P re v e n t i n g E x t u b a t i o n F a i l u re s i n a P e d i a t r i c In t en si ve C are U n it Susan Bankhead, MSN, DNPa,b,*, Kolea Chong, Sally Kamai, RN, MBA-HCMc
BSN, CCRN
a
,
KEYWORDS Extubation Mechanical ventilation PICU Iowa Model for Evidence-based Practice KEY POINTS Caring for critically ill children from birth to 21 years of age in the pediatric intensive care unit (PICU) requires multiple life-supporting interventions. Although mechanical ventilation can be a necessary life-supporting intervention, there are associated complications. The reduction of failed extubations in the PICU from 2.47 per 1000 ventilator days to 0.80 per 1000 ventilator days is attributed to the increased collaboration among care providers, use of the ERA checklist, and implementation of the ERA checklist into the work flow.
INTRODUCTION
Caring for critically ill children from birth to 21 years of age in the pediatric intensive care unit (PICU) requires multiple life-supporting interventions. One necessary intervention is the use of mechanical ventilation for children experiencing progressive respiratory distress, such as labored respirations, decreased oxygen saturation, or airway obstruction. Mechanical ventilation includes the process of intubation, placing an endotracheal tube (ETT) through the mouth and into the lungs, and continued interventions to assist with breathing. These interventions continue until the child recovers and is able to support their respiratory needs with or without the use of noninvasive respiratory initiatives. Although mechanical ventilation can be a necessary life-supporting intervention, there are associated complications. Some of these complications include ventilatorassociated pneumonia, lung and upper airway injury, and prolonged length of stays Disclosure: None. a Pediatric Intensive Care Unit, Kapiolani Medical Center for Women & Children, 1319 Punahou Street, Honolulu, HI 96826, USA; b Eastern Idaho Regional Medical Center, 3100 Channing Way, Idaho Falls, ID 83404, USA; c Clinical Improvement, Hawaii Pacific Health, 55 Merchant Street 26th Floor, Honolulu, HI 96813, USA * Corresponding author. Pediatric Intensive Care Unit, Kapiolani Medical Center for Women & Children, 1319 Punahou Street, Honolulu, HI 96826. E-mail address: [email protected] Nurs Clin N Am 49 (2014) 321–328 http://dx.doi.org/10.1016/j.cnur.2014.05.006 nursing.theclinics.com 0029-6465/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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in the PICU. The risk of complications is positively associated with the length of time on mechanical ventilation.1 To reduce the risk of complications, a multidisciplinary team of registered nurses (RN), respiratory therapists (RT), and physicians closely monitors the child’s respiratory status to ensure that mechanical ventilation is not used longer than necessary. After the child demonstrates recovery in oxygen saturation, improved respiratory rate and effort, and minimal need for mechanical ventilation, they transition to noninvasive respiratory support. The transition to noninvasive respiratory support involves planning and coordinating the removal of the ETT and mechanical ventilation, referred to as extubation. Unfortunately, not all planned extubations are successful and some children may need the ETT replaced and restarted on mechanical ventilation. Failed extubation is defined in the literature as the need to reintubate the patient within 24 to 72 hours after a planned extubation.2 Restarting a patient on mechanical ventilation soon after extubation can significantly increase a patient’s risk for ventilator complications and mortality.3 The objective of this project was to reduce the number of failed extubations in the Kapiolani Medical Center for Women & Children PICU, a 14-bed regional pediatric academic center that serves the children and families of Hawaii and the Pacific Basin. Failed extubation was defined for this project as the need to reintubate within 48 hours after a planned extubation. After evaluating extubation failures in the PICU and reviewing the literature for best practices for prevention of extubation, the team determined that the creation of an extubation readiness checklist and protocol to predict extubation readiness would assist in decreasing the failed extubation rate. This article describes extubation failures in the PICU and the development and implementation of an extubation readiness protocol using the Iowa Model for Evidence-based Practice as a guideline. The Iowa Model consists of processes for implementing evidence into practice, such as critiquing and synthesizing the literature, identifying stakeholders, and recognizing triggers.4 The extubation protocol was developed excluding children with previous lung injury and/or neuromuscular conditions, which contribute to an increase risk and complexity of planned extubations. EVIDENCE FOR PRACTICE IMPROVEMENT Critiquing and Synthesizing the Literature
