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Original Investigation
April 13, 2020

Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children

Author Affiliations
  • 1Divisions of Cardiac Critical Care Medicine and Cardiology, Children’s National Hospital, The George Washington University School of Medicine, Washington, DC
  • 2Division of Neonatology, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 3Pediatric Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 4James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
  • 5Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children’s Hospital, University of Louisville, Louisville, Kentucky
  • 6Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
  • 7Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
  • 8Departments of Pediatrics and Bioethics, UH Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
JAMA Pediatr. 2020;174(6):e200268. doi:10.1001/jamapediatrics.2020.0268
Key Points

Question  Is the implementation of an unplanned extubation (UE) bundle, as part of a national quality improvement initiative, associated with a reduction in UEs in critically ill neonates, infants, and children?

Findings  In this quality improvement study of neonates, infants, and children from 43 participating children’s hospitals, use of the UE bundle was associated with a 24.1% reduction in UEs. Importantly, there was also a 36.6% reduction in cardiovascular collapse associated with UE's across the cohort.

Meaning  A widespread quality improvement initiative with bundle implementation led to a meaningful and sustained reduction in pediatric UEs and morbidity associated with these events.

Abstract

Importance  Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events.

Objective  To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events.

Design, Setting, and Participants  This multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children’s hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study.

Interventions  Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses.

Main Outcomes and Measures  The main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level.

Results  Among the 43 children’s hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days.

Conclusions and Relevance  This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.

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