extubation rate per 100 ventilator days was 0.4. Patients who had an unplanned extubation were younger (0.09 vs 5.45 mo; p < 0.001), weighed less (unplanned extubation median weight of 3.0 kg [interquartile range, 2.5-4.5 kg] vs control median weight of 6.0 kg [interquartile range, 3.5-13.9 kg]) (p < 0.001), and had a longer length of mechanical ventilation (8 vs 2 d; p < 0.001). Patients who had an unplanned extubation were more likely to require cardiopulmonary resuscitation during their hospital stay (54% vs 18%; p < 0.001) and had a higher likelihood of in-hospital mortality (15% vs 7%; p = 0.001). There was a significant difference in surgical acuity as denoted by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score and patients with an unplanned extubation had a higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category (p = 0.019). Contributing factors associated with unplanned extubation were poor endotracheal tube tape integrity, inadequate tube securement, and/or inadequate sedation. A low rate of unplanned extubation was maintained even in the setting of increasing patient complexity and an increase in patient volume.

CONCLUSIONS

A low rate of unplanned extubation is sustainable even in the setting of increased patient volume and acuity. Additionally, early identification of patients at higher risk of unplanned extubation may also contribute to decreasing the incidence of unplanned extubation.

Influence of mutual support and a culture of blame among staff in acute care units on the frequency of physical restraint use in patients undergoing mechanical ventilation

Aim

Reducing the use of physical restraint in intensive care units is challenging, and little is known about the influence of culture on physical restraint use in this setting. The present study aims to verify the hypothesis that mutual support and a culture of blame among staff are associated with higher physical restraint use for mechanically ventilated patients.

Methods

We undertook a survey of nurses in intensive care units caring for mechanically ventilated patients in acute care units. The perceived frequency of physical restraint, mutual support, and culture of blame were measured. We predefined a high frequency physical restraint use group and compared the institutional characteristics, human resources, mutual support, and culture of blame between this group and the others (the control).

Results

Three hundred and thirty-three responses were analyzed. The mean number of beds per nurse was not significantly different between the groups; the mean and percentage of positive responses about mutual support and a culture of blame were significantly lower in the high frequency physical restraint use group. After adjusting variables in a multivariable regression analysis, a less positive response about the culture of blame was the only independent factor to predict high frequency physical restraint use.

Conclusion

The study suggests that changing the culture of blame, rather than increasing the number of nurses, is important for reducing physical restraint use.

Reducing Unplanned Extubations Across a Children's Hospital Using Quality Improvement Methods

Supplemental Digital Content is available in the text.

Introduction:

Children who require an endotracheal (ET) tube for care during critical illness are at risk of unplanned extubations (UE), or the unintended dislodgement or removal of an ET tube that can lead to significant patient harm. A proposed national benchmark is 1 UE per 100 ventilator days. We aimed to reduce the rate of UEs in our intensive care units (ICUs) from 1.20 per 100 ventilator days to below the national benchmark within 2 years.

Methods:

We identified several key drivers including ET securement standardization, safety culture, and strategies for high-risk situations. We employed quality improvement methodologies including apparent cause analysis and plan-do-study-act cycles to improve our processes and outcomes.

Results:

Over 2 years, we reduced the rate of UEs hospital-wide by 75% from 1.2 to 0.3 per 100 ventilator days. We eliminated UEs in the pediatric ICU during the study period, while the UE rate in the neonatal ICU also decreased from 1.2 to 0.3 per 100 ventilator days.

Conclusion:

We demonstrated that by using quality improvement methodology, we successfully reduced our rate of UE by 75% to a level well below the proposed national benchmark.

Nurse Decision Making and Attitudes About Circuit Disconnection During Ventilator Therapy at a Swedish Neonatal Intensive Care Unit

BACKGROUND

There are many challenges to providing care to infants in need of ventilator therapy. Yet, few studies describe the practical handling of the ventilator circuit during nursing care.

PURPOSE

To describe neonatal intensive care unit (NICU) nurses' decision making regarding whether or not to disconnect the ventilator circuit when changing the infant's position and to investigate the grounds for their decisions.

METHODS

A descriptive questionnaire study with both quantitative and qualitative elements was conducted. In 2015, a convenience sample of nurses working in an NICU completed a questionnaire including both closed-ended and open-ended, free-text questions. Answers to the closed-ended questions were analyzed with descriptive statistics, whereas answers to the free-text questions were analyzed using qualitative content analysis.