A literature search was conducted using CINAHL and PubMed databases to identify publications related to pediatric extubation readiness and extubation failure. The following search terms were used: extubation readiness, pediatric extubation, extubation guidelines, and extubation failure. Seven articles related to pediatric extubation were retrieved and reviewed by the team. The articles ranged in level of evidence from one at level II, two at level VI, and four at level VII using Mosby’s criteria. In addition, the team reviewed two pediatric extubation guidelines from other pediatric institutions. All of the articles supported the development of a standardized extubation tool and protocol to guide a multidisciplinary team’s assessment of readiness for extubation and to reduce the incidence of extubation failure. Failed extubation results in patients being reintubated and restarted on mechanical ventilation. The risks associated with reintubation are similar to those of mechanical ventilation and include an increased risk for ventilator-associated pneumonia, lung injury, increased length of stay, and increased mortality in some studies on adults.3 The collective task force of the American College of Chest Physicians, Association of Respiratory Care, and American College of Critical Care Medicine reports that reintubation carries an eight-fold increase for nosocomial pneumonia, and a 6- to 12-fold
Extubation Failures
increase in mortality.5 The risks associated with reintubation, therefore, support the importance of preventing failed extubations. Extubation failure rates ranging from 2% to 20% have been reported.6 Failed extubation rates have been reported to be approximately 16.3% in infants and children.7 When specific parameters are used to plan extubation, failure rates are reported between 8% and 9%.8 It is estimated that based on clinical assessment alone only 35% of intubated patients ready for extubation are properly identified. Thus, the American College of Chest Physicians, Association of Respiratory Care, and the American College of Critical Care Medicine task force support the development of an extubation tool and protocol.5 This task force recommends patients receiving mechanical ventilation for respiratory failure should undergo a formal assessment before the extubation process. Without the use of a protocol, the decision to extubate is subjective and physiciandependent. Initial assessment of the extubation process in the PICU demonstrated that the planning of extubation involved an uncoordinated bedside assessment of the child’s respiratory status. Consideration was given to the initial causes of the respiratory distress and current level of improvement. However, the decision to extubate was primarily physician driven with support from the bedside RN and RT. Once the child had progressed to minimal mechanical ventilator settings for respiratory support and the child’s respiratory status was stable, the bedside team began to focus on the extubation process. The criteria used to remove ventilator support included the ability of the child to maintain spontaneous respirations, presence of a cough/gag to protect the airway, and review of the plan of care for the next 24 hours to ensure that there are no procedures that would require intubation. The lack of collaboration and inconsistencies in the implementation of the criteria contributed to the PICU’s failed extubations. Although the decision to extubate was derived from assessment of the child’s respiratory status and physician experiences with extubation, the PICU staff was concerned about the number of failed extubations in the PICU. Fig. 1 displays the number of failed extubations from 2009 to 2012 per 1000 ventilator days. IMPLEMENTATION STRATEGIES Identifying the Stakeholders and Recognizing Triggers
A multidisciplinary team of stakeholders consisting of RNs, RTs, the nurse manager, and a physician champion surveyed 8 of 35 care team members of the PICU to evaluate their current perceptions related to the extubation process and extent of multidisciplinary collaboration. Staff response showed 66% of the staff was not comfortable with the current planned extubation procedure in PICU. When asked about inclusion or collaboration with the extubation plan, only 33% of the staff indicated they were included in the decision-making process. The development of an extubation tool was supported by 87% of the staff who responded to the survey. A retrospective chart review was conducted using the electronic medical record identifying PICU patients who were reintubated within 48 hours and therefore met the project definition of failed extubations. Electronic medical records of children with previous lung injury and/or neuromuscular conditions were excluded from the review because of the complexity of their disease processes. The failed extubation rate per 1000 ventilator days was 2.47 in 2009 and 1.62 in 2010 based on internal data collection and comparable with failed extubation rates reported in the literature.6–8 Currently, benchmark data are not available for planned failed extubations. Based on the staff survey results and the retrospective chart review of all failed extubations (with the exclusion of children with previous lung injury and/or neuromuscular
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Fig. 1. Rate of failed extubations in the PICU, 2009–2012. LCL, lower control limit; UCL, upper control limit.
