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

To evaluate the quality improvement (QI) of a structured, context-specific care bundle for reducing unplanned extubation (UPE) rates of endotracheal tubes (ETTs) in a resource-limited PICU in India using the Plan-Do-Study-Act (PDSA) QI methodology.

Prospective, QI study using pre- and post-intervention comparison.

Fifteen-bed multidisciplinary PICU at the Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

All intubated children 1 month to 12 years old admitted to the PICU during the 14-month study period (2022-2023). Children with tracheostomies, planned extubations, or tube changes for obstruction were excluded.

Structured care bundle targeting root causes of UPE implemented in four PDSA cycles over 4 months, followed by a 2-month sustainment phase. Bundle components included standardized ETT fixation (YY method), Comfort-B sedation scoring, high-risk procedure protocols, real-time UPE documentation, and structured staff training.

The primary outcome was the rate of UPEs per 100 intubated patient-days. Process measures included staff training coverage, compliance with ETT fixation, sedation documentation, and event reporting. Over 14 months, data from 421 intubated patients (3556 ventilator days) were analyzed. UPE rates declined from 1.9 to 1.3 per 100 ventilator days post-intervention. Process compliance improved substantially (e.g., sedation scoring rose from 65% to 98%). No UPEs occurred in the final PDSA cycle, and rates remained less than 0.6 during the sustainment phase. The care bundle was implemented with minimal cost and without additional staff or technology.

Over 2022-2023, our low-cost, structured care bundle reduced UPE rates and improved safety practices in a high-burden PICU. The findings demonstrate the feasibility and sustainability of QI-driven airway safety interventions in resource-constrained settings and support broader adoption of such strategies across low- and middle-income countries.