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Quality & Patient Safety

Research Snapshot Theater: Quality and Patient Safety, Pediatric III

(1339) Standardizing Extubation Readiness Assessment to Reduce Failure in the PICU: QI initiative

Tuesday, February 25, 2025
10:00am – 11:00am Eastern Time
Location: Connections Central - RST 13

    First Author(s)

  • Matthew G. Smith, MD

    MD
    University of Arkansas for Medical Sciences Arkansas Childrens Hospital
    Little Rock, Arkansas, United States

    • Co-Author(s)

  • SA

    Salim Aljabari, MD

    Assistant Professor, Pediatric Critical Care Medicine
    University of Arkansas for Medical Sciences
    Little Rock, Arkansas, United States

  • OI

    Olivia Irby, MD

    Associate Professor of Pediatrics, PCCM Fellowship Program Director
    University of Arkansas for Medical Sciences, United States

  • EB

    Esma Birisci, N/A

    N/A
    n/a, United States

Introduction: Invasive mechanical ventilation (IMV) is a vital intervention for managing respiratory failure in pediatric patients, enhancing oxygenation and ventilation. However, prolonged IMV risks complications like ventilator-associated lung injury (VALI) and pneumonia. Conversely, premature extubation can increase morbidity and mortality. Spontaneous breathing trials (SBTs) have been effective in assessing extubation readiness, yet a standardized approach for pediatric patients has been lacking until recent guidelines from the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) group in 2022. This project aimed to develop and implement a standardized SBT protocol to improve extubation outcomes in our pediatric intensive care unit (PICU).

Methods: This quality improvement initiative was conducted at Arkansas Children’s Hospital, a large academic center. We created an SBT protocol using CPAP with pressure support, and employed quality improvement (QI) methodology including three Plan-Do-Study-Act (PDSA) cycles. A key driver diagram and fishbone diagram were used to identify primary drivers and barriers in implementing the protocol. We compared extubation failure rates and other metrics before (March 1, 2022 - December 31, 2022) and after (March 1, 2023 - December 31, 2023) protocol implementation. Patients requiring mechanical ventilation for over 24 hours were included. Extubation failure was defined as reintubation within 24 hours

Results: During the pre-implementation phase, 299 patients were intubated, with a 5.48% extubation failure rate. Post-implementation, involving 295 patients, the failure rate decreased to 2.33%. SBT utilization reached 65.1% of eligible patients, exceeding the 50% goal by July 2023. Median ventilation days remained stable (4.87 vs. 5.12 days). The rate of unplanned extubations slightly increased but was not linked to SBT performance. Analysis of extubation failures showed issues with airway tone, secretions, and work of breathing.

Conclusions: Implementing a standardized SBT protocol through a structured QI approach led to a significant reduction in extubation failures. This project demonstrates the value of a systematic, evidence-based approach in improving extubation readiness assessments in the PICU.