conditions), it was determined that a standardized protocol for planned extubation was needed and would be supported by the staff. The standardized approach to planned extubations would address practice inconsistencies and include RN, RT, and physician collaboration with the planned extubations. The multidisciplinary team created an extubation readiness assessment (ERA) checklist based on published literature and guidelines. This checklist, to be used by the care providers, assists in the determination of readiness for extubation. The newly created ERA checklist includes
A review of the child’s plan of care Current ventilator settings Level of sedation Feeding status Presence of a cough/gag Child’s respiratory effort
Descriptions of predetermined parameters were included on the checklist to assist with and promote standardization in the assessment ERA trial as shown in Fig. 2. Implementing Evidence into Practice
Initiation of the ERA checklist followed a presentation to the PICU intensivists conducted by the physician champion. Because care for the intubated patient includes a multidisciplinary approach, staff education was multifaceted and included team huddles conducted by the managers for the PICU and RT staff. Departmentspecific education was conducted during staff meetings with the inclusion of the department educators. Individual education was conducted as intubated pediatric patients meeting project criteria were identified during patient rounds as potentially ready for extubation. Individual education was accomplished by assisting the RT and RN in completing the ERA checklist. The ERA checklist was trialed in paper format with
Extubation Failures
Fig. 2. Sample of the PICU ERA trial tool.
feedback requested and collected from RNs, RTs, and physicians. The feedback, such as best practice alerts and standard physiologic limits, was evaluated by the multidisciplinary team and used to make improvements to the checklist. At the completion of the ERA checklist trial, a recommendation was made to have the ERA checklist integrated into the electronic medical record. The multidisciplinary team worked with the information technology department to adapt the ERA checklist into the electronic medical record workflow; Fig. 3 depicts the ERA assessment in the
Fig. 3. PICU extubation readiness checklist converted into the electronic medical record. * reference for acceptable respiratory rates. ** reference for acceptable sedation level.
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electronic medical record. The addition of best practice alerts, such as physiologic norms for vital signs based on age, helped make the checklist user friendly. To ensure that an ERA was performed for all intubated children without chronic lung conditions, an order for the ERA was added to the physician intubation order set. This order set included ventilator settings and daily alerts to the care team to perform the ERA checklist when the child progressed to needing less ventilator support. This addition to the order set and electronic medical record created a daily standardized approach for intubated pediatric patients and the plan for extubation (see Fig. 3). EVALUATION
The creation of the ERA checklist tool (see Fig. 3) and protocol (see Fig. 2) was adopted into practice for children of the PICU in 2011. The ERA checklist systematically incorporates the clinical judgment of the care providers, evaluation of the child’s clinical respiratory status, and encourages collaboration among the clinical team in the child’s plan of care. A resurvey of the RNs and RTs (N 5 6 of 32) in the PICU indicated a decrease in variation of extubation practice among the care provider team from 66% to 0%, and collaboration among the care team increased from 33% to 66%. This outcome demonstrated an improvement in the care team’s collaboration and a decrease in the variation of the extubation assessment. The incorporation of the ERA checklist into the electronic medical record has created a standardized approach for identifying when a child has met the extubation readiness criteria. A review of all PICU failed extubations for children without previous lung injury and/or neuromuscular conditions was conducted at the end of the ERA checklist trial that lasted 14 months. These results demonstrated an overall reduction in failed extubations from 2.47 per 1000 ventilator day in 2009 and 1.67 per 1000 ventilator day in 2010 to 0.81 in 2011 and 0.80 in 2012 per 1000 ventilator days. Use of the ERA checklist in paper format was inconsistent at the outset of the project implementation. This situation led to some children not having an ERA conducted despite meeting assessment criteria and thus failed extubations. Inconsistent adoption of the paper ERA was attributed to the checklist not being part of the workflow, the culture of belief that failed extubations are acceptable, and unclear role expectations for the RNs and RTs. Subsequently, the inclusion of the RT educator assisted with RT role definition and adoption of the ERA checklist and protocol. The integration of the ERA into the electronic medical record assisted with the easy use of the ERA because it became part of the workflow. From the initiation of the intubation, through the daily patient assessment and the plan for extubation, the ERA guided the process. Continued education of the PICU RN staff was accomplished through staff huddles and individual sessions, which addressed role expectations. Staff education also included an introduction of the evidence-based process and sharing of current literature findings from the nurse manager. With the assistance of the physician champion, updates were conducted for the PICU intensivists. The inclusion of the ERA checklist orders at the initiation of intubation assisted with collaboration at the bedside and ERA. Changing the culture from acceptance of reintubations to one of nonacceptance of reintubations was accomplished with the assistance of the physician champion and the PICU medical director. Supporting the culture of collaboration for extubation readiness involved the nurse manager with the team members proactively identifying patients ready for an ERA trail.
