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Guidelines for Elective Pediatric Fiberoptic Intubation
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Reducing Pediatric Unplanned Extubation Across Multiple ICUs Using Quality Improvement.

Kristin Melton1, Caitlin Ryan2, Angela Saunders3

  • 1Department of Pediatrics, Division of Neonatology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio.

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|May 1, 2022
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Summary
This summary is machine-generated.

Unplanned extubation (UE) in pediatric intensive care units (ICUs) was significantly reduced by 84% through a hospital-wide quality improvement initiative. This led to decreased harm and resource utilization for pediatric patients requiring mechanical ventilation.

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Area of Science:

  • Pediatric Critical Care Medicine
  • Quality Improvement Science
  • Patient Safety

Background:

  • Unplanned extubation (UE) in pediatric patients poses significant risks, including mortality and severe harm.
  • Previous efforts to reduce UE within our institution were fragmented, hindering knowledge sharing and consistent improvement.
  • A need existed for a unified approach to mitigate harm from UE across pediatric intensive care settings.

Purpose of the Study:

  • To implement and evaluate shared quality improvement initiatives across pediatric, neonatal, and cardiac ICUs to reduce unplanned extubations.
  • To decrease serious harm and mortality associated with unplanned extubations in critically ill children.
  • To establish a sustainable, institution-wide strategy for minimizing unplanned extubations.

Main Methods:

  • A prospective, single-center quality improvement initiative was conducted using the Model for Improvement and Plan-Do-Study-Act cycles.
  • A multidisciplinary team implemented a bundle of interventions aimed at reducing UE rates across multiple pediatric ICUs.
  • The primary outcome measure was the monthly UE rate per 100 ventilator days, monitored using statistical process control charts.

Main Results:

  • The institutional monthly UE rate decreased by 84%, from 1.22 to 0.2 UE per 100 ventilator days.
  • These improvements were observed across all participating ICUs, indicating successful implementation of shared initiatives.
  • A significant proportion of UEs led to adverse events, including difficult airways (16-21%) and cardiovascular collapse requiring resuscitation (10-22%).

Conclusions:

  • Implementing a bundled approach to reduce unplanned extubations across pediatric ICUs significantly lowered UE rates and associated harm.
  • Allowing for unit-specific variations in intervention implementation, while aiming for a common goal, fostered success and sustainability.
  • This quality improvement initiative demonstrates the effectiveness of collaborative, multi-ICU strategies in enhancing patient safety for critically ill children.