RESULTS

Nurses' decisions on whether to disconnect or keep the ventilator circuit closed were based on the infant's needs for ventilator support. The nurses gave several reasons and motivations both for why they disconnected the circuit and for why they did not. The handling of the circuit and the reasons and motivations given were inconsistent among the nurses.

IMPLICATIONS FOR PRACTICE

This study highlights the need for continuous, repetitive education and training for NICU nurses, as well as demonstrating the importance of clear and distinct guidelines and working methods regarding the care of infants on ventilator support.

IMPLICATIONS FOR RESEARCH

Future research should continue to find ways of working and handling an infant on ventilator support that are least harmful to the infant.

Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes

Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.

Multi-modal Educational Curriculum to Improve Richmond Agitation-sedation Scale Inter-rater Reliability in Pediatric Patients

Introduction:

The Richmond Agitation-sedation Scale (RASS) is a reliable and valid scale for assessing sedation in critically ill pediatric patients. This investigation evaluates the inter-rater reliability of the RASS in mechanically ventilated pediatric patients before and after an educational intervention.

Methods:

This prospective, interventional quality improvement study was completed in a 20-bed pediatric intensive care unit from July 2013 to July 2014. Children 0–18 years of age requiring mechanical ventilation and receiving sedative or analgesic medications were eligible. Staff completed simultaneous paired RASS assessments in 3 phases: baseline, after educational intervention, and maintenance.

Results:

Staff completed 347 paired assessments on 45 pediatric intensive care unit patients: 49 in the baseline phase, 228 in the postintervention phase, and 70 in the maintenance phase. There was a significant increase in the weighted κ after the intervention, from 0.56 (95% CI, 0.39–0.72) to 0.86 (95% CI, 0.77–0.95; P < 0.001). The improvement was maintained months later with weighted κ 0.78 (95% CI, 0.61–0.94). In subgroup analysis, there was an increase in weighted κ in patients less than 1 year of age (0.41–0.87) and those with developmental delay (0.49–0.84).

Conclusions:

The RASS is a reliable tool for sedation assessment in mechanically ventilated, sedated pediatric patients after implementation of an educational intervention. It is also reliable in patients less than 12 months of age and patients with developmental delay. The ability to easily educate providers to utilize a valid, reliable sedation tool is an important step toward using it to provide consistent care to optimize sedation.

Prevention of neonatal unplanned extubations in the neonatal intensive care unit: a best practice implementation project

BACKGROUND

Adverse events of mechanically ventilated neonates such as unplanned extubations may be associated with serious negative outcomes. Unplanned extubation rates have been monitored by many neonatal intensive care units as a quality of care metric.

OBJECTIVES

The objective was to implement evidence-based best practice and assess the effects of these strategies on minimizing unplanned extubation in the neonatal intensive care unit in a large tertiary children's hospital.

METHODS

Evidence-based audit criteria were used to conduct an audit in the neonatal intensive care unit, Children's Hospital of Fudan University, Shanghai. The program included three phases and was conducted from May 2016 to October 2016. The Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in health practice were used to ascertain compliance with the criteria before and after the implementation of best practice.

RESULTS

Compared with the baseline audit, the follow-up audit results demonstrated increased compliance rates for securement procedures, documentation of position and security of the endotracheal tube. Compliance for standardized care practice documentation increased from 0% to 100%; compliance for standard care practice implementation increased from 0% to 54.9%; and compliance for staff education increased from 66.7% to 100%. The neonatal intensive care unit also achieved the benchmark of less than one UE per 100 intubation days.

CONCLUSIONS

This implementation project achieved a significant improvement in establishing evidence-based prevention of unplanned extubations in the neonatal intensive care unit of Children's Hospital of Fudan University, China. Standardizing the procedures represented an important step toward refining the quality improvement process.

As-needed endotracheal suctioning protocol vs a routine endotracheal suctioning in Pediatric Intensive Care Unit: A randomized controlled trial

Objective:

To compare two endotracheal suctioning protocols according to morbidity, days of mechanical ventilation, length of stay in the Pediatric Intensive Care Unit (PICU), incidence of Ventilator-Associated Pneumonia (VAP) and mortality.