Extubation Failures
RECOMMENDATIONS AND LESSONS LEARNED
The creation of the PICU ERA checklist was accomplished by recognizing and coordinating a multidisciplinary team of stakeholders. Each team member brought a specific skill set and focus that contributed to the overall creation and success of the ERA. Commitment to the team process, such as attending meetings, and fulfilling assigned responsibilities are essential agreements that need to be presented early in the process. Another lesson learned was to conduct an evaluation of the cultural norms of the PICU as part of the initial assessment survey process. The implementation of the ERA trial revealed a long-standing perception and cultural norm that failed extubations were to be expected and demonstrated proactive mechanical ventilator management from the physician perspective. These perceptions and cultural norms were challenges that needed to be addressed. Sharing current literature that supported the reduction of failed extubations and the potential harms associated with reintubations changed these beliefs and fostered adoption by the physician champion and the medical director of the PICU. The third lesson learned was the importance of assigning responsibility for staff education and implementation early in the project. Not having someone designated to deliver staff education can be a barrier to the adoption of a new tool. By collaborating with the department-designated educators, staff education for the ERA trial and implementation was eventually accomplished. Team members developed consensus as to who was responsible for staff education and began face-to-face promotion of the ERA trial with department educators. Physician education and follow through was assigned to the physician champion and included promotion of the new practice and performance feedback. The fourth lesson learned was the value of a trial period to test the appropriateness of the criteria and determine how to fit the ERA assessment into the existing work flow. To better assist the trial period, clarity of roles and expectations of the team members would have improved the introduction of the ERA into the work flow. The team created the ERA to be adapted for the electronic medical record. However, the transition from the paper trial to the electronic medical record was delayed because of the lack of information technology department representatives on the team at the outset. This delay slowed the operationalization of the ERA into the work flow including order entry and documentation of the assessment. Early inclusion of personnel from the information technology department would have enhanced the efficiency and adoption of the ERA. SUMMARY
The reduction of failed extubations in the PICU from 2.47 per 1000 ventilator days to 0.80 per 1000 ventilator days is attributed to the increased collaboration among care providers, use of the ERA checklist, and implementation of the ERA checklist into the work flow. The resulting protocol can now be used to identify and prepare children with nonchronic conditions for extubation. The inclusion of the ERA into the electronic medical record, the clarification of roles and expectations, and a culture shift related to nonacceptance of failed extubations changed and improved patient care. The use of an evidence-based practice approach in addressing failed extubations for children without previous lung injury and/or neuromuscular conditions created a model for sustained practice change. Inclusion of multidisciplinary stakeholders in the creation, implementation, and evaluation of the ERA checklist enhanced the evidence-based competencies of team members and contributed to other positive outcomes of the project.
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An additional and unexpected benefit of this evidence-based practice project included increased collaboration among care providers that will assist in future evaluation of extubation readiness in children, potentially including those with previous lung disease and/or neuromuscular conditions and new quality improvement initiatives in many other areas of PICU patient care. REFERENCES
1. Ferguson LP, Walsh BK, Munhall D. A spontaneous breathing trial with pressure support overestimates readiness for extubation in children. Pediatr Crit Care Med 2011;12(6):330–5. 2. Frutos-Vivar F, Esteban A, Apeztequia C, et al. Outcome of reintubated patients after scheduled extubation. J Crit Care 2011;26:502–9. 3. Bittner EA, Schmidt UH. Tracheal reintubation: caused by too much of a good thing? Respir Care 2012;57(10):1687–91. 4. Titler MG, Kleiber C, Steelman V, et al. The Iowa Model of Evidence-based Practice to promote quality care. Crit Care Nurs Clin North Am 2001;13(4):497–509. 5. MacIntyre E. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120(6):375S–95S. 6. Newth CJ, Venkataraman S, Wilson DF, et al. Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009;10(1):1–11. 7. Vankataraman ST, Khan N, Brown A. Validation of predictors of extubation success and failure in mechanically ventilated infants and children. Crit Care Med 2000;28(8):2991–6. 8. Laham JL, Brehemy PJ, Rush A. Do clinical parameters predict first planned extubation outcome in the pediatric intensive care unit? J Intensive Care Med 2013. http://dx.doi.org/10.117/088506661349338.
