1
|
Jayawardena ADL, Ghersin ZJ, Guzman LJ, Bonilla JA, Abrego S, Aguilar A, Ramos D, Zablah E, Callans K, Macduff M, Cayer M, Gallagher TQ, Vangel MG, Peikin MH, Yager PH, Hartnick CJ. A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units. Int J Pediatr Otorhinolaryngol 2021; 149:110857. [PMID: 34343831 DOI: 10.1016/j.ijporl.2021.110857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU. METHODS This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was $1.32 per child. PICU mortality was evaluated as an exploratory outcome. RESULTS Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28-0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17-0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24-0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is $30.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44. CONCLUSION This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.
Collapse
Affiliation(s)
- Asitha D L Jayawardena
- Children's Minnesota, Department of Otolaryngology, Minneapolis, MN, USA; Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA
| | - Zelda J Ghersin
- Massachusetts General Hospital, Pediatric Intensive Care Unit, Boston, MA, USA
| | - Luis Jose Guzman
- Benjamin Bloom Hospital, Pediatric Intensive Care, San Salvador, El Salvador
| | - Jose A Bonilla
- Benjamin Bloom Hospital, Department of Otolaryngology San Salvador, El Salvador
| | - Susana Abrego
- Benjamin Bloom Hospital, Pediatric Anesthesia, San Salvador, El Salvador
| | - Alejandra Aguilar
- Benjamin Bloom Hospital, Respiratory Therapy, San Salvador, El Salvador
| | - Daniel Ramos
- Benjamin Bloom Hospital, Department of Otolaryngology San Salvador, El Salvador
| | - Evelyn Zablah
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; The Benjamin Harry Peikin Foundation, Boston, MA, USA
| | - Kevin Callans
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; Massachusetts General Hospital for Children, Boston, MA, USA
| | - Megan Macduff
- Massachusetts General Hospital, Department of Respiratory Care Services, Boston, MA, USA
| | - Makara Cayer
- Massachusetts Eye and Ear Infirmary, Department of Anesthesia, Boston, MA, USA
| | - Thomas Q Gallagher
- Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Department of Otolaryngology-Head and Neck Surgery, Pediatric Otolaryngology, 601 Children's Lane, 2nd Floor, Norfolk, VA, 23507, USA
| | - Mark G Vangel
- Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Mark H Peikin
- The Benjamin Harry Peikin Foundation, Boston, MA, USA
| | - Phoebe H Yager
- Massachusetts General Hospital, Pediatric Intensive Care Unit, Boston, MA, USA
| | | |
Collapse
|