Methods:

A Pragmatic randomized controlled trial performed at University Hospital Pablo Tobón Uribe, Medellin-Colombia. Forty-five children underwent an as-needed endotracheal suctioning protocol and forty five underwent a routine endotracheal suctioning protocol. Composite primary end point was the presence of hypoxemia, arrhythmias, accidental extubation and heart arrest. A logistic function trough generalized estimating equations (GEE) were used to calculate the Relative Risk for the main outcome.

Results:

Characteristics of patients were similar between groups. The composite primary end point was found in 22 (47%) of intervention group and 25 (55%) children of control group (RR= 0.84; 95% CI: 0.56-1.25), as well in 35 (5.8%) of 606 endotracheal suctioning performed to intervention group and 48 (7.4%) of 649 performed to control group (OR= 0.80; 95% CI: 0.5-1.3).

Conclusions:

There were no differences between an as-needed and a routine endotracheal suctioning protocol.

Trial registration:

ClinicalTrials.gov identifier NCT01069185

Blood Transfusion Incidence, Risk Factors, and Associated Complications in Surgical Treatment of Hip Dysplasia

BACKGROUND

Perioperative bleeding requiring blood transfusion is a known complication of hip dysplasia (HD) surgery. Here we examine rates of, risk factors for, and postoperative complications associated with transfusion during HD surgery.

METHODS

The National Surgical Quality Improvement Program (NSQIP) Pediatric database was queried for patients treated by an orthopaedist from 2012 to 2013. HD cases were categorized by Current Procedural Terminology codes into femoral osteotomies, acetabular osteotomies, combined femoral/acetabular osteotomies, and open reductions. Patients were grouped by comorbidities: neuromuscular (NM) disease (eg, cerebral palsy) group, non-NM with other comorbidity (Other) group, and no known comorbidity (NL) group. Patients were stratified by weight-normalized transfusion volume. Multivariate regression analysis of transfusion association with procedures, demographics, comorbidities, preoperative laboratory values, and 30-day complications was performed.

RESULTS

A total of 1184 HD cases were included. Transfusion rates for the NL, Other, and NM groups, respectively, were 44/451 (9.8%), 61/216 (28.2%), and 161/517 (31.1%). Transfusion volumes (mean±SD) for the NL, Other, and NM groups, respectively, were 8.4±5.4, 13.9±8.8, and 15.5±10.0 mL/kg (P<0.001). Combined osteotomies had the highest transfusion rates in the NM and Other groups (35.7% and 45.8%, respectively), whereas acetabular osteotomies had the highest rate in the NL group (15.8%). Open reductions had the lowest transfusion rate (all groups). Longer operations were independently associated with transfusion (all groups, per hour increase, OR>1.5, P<0.001). Independent patient risk factors included preoperative hematocrit <31% (NM group, OR=18.42, P=0.013), female sex (NL group, OR=3.55, P=0.008), developmental delay (NM group, OR=2.37, P=0.004), pulmonary comorbidity (NM group, OR=1.73, P=0.032), and older age (NL group, per year increase: OR=1.29, P<0.001). In all groups, transfusion was associated with longer hospitalization (P<0.001). We observed a volume-dependent increase in overall complication rate within the Other group for transfusion volumes >15 mL/kg (25.0% vs. 5.4% for <15 mL/kg, P=0.048).

CONCLUSIONS

We identified several risk factors for transfusion in HD surgery. The incidence of transfusion in HD surgery and its association with adverse outcomes warrants development of appropriate patient management guidelines.

LEVEL OF EVIDENCE

Level III-prognostic.

Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK)

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience

PURPOSE

Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation.

MATERIALS AND METHODS

Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days.

RESULTS

The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses.

CONCLUSION

Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.

An Interprofessional Quality Improvement Initiative to Standardize Pediatric Extubation Readiness Assessment

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.

Factors Associated With Unplanned Extubation in Children: A Case–Control Study

Purpose:

Although several studies assess unplanned extubation (UE) in children, few have addressed determinants of UE and factors associated with reintubation in a case-controlled manner. We aimed to identify the risk factors and outcomes associated with UE in a pediatric intensive care unit.

Methods:

Cases of UE were randomly matched with control patients at a ratio of 1:4 for age, severity of illness, and admission diagnosis. For cases and controls, we also collected data associated with UE events, reintubation, and outcomes.

