Nurse-Led Care Bundle for Reducing Unplanned Extubations: Single-Center PICU Experience in India, 2022-2023

Area of Science:

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

Background:

• Unplanned extubation (UPE) is a significant risk in pediatric intensive care units (PICUs), particularly in resource-limited settings.
• Implementing effective strategies to reduce UPE rates is crucial for improving patient outcomes and reducing healthcare costs.

Purpose of the Study:

• To evaluate the effectiveness of a structured, context-specific care bundle in reducing UPE rates of endotracheal tubes (ETTs) in a resource-limited Indian PICU.
• To assess the feasibility and sustainability of a quality improvement (QI) initiative using the Plan-Do-Study-Act (PDSA) methodology.

Main Methods:

• A prospective QI study was conducted in a 15-bed multidisciplinary PICU in India.
• A structured care bundle, including standardized ETT fixation, sedation scoring, high-risk procedure protocols, and staff training, was implemented over four PDSA cycles.
• Data from 421 intubated children (1 month to 12 years) were analyzed using pre- and post-intervention comparisons.

Main Results:

• UPE rates decreased from 1.9 to 1.3 per 100 ventilator days post-intervention.
• Compliance with care bundle components significantly improved, with sedation scoring rising from 65% to 98%.
• No UPEs were recorded in the final PDSA cycle, and rates remained below 0.6 during the 2-month sustainment phase.

Conclusions:

• A low-cost, structured care bundle effectively reduced UPE rates and enhanced safety practices in a high-burden PICU.
• The QI-driven intervention proved feasible and sustainable in a resource-constrained environment.
• Findings support the broader adoption of similar airway safety strategies in low- and middle-income countries.