Improving Cuff Leak Test Documentation: A Single Center Quality Improvement Project

The cuff leak test is commonly performed before extubation in critically ill children to estimate the risk of postextubation upper-airway obstruction (UAO). Therefore, documentation of cuff leak test results is important for clinical decision-making. We noted delays in extubation related to the absence of clearly documented cuff leak test results and sought to address this through electronic medical record (EMR) enhancement.

We conducted a single-center quality improvement project with multiple Plan-Do-Study-Act cycles to improve cuff leak test documentation. Interventions included test standardization and the addition of a dedicated EMR flowsheet row for documentation. Outcomes were compared before and after flowsheet row implementation using run charts. The primary outcome was cuff leak test documentation, with UAO requiring treatment and postextubation dexamethasone as balancing measures.

Following flowsheet row implementation, overall cuff leak documentation increased from 78% to 91% (P < .001), respiratory therapist (RT) documentation increased from 60% to 86% (P < .001), and inclusion in a progress or extubation note increased from 47% to 83% (P < .001). More subjects had a documented cuff leak before extubation (74% vs 63%, P < .001), and fewer received dexamethasone before extubation (28% vs 34%, P = .03). Run charts demonstrated a statistically significant shift in overall documentation from 78% to 92% following flowsheet row implementation, RT documentation increased from 61% to 91% before declining to 83%, while provider documentation increased from 45% to 79%, followed by a second shift to 89%. No changes were observed in UAO requiring treatment or dexamethasone administration.

Addition of a dedicated EMR flowsheet row significantly improved overall cuff leak documentation, RT documentation, and provider documentation. It was also associated with reduced pre-extubation dexamethasone exposure with no change in UAO requiring treatment.