Results:

We analyzed 94 UE patients (0.75 UE per 100 intubation days) and found no differences in demographics between the 2 groups. Logistic regression revealed that patient agitation (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.28-4.65), continuous sedation infusion (OR: 3.27; 95% CI: 1.70-6.29), night shifts (OR: 9.16; 95% CI: 4.25-19.72), in-charge nurse experience <2 years (OR: 2.38; 95% CI: 1.13-4.99), and oxygenation index (OI) >5 (OR: 76.9; 95% CI: 16.79-352.47) were associated with UE. Risk factors for reintubation after UE included prior level of sedation (COMFORT score < 27; OR: 7.93; 95% CI: 2.30-27.29), copious secretion (OR: 11.88; 95% CI: 2.20-64.05), and OI > 5 (OR: 9.32; 95% CI: 2.45-35.48).

Conclusions:

This case–control study showed that both patient- and nurse-associated risk factors were related to UE. Risk factors associated with reintubation included lower levels of consciousness, copious secretions, and higher OI. Further evidence-based studies, including a larger sample size, are warranted to identify predisposing factors in UEs.

Revisiting unplanned extubation in the pediatric intensive care unit: What's new?

In 2010, recommendations for preventing unplanned extubations (UEs) in pediatric patients were published based on a literature review. Since then, there have been an increasing number of publications related to UE focusing on children. If the introduction of care bundles and larger body of evidence on UE had impact on UE occurrence, this would have important implications on clinical practice. We searched for relevant publications published between Jan 1, 2010 and Jun 30, 2016 in the MEDLINE, EMBASE, and Cochrane systems. Eight articles were eligible for data abstraction. Three studies were of high methodological quality. The mean contemporaneous incidence of UEs was 1.19 UEs/100 intubation days. The primary risk factors were as follows: caregiver bedside procedures/manipulation, agitation, and endotracheal tube care. The ideal incidence of UEs remains unknown. Key areas identified in the current review may be amenable to changes in unit processes by implementing a care bundle strategy.

Open-label randomised controlled trial about application of bundle care in prevention of unplanned extubation of nasobiliary drainage catheter after endoscopic retrograde cholangiopancreatography

AIMS AND OBJECTIVES

To observe the effects of bundle care on preventing unplanned extubation of nasobiliary drainage catheter after endoscopic retrograde cholangiopancreatography.

BACKGROUND

Preventing unplanned extubation has become a difficult problem for nursing staff because the catheter is stiff, fine and long.

DESIGN

A total of 114 cases that experienced nasobiliary drainage after endoscopic retrograde cholangiopancreatography for the first time in our hospital from April 2015-July 2016 were enrolled in this study. According to receiving routine nurse or bundle nurse, these cases were randomly divided into control (n = 56) and intervention (n = 58) group.

METHOD

The unplanned extubation incidence, contact area between tape and catheter and tensile resistance were compared between the two groups.

RESULTS

The contact area was one square centimetre in the control group and 5 cm² in the intervention group. Tensile resistance was significantly higher in the intervention group than in the control (all p < .05). Unplanned extubation incidence was significantly lower in the intervention group (1.72%, 1/58) than in the control (12.5%, 7/56) (p = .0305).

CONCLUSION

Bundle care can effectively decrease unplanned extubation incidence after endoscopic retrograde cholangiopancreatography.

RELEVANCE TO CLINICAL PRACTICE

This study provides a basis for decreasing unplanned extubation incidence.

Development and implementation of an early mobility program for mechanically ventilated pediatric patients

PURPOSE

Early mobility (EM) is being used in adult ICUs in an effort to treat and prevent intensive care unit acquired weakness (ICU-AW) and Post-Intensive Care Syndrome (PICS). Data supports children suffer from ICU-AW and PICS as well. Our objective was to create and implement an EM protocol for pediatric patients receiving invasive mechanical ventilation.

METHODS

A multidisciplinary EM committee was formed to create and implement an EM protocol in a quarternary care PICU. A quality database was used to prospectively monitor patient tolerance of EM sessions and for serious adverse events, defined as unplanned extubation, hemodynamic instability, loss of central venous line, loss of arterial line, displacement of ECMO cannula, or cardiopulmonary arrest.

RESULTS

Between December 2013 and October 2016, 74 patients received EM for a total of 130 unique sessions. No serious adverse events occurred. Two patients had an oxygen desaturation episode during mobility that resolved with ventilator modifications, and one patient had nasogastric tube displacement during mobility.

CONCLUSIONS

Early mobility is attainable in a quaternary care PICU population without serious adverse events, using a multidisciplinary approach and appropriate staff education. Further research is needed to understand the physical and neurocognitive benefits of EM in children.