BSN, CCRN
a
,
KEYWORDS Extubation Mechanical ventilation PICU Iowa Model for Evidence-based Practice KEY POINTS Caring for critically ill children from birth to 21 years of age in the pediatric intensive care unit (PICU) requires multiple life-supporting interventions. Although mechanical ventilation can be a necessary life-supporting intervention, there are associated complications. The reduction of failed extubations in the PICU from 2.47 per 1000 ventilator days to 0.80 per 1000 ventilator days is attributed to the increased collaboration among care providers, use of the ERA checklist, and implementation of the ERA checklist into the work flow.
INTRODUCTION
Caring for critically ill children from birth to 21 years of age in the pediatric intensive care unit (PICU) requires multiple life-supporting interventions. One necessary intervention is the use of mechanical ventilation for children experiencing progressive respiratory distress, such as labored respirations, decreased oxygen saturation, or airway obstruction. Mechanical ventilation includes the process of intubation, placing an endotracheal tube (ETT) through the mouth and into the lungs, and continued interventions to assist with breathing. These interventions continue until the child recovers and is able to support their respiratory needs with or without the use of noninvasive respiratory initiatives. Although mechanical ventilation can be a necessary life-supporting intervention, there are associated complications. Some of these complications include ventilatorassociated pneumonia, lung and upper airway injury, and prolonged length of stays Disclosure: None. a Pediatric Intensive Care Unit, Kapiolani Medical Center for Women & Children, 1319 Punahou Street, Honolulu, HI 96826, USA; b Eastern Idaho Regional Medical Center, 3100 Channing Way, Idaho Falls, ID 83404, USA; c Clinical Improvement, Hawaii Pacific Health, 55 Merchant Street 26th Floor, Honolulu, HI 96813, USA * Corresponding author. Pediatric Intensive Care Unit, Kapiolani Medical Center for Women & Children, 1319 Punahou Street, Honolulu, HI 96826. E-mail address: [email protected] Nurs Clin N Am 49 (2014) 321–328 http://dx.doi.org/10.1016/j.cnur.2014.05.006 nursing.theclinics.com 0029-6465/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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in the PICU. The risk of complications is positively associated with the length of time on mechanical ventilation.1 To reduce the risk of complications, a multidisciplinary team of registered nurses (RN), respiratory therapists (RT), and physicians closely monitors the child’s respiratory status to ensure that mechanical ventilation is not used longer than necessary. After the child demonstrates recovery in oxygen saturation, improved respiratory rate and effort, and minimal need for mechanical ventilation, they transition to noninvasive respiratory support. The transition to noninvasive respiratory support involves planning and coordinating the removal of the ETT and mechanical ventilation, referred to as extubation. Unfortunately, not all planned extubations are successful and some children may need the ETT replaced and restarted on mechanical ventilation. Failed extubation is defined in the literature as the need to reintubate the patient within 24 to 72 hours after a planned extubation.2 Restarting a patient on mechanical ventilation soon after extubation can significantly increase a patient’s risk for ventilator complications and mortality.3 The objective of this project was to reduce the number of failed extubations in the Kapiolani Medical Center for Women & Children PICU, a 14-bed regional pediatric academic center that serves the children and families of Hawaii and the Pacific Basin. Failed extubation was defined for this project as the need to reintubate within 48 hours after a planned extubation. After evaluating extubation failures in the PICU and reviewing the literature for best practices for prevention of extubation, the team determined that the creation of an extubation readiness checklist and protocol to predict extubation readiness would assist in decreasing the failed extubation rate. This article describes extubation failures in the PICU and the development and implementation of an extubation readiness protocol using the Iowa Model for Evidence-based Practice as a guideline. The Iowa Model consists of processes for implementing evidence into practice, such as critiquing and synthesizing the literature, identifying stakeholders, and recognizing triggers.4 The extubation protocol was developed excluding children with previous lung injury and/or neuromuscular conditions, which contribute to an increase risk and complexity of planned extubations. EVIDENCE FOR PRACTICE IMPROVEMENT Critiquing and Synthesizing the Literature
