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Challenges With Implementation of a Respiratory Therapist-Driven Protocol of Spontaneous Breathing Trials in the
Conrad Krawiec1, Dale Carl2, Christy Stetter3
1Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA. ckrawiec@hmc.psu.edu.
Insights
A respiratory therapist-led protocol for spontaneous breathing trials (SBTs) was implemented in a pediatric ICU. The protocol did not significantly change the timing of SBT initiation but increased post-extubation noninvasive support.
Area of Science:
- Pediatric critical care medicine
- Respiratory therapy
- Quality improvement initiatives
Background:
- Timely ventilator liberation is essential in pediatric intensive care units (PICUs).
- Physician-driven weaning decisions can cause delays in initiating spontaneous breathing trials (SBTs).
- Respiratory therapist (RT)-led protocols aim to streamline SBT readiness screening.
Purpose of the Study:
- To develop and implement an RT-led protocol for screening spontaneous breathing trial (SBT) readiness in a pediatric ICU.
- To assess the feasibility of the RT-driven protocol.
- To evaluate the protocol's impact on the timing of SBT initiation.
Main Methods:
- Retrospective chart review of intubated patients over 18 months pre- and post-protocol implementation.
- Development and implementation of an RT-driven protocol for consistent SBT readiness screening.
- Comparison of the time to the first SBT between physician-directed and RT-driven approaches.
Main Results:
- No significant difference in the median time to the first SBT between the pre-intervention and intervention groups (42.6 vs. 39.5 hours).
- Increased odds of noninvasive respiratory support post-extubation in the RT-driven group (1-hour OR 2.29, 12-hour OR 2.53).
- RT adherence to patient screening was 56.4%, with no significant increase in re-intubation rates.
Conclusions:
- An RT-driven protocol was successfully introduced in an academic pediatric ICU.
- The protocol did not significantly impact the timing of SBT initiation.
- Sustained adherence challenges may limit the effectiveness of RT-driven protocols, warranting further investigation.
Background:
Timely ventilator liberation is crucial in the pediatric ICU. In many pediatric ICUs, the decision to initiate weaning is driven by the physician, which may lead to delays in ventilator liberation. The objectives of this quality improvement project were to develop and implement a respiratory therapist (RT)-led protocol for screening for spontaneous breathing trial (SBT) readiness, to test protocol feasibility, and to evaluate its impact on SBT timing.
Methods:
A retrospective chart review was performed on all intubated patients in the pediatric ICU for 18 months prior to protocol institution. An RT-driven protocol was developed and implemented, enabling consistent screening for SBT readiness. When criteria were met, an SBT was initiated after order placement. The difference in the timing of the first SBT between physician-directed screening and the RT-driven protocol was evaluated.
Results:
A total of 219 subjects were included in this project (128 pre-intervention; 91 intervention). Baseline demographic data, including mortality risk and endotracheal tube size, were similar in both groups. The time of the first SBT (median [25th, 75th percentile]) was not significantly different between the intervention and preintervention groups (39.5 [25.3, 85.2] vs 42.6 [26.4, 81.3], respectively). There was no difference in mechanical ventilation duration, or length of hospital and ICU stay. The odds of being placed on noninvasive respiratory support were higher in the intervention group at 1 h (odds ratio [95% CI]: 2.29 [1.10, 4.78], P = .03) and 12 h (odds ratio 2.53 [1.23, 5.20], P = .01) postextubation, but the odds of re-intubation did not reach statistical significance (odds ratio 2.60 [0.73, 9.27], P = .14). RT adherence with patient screening was 56.4%.
Conclusions:
An RT-driven protocol was successfully introduced in an academic pediatric ICU. However, it did not impact time of SBT initiation, potentially due to the difficulty in maintaining adherence over time. RT-driven protocols require further study.
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