Capnography Use During Intubation and Cardiopulmonary Resuscitation in the Pediatric Emergency Department

OBJECTIVE

Capnography is indicated as a guide to assess and monitor both endotracheal intubation and cardiopulmonary resuscitation (CPR). Our primary objective was to determine the effect of the 2010 American Heart Association (AHA) guidelines on the frequency of capnography use during critical events in children in the emergency department (ED). Our secondary objective was to examine associations between patient characteristics and capnography use among these patients.

METHODS

A retrospective chart review was performed on children aged 0 to 21 years who were intubated or received CPR in 2 academic children's hospital EDs between January 2009 and December 2012. Age, sex, time of arrival, medical or traumatic cause, length of CPR, return of spontaneous circulation (ROSC), documented use of capnography and colorimetry, capnography values, and adverse events were recorded.

RESULTS

Two hundred ninety-two patients were identified and analyzed. Intubation occurred in 95% of cases and CPR in 30% of cases. Capnography was documented in only 38% of intubated patients and 13% of patients requiring CPR. There was an overall decrease in capnography use after publication of the 2010 AHA recommendations (P = 0.05). Capnography use was associated with a longer duration of CPR and return of spontaneous circulation.

CONCLUSIONS

Despite the 2010 AHA recommendations, a minority of critically ill children are being monitored with capnography and an unexpected decrease in documented use occurred among our sample. Further education and implementation of capnography should take place to improve the use of this monitoring device for critically ill pediatric patients in the ED.

An Airway Risk Assessment Score for Unplanned Extubation in Intensive Care Pediatric Patients

OBJECTIVE

As a result of a workshop to identify common causes of unplanned extubation, Children's Healthcare of Atlanta developed a scoring tool (Risk Assessment Score) to stratify patients into groups of low, moderate, high, and extreme risk. This tool could be used to institute appropriate monitoring or interventions for patients with high risks of unplanned extubation to enhance safety. The objective of this study is to test the hypothesis that the Risk Assessment Score will correlate with the occurrence rate of unplanned extubation in pediatric patients.

DESIGN

Retrospective review of 2,811 patients at five ICUs conducted between December 2012 and July 2014.

SETTING

Five ICUs at two freestanding pediatric hospitals within a large children's healthcare system in the United States.

PATIENTS

All intubated pediatric patients.

INTERVENTIONS

Data of intubations and Risk Assessment Score were collected. Extubation outcomes and severity levels were compared across demographic groups and with the maximum Risk Assessment Score of each intubation.

MEASUREMENTS AND MAIN RESULTS

Out of 4,566 intubations, 244 were unplanned extubations (5.3%). The occurrence rates of unplanned extubations in those less than 1, 1-6, and more than 6 years old were 6.7%, 3.6%, and 2.7%, respectively, corresponding to a rate of 0.59, 0.53, and 0.58 unplanned extubation every 100 ventilator days. The occurrence rates were 13.6% for patients weighing less than 1 kg (0.59 unplanned extubation per 100 ventilation days) and 3.8% for patients weighing greater than or equal to 1 kg (0.58 unplanned extubation per 100 ventilation days). For intubations with maximum risk score falling in risk categories of low, moderate, high, and extreme, the occurrence rates were 4.7%, 7.7%, 12.0%, and 8.3%, respectively, which corresponded to rates of 0.54, 0.62, 0.95, and 0.92 unplanned extubation per 100 ventilator days.

CONCLUSIONS

Higher Risk Assessment Scores are associated with occurrence rates of unplanned extubation.

Set of Quality Indicators of Pediatric Intensive Care in Spain: Delphi Method Selection

INTRODUCTION

This study objective was to identify, select, and define a basic set of quality indicators for pediatric intensive care in Spain.

METHODS

(1) Review of the literature to identify quality indicators and their defining elements and (2) selection of indicators by consensus of a group of experts using basic Delphi methodology (2 rounds) and forms distributed by email among experts from the Spanish society of pediatric intensive care.

RESULTS

We selected quality indicators according to their relevance and feasibility and the experts' agreement on their incorporation in the final set. We included only those indicators whose assessment was within the highest tertile and greater than or equal to 70% evaluator agreement in the final selection. Starting from an initially proposed set of 136 indicators, 31 experts first selected 43 indicators for inclusion in the second round. Twenty indicators were selected for the final set. This "top 20" set comprised 9 process indicators, 9 of results (especially treatment-associated adverse effects), and 2 indicators of structure. Several of them are classical indicators in intensive care medicine (rates of hospital-acquired infections, pressure ulcers, etc.), whereas others are specifically pediatric (eg, unrestricted parent visitation or training the parents of technology-dependent children).