A literature search was conducted using CINAHL and PubMed databases to identify publications related to pediatric extubation readiness and extubation failure. The following search terms were used: extubation readiness, pediatric extubation, extubation guidelines, and extubation failure. Seven articles related to pediatric extubation were retrieved and reviewed by the team. The articles ranged in level of evidence from one at level II, two at level VI, and four at level VII using Mosby’s criteria. In addition, the team reviewed two pediatric extubation guidelines from other pediatric institutions. All of the articles supported the development of a standardized extubation tool and protocol to guide a multidisciplinary team’s assessment of readiness for extubation and to reduce the incidence of extubation failure. Failed extubation results in patients being reintubated and restarted on mechanical ventilation. The risks associated with reintubation are similar to those of mechanical ventilation and include an increased risk for ventilator-associated pneumonia, lung injury, increased length of stay, and increased mortality in some studies on adults.3 The collective task force of the American College of Chest Physicians, Association of Respiratory Care, and American College of Critical Care Medicine reports that reintubation carries an eight-fold increase for nosocomial pneumonia, and a 6- to 12-fold
Extubation Failures
increase in mortality.5 The risks associated with reintubation, therefore, support the importance of preventing failed extubations. Extubation failure rates ranging from 2% to 20% have been reported.6 Failed extubation rates have been reported to be approximately 16.3% in infants and children.7 When specific parameters are used to plan extubation, failure rates are reported between 8% and 9%.8 It is estimated that based on clinical assessment alone only 35% of intubated patients ready for extubation are properly identified. Thus, the American College of Chest Physicians, Association of Respiratory Care, and the American College of Critical Care Medicine task force support the development of an extubation tool and protocol.5 This task force recommends patients receiving mechanical ventilation for respiratory failure should undergo a formal assessment before the extubation process. Without the use of a protocol, the decision to extubate is subjective and physiciandependent. Initial assessment of the extubation process in the PICU demonstrated that the planning of extubation involved an uncoordinated bedside assessment of the child’s respiratory status. Consideration was given to the initial causes of the respiratory distress and current level of improvement. However, the decision to extubate was primarily physician driven with support from the bedside RN and RT. Once the child had progressed to minimal mechanical ventilator settings for respiratory support and the child’s respiratory status was stable, the bedside team began to focus on the extubation process. The criteria used to remove ventilator support included the ability of the child to maintain spontaneous respirations, presence of a cough/gag to protect the airway, and review of the plan of care for the next 24 hours to ensure that there are no procedures that would require intubation. The lack of collaboration and inconsistencies in the implementation of the criteria contributed to the PICU’s failed extubations. Although the decision to extubate was derived from assessment of the child’s respiratory status and physician experiences with extubation, the PICU staff was concerned about the number of failed extubations in the PICU. Fig. 1 displays the number of failed extubations from 2009 to 2012 per 1000 ventilator days. IMPLEMENTATION STRATEGIES Identifying the Stakeholders and Recognizing Triggers
A multidisciplinary team of stakeholders consisting of RNs, RTs, the nurse manager, and a physician champion surveyed 8 of 35 care team members of the PICU to evaluate their current perceptions related to the extubation process and extent of multidisciplinary collaboration. Staff response showed 66% of the staff was not comfortable with the current planned extubation procedure in PICU. When asked about inclusion or collaboration with the extubation plan, only 33% of the staff indicated they were included in the decision-making process. The development of an extubation tool was supported by 87% of the staff who responded to the survey. A retrospective chart review was conducted using the electronic medical record identifying PICU patients who were reintubated within 48 hours and therefore met the project definition of failed extubations. Electronic medical records of children with previous lung injury and/or neuromuscular conditions were excluded from the review because of the complexity of their disease processes. The failed extubation rate per 1000 ventilator days was 2.47 in 2009 and 1.62 in 2010 based on internal data collection and comparable with failed extubation rates reported in the literature.6–8 Currently, benchmark data are not available for planned failed extubations. Based on the staff survey results and the retrospective chart review of all failed extubations (with the exclusion of children with previous lung injury and/or neuromuscular
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Fig. 1. Rate of failed extubations in the PICU, 2009–2012. LCL, lower control limit; UCL, upper control limit.
