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Updated: Jan 31, 2026
A Structured Approach to Extubation in Mechanically Ventilated Rats
Published on: July 18, 2025
Variation in Implementation and Outcomes of Early Extubation Practices After Infant Cardiac Surgery
Katherine E Bates1, William T Mahle2, Lauren Bush1
1Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
Insights
The Pediatric Heart Network Collaborative Learning Study successfully reduced early extubation times for infants after heart surgery. Implementation strategies varied, impacting the magnitude of improvement in extubation and length of stay outcomes.
Area of Science:
- Pediatric cardiac surgery outcomes
- Clinical practice guideline implementation
- Healthcare quality improvement
Background:
- The Pediatric Heart Network Collaborative Learning Study (PHN CLS) aimed to improve early extubation rates post-infant heart repair.
- A clinical practice guideline (CPG) was implemented across participating sites to standardize care.
- Variability in CPG implementation and its impact on patient outcomes were evaluated.
Purpose of the Study:
- To assess the variability in clinical practice guideline (CPG) implementation across different sites.
- To evaluate the impact of CPG implementation on patient outcomes, specifically time to extubation and length of stay.
- To identify factors contributing to the variation in outcomes among sites.
Main Methods:
- Compared patient characteristics and outcomes (time to extubation, length of stay) across sites.
- Analyzed pre-CPB to post-CPG changes in outcomes.
- Utilized semistructured interviews to understand implementation strategies and variations.
Main Results:
- All sites significantly reduced median time to extubation post-CPG implementation.
- Variability existed in post-CPG median extubation times (0.3 to 5.3 hours) and magnitude of change (-73.3% to -99.2%).
- Site A demonstrated the shortest post-CPG extubation time and greatest improvement; some sites saw reduced ICU LOS for TOF patients.
Conclusions:
- All participating sites successfully reduced time to extubation for infants undergoing tetralogy of Fallot and coarctation repair.
- Differences in CPG implementation strategies likely contributed to the observed variations in outcome improvements.
- Findings offer guidance for disseminating CPGs and designing future quality improvement initiatives in pediatric cardiac surgery.
Background:
The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation after infant tetralogy of Fallot (TOF) and coarctation repair overall at participating sites through implementing a clinical practice guideline (CPG). We evaluated variability across sites in CPG implementation and outcomes.
Methods:
Patient characteristics and outcomes (time to extubation, length of stay [LOS]) were compared across sites, including pre-CPB to post-CPG changes. Semistructured interviews were analyzed to assess similarities and differences in implementation strategies across sites.
Results:
A total of 322 patients were included (4 active sites, 1 model site). Patient characteristics were similar across active sites, whereas pre-CPG median time to extubation varied from 15.4 to 35.5 hours. All active sites had a significant post-CPG decline (p < 0.001); however, there was variation in the post-CPG median time to extubation (0.3 to 5.3 hours, p = 0.01) and magnitude of change (-73.3% to -99.2%). Site A achieved the shortest post-CPG time to extubation and had the greatest percentage change. Two sites had significant decreases in medical ICU LOS in TOF patients; no hospital LOS changes were seen. All sites valued the collaborative learning strategy, site visits, CPG flexibility, and had similar core team composition. Site A used several unique strategies: inclusion of other staff and fellows, regular in-person data reviews, additional data collection, and creation of complementary protocols.
Conclusions:
All PHN CLS sites successfully reduced time to extubation. The magnitude of change varied and may be partly explained by different CPG implementation strategies. These data can guide CPG dissemination and design of future improvement projects.
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