CONCLUSIONS

We reached a consensus on a set of 20 essential quality indicators for pediatric intensive care in Spain. A significant subset reflects the peculiarities of pediatric care. We consider this subset as a starting point for future projects of network collaboration between pediatric intensive care units in Spain.

Predicting Reintubation After Unplanned Extubations in Children: Art or Science?

PURPOSE

Reintubation following unplanned extubation (UE) is often required and associated with increased morbidity; however, knowledge of risk factors leading to reintubation and subsequent outcomes in children is still lacking. We sought to determine the incidence, risk factors, and outcomes related to reintubation after UEs.

METHODS

All mechanically ventilated children were prospectively tracked for UEs over a 7-year period in a pediatric intensive care unit. For each UE event, data associated with reintubation within 24 hours and outcomes were collected.

RESULTS

Of 757 intubated patients, 87 UE occurred out of 11 335 intubation days (0.76 UE/100 intubation days), with 57 (65%) requiring reintubation. Most of the UEs that did not require reintubation were already weaning ventilator settings prior to UE (73%). Univariate analysis showed that younger children (<1 year) required reintubation more frequently after an UE. Patients experiencing UE during weaning experienced significantly fewer reintubations, whereas 90% of patients with full mechanical ventilation support required reintubation. Logistic regression revealed that requirement of full ventilator support (odds ratio: 37.5) and a COMFORT score <26 (odds ratio: 5.5) were associated with UE failure. There were no differences between reintubated and nonreintubated patients regarding the length of hospital stay, ventilator-associated pneumonia rate, need for tracheostomy, and mortality. Cardiovascular and respiratory complications were seen in 33% of the reintubations.

CONCLUSION

The rate of reintubation is high in children experiencing UE. Requirement of full ventilator support and a COMFORT score <26 are associated with reintubation. Prospective research is required to better understand the reintubation decisions and needs.

Prevention of unplanned extubations in neonates through process standardization

OBJECTIVE

Unplanned extubation events (UPEs) in neonates are hazardous to patient safety. Our goal was to reduce UPE rate (#UPEs per 100 ventilator days) by 50% in 12 months at our 25-bed level III inborn unit.

STUDY DESIGN

Baseline data were gathered prospectively for 7 months. Three Plan-Do-Study-Act (PDSA) cycles targeting main causes of UPEs were developed over the next 20 months. Causes of UPEs were analyzed using Pareto charts; and a U control chart was created with QI Charts(©). Standard rules for detecting special cause variation were applied.

RESULT

Mean UPE rate decreased from 16.1 to 4.5 per 100 ventilator days, a 72% decrease, exceeding our goal. Analysis of U-chart demonstrated special cause variation, with eight consecutive points below the mean. Improvement was sustained throughout the study period.

CONCLUSION

UPEs in neonates can be reduced with process standardization and frontline staff education, emphasizing vigilant endotracheal tube (ETT) maintenance.

Assessing nursing quality in paediatric intensive care units: a cross-sectional study in China

BACKGROUND

Nursing-sensitive indicators are considered effective tools for improving the quality of care in hospitals. However, these have not been used in paediatric intensive care units (PICUs) in China.

AIM

To develop nursing-sensitive indicators for PICUs and to assess the quality of nursing in PICUs in China based on the nursing-sensitive indicators.

DESIGN

Multi-centre, cross-sectional study.

METHODS

Structure, process and outcome indicators were developed and measured from 1 January to 31 March 2014 in seven PICUs in China.

RESULTS

The structure indicators showed that one nurse cared for an average of 2·8 patients in a PICU, and 44% of nurses had a bachelor's degree. The process indicators revealed that hand-washing compliance varied across PICUs, whereas pain management and physical restraint have not been adequately addressed in China. The outcome indicators revealed that the incidence rates of ventilator-associated pneumonia and central-line-associated blood stream infections were 2·96 and 0·7, respectively, per 1000 device days. Patients were intubated for a total of 4392 mechanical ventilator days, and 32 patients (7·29‰) had an unplanned extubation. Nurses were moderately satisfied in their jobs (3·1 ± 0·3), and parents reported that nurses provide high quality of care.

CONCLUSIONS

This study developed and used nursing-sensitive indicators to assess the quality of nursing in PICUs in China, which provided a reference for national and international comparisons of nursing quality in PICUs. Nursing staffing levels and education should be improved. Pain management and physical restraints should be regulated in China's PICUs. Nurse managers need to explore staff attitudes towards implementation of family-centred care. The development of a national database of nursing quality indicators can contribute to quality and safety improvement.

RELEVANCE TO CLINICAL PRACTICE

This study developed a set of nursing-sensitive indicators, and these indicators were used to assess and improve the quality of nursing in PICUs.

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format to assist acute care hospitals in implementing and prioritizing strategies to prevent ventilator-associated pneumonia (VAP) and other ventilator-associated events (VAEs) and to improve outcomes for mechanically ventilated adults, children, and neonates. This document updates "Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Endotracheal tube displacement during head and neck movements. Observational clinical trial

STUDY OBJECTIVE

Measure the displacements of endotracheal tube (ETT) tip displacement during head and neck movements.

DESIGN

Observational study.

SETTING

Ear-nose-throat (ENT) and neurosurgery operating room.

PATIENTS

We performed a maximal head-neck movement trial on 50 adult patients, American Society of Anaesthesiologists 1 or 2. Patients with body mass index >35 kg · m(-2), height <150 cm, airway malformations, pulmonary diseases, difficulties in neck flexion or extension, previous ENT surgery or radiotherapy, gastroesophageal reflux, or dental instability were excluded from the study.

INTERVENTIONS

ENT and neurosurgery.

MEASUREMENTS

We measured the change in distance between the ETT tip and the carina, using a fiberscope through the ETT.

RESULTS

After intubation, a wide disparity of tube tip distance to the carina in the neutral position was noted with a median of 5.0 (3.5-7.0) cm. Cephalad tube movement was documented following maximal head and neck extension in 34 (68%) patients and right head rotation in 25 patients (50%). Caudal tube displacement was due to maximal head and neck flexion in 38 patients (76%) and left head rotation in 25 patients (50%). Selective right main bronchus intubation was noted in 2 (4%) patients after maximal head extension.

CONCLUSION

Maximal head and neck movements led to unpredictable tube displacements. Proper reassessment of tube positioning after head and neck movement of intubated patients is therefore mandatory.

Multicenter Analysis of the Factors Associated With Unplanned Extubation in the PICU

OBJECTIVE

To identify factors associated with unplanned extubation in PICUs.

DESIGN

A prospective, case-controlled multicenter study.

SETTING

Eleven Pediatric Intensive Care Units collaborating through the National Association of Children's Hospitals and Related Institutions PICU focus group.

PATIENTS

Patients with unplanned extubation events and control patients without unplanned extubation.

INTERVENTIONS

Unplanned extubation events were prospectively tracked for 1 year at 11 centers. When an unplanned extubation occurred, up to four controls were randomly identified of other intubated patients in the unit. For each event and control, data associated with unplanned extubation events, reintubation, and outcomes were collected.

MEASUREMENTS AND MAIN RESULTS

One hundred eighty-nine unplanned extubation events occurred out of 25,500 endotracheal tube days in the study (0.74 unplanned extubations/100 endotracheal days; 95% CI, 0.64-0.85), with 654 associated controls. Unplanned extubation rates ranged by site from 0.3 to 2.1 unplanned extubations/100 endotracheal days. Children less than 6 years had an increased rate of unplanned extubation (0.83 for < 6 yr vs 0.45 for ≥ 6 yr; p = 0.001). After multivariate analysis, inadequate patient sedation (odds ratio, 9.1; 95% CI, 4.5-18.5), loose or slimy endotracheal tube (odds ratio, 10.4; 95% CI, 5.0-22.2), a planned extubation in the next 12 hours (odds ratio, 2.3; 95% CI, 1.3-4.1), and a nurse pulled from another unit (odds ratio, 3.8; 95% CI, 1.4-9.9) were associated with unplanned extubation. Sixty percent of unplanned extubations required reintubation.

CONCLUSIONS

The rate of unplanned extubation is higher in patients aged less than 6 years. Patient factors, such as decreased level of sedation, loose or slimy endotracheal tube, and staffing factors such as floating nurse from another unit, contribute to unplanned extubation in children.