conditions), it was determined that a standardized protocol for planned extubation was needed and would be supported by the staff. The standardized approach to planned extubations would address practice inconsistencies and include RN, RT, and physician collaboration with the planned extubations. The multidisciplinary team created an extubation readiness assessment (ERA) checklist based on published literature and guidelines. This checklist, to be used by the care providers, assists in the determination of readiness for extubation. The newly created ERA checklist includes
A review of the child’s plan of care Current ventilator settings Level of sedation Feeding status Presence of a cough/gag Child’s respiratory effort
Descriptions of predetermined parameters were included on the checklist to assist with and promote standardization in the assessment ERA trial as shown in Fig. 2. Implementing Evidence into Practice
Initiation of the ERA checklist followed a presentation to the PICU intensivists conducted by the physician champion. Because care for the intubated patient includes a multidisciplinary approach, staff education was multifaceted and included team huddles conducted by the managers for the PICU and RT staff. Departmentspecific education was conducted during staff meetings with the inclusion of the department educators. Individual education was conducted as intubated pediatric patients meeting project criteria were identified during patient rounds as potentially ready for extubation. Individual education was accomplished by assisting the RT and RN in completing the ERA checklist. The ERA checklist was trialed in paper format with
Extubation Failures
Fig. 2. Sample of the PICU ERA trial tool.
feedback requested and collected from RNs, RTs, and physicians. The feedback, such as best practice alerts and standard physiologic limits, was evaluated by the multidisciplinary team and used to make improvements to the checklist. At the completion of the ERA checklist trial, a recommendation was made to have the ERA checklist integrated into the electronic medical record. The multidisciplinary team worked with the information technology department to adapt the ERA checklist into the electronic medical record workflow; Fig. 3 depicts the ERA assessment in the
Fig. 3. PICU extubation readiness checklist converted into the electronic medical record. * reference for acceptable respiratory rates. ** reference for acceptable sedation level.
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electronic medical record. The addition of best practice alerts, such as physiologic norms for vital signs based on age, helped make the checklist user friendly. To ensure that an ERA was performed for all intubated children without chronic lung conditions, an order for the ERA was added to the physician intubation order set. This order set included ventilator settings and daily alerts to the care team to perform the ERA checklist when the child progressed to needing less ventilator support. This addition to the order set and electronic medical record created a daily standardized approach for intubated pediatric patients and the plan for extubation (see Fig. 3). EVALUATION
The creation of the ERA checklist tool (see Fig. 3) and protocol (see Fig. 2) was adopted into practice for children of the PICU in 2011. The ERA checklist systematically incorporates the clinical judgment of the care providers, evaluation of the child’s clinical respiratory status, and encourages collaboration among the clinical team in the child’s plan of care. A resurvey of the RNs and RTs (N 5 6 of 32) in the PICU indicated a decrease in variation of extubation practice among the care provider team from 66% to 0%, and collaboration among the care team increased from 33% to 66%. This outcome demonstrated an improvement in the care team’s collaboration and a decrease in the variation of the extubation assessment. The incorporation of the ERA checklist into the electronic medical record has created a standardized approach for identifying when a child has met the extubation readiness criteria. A review of all PICU failed extubations for children without previous lung injury and/or neuromuscular conditions was conducted at the end of the ERA checklist trial that lasted 14 months. These results demonstrated an overall reduction in failed extubations from 2.47 per 1000 ventilator day in 2009 and 1.67 per 1000 ventilator day in 2010 to 0.81 in 2011 and 0.80 in 2012 per 1000 ventilator days. Use of the ERA checklist in paper format was inconsistent at the outset of the project implementation. This situation led to some children not having an ERA conducted despite meeting assessment criteria and thus failed extubations. Inconsistent adoption of the paper ERA was attributed to the checklist not being part of the workflow, the culture of belief that failed extubations are acceptable, and unclear role expectations for the RNs and RTs. Subsequently, the inclusion of the RT educator assisted with RT role definition and adoption of the ERA checklist and protocol. The integration of the ERA into the electronic medical record assisted with the easy use of the ERA because it became part of the workflow. From the initiation of the intubation, through the daily patient assessment and the plan for extubation, the ERA guided the process. Continued education of the PICU RN staff was accomplished through staff huddles and individual sessions, which addressed role expectations. Staff education also included an introduction of the evidence-based process and sharing of current literature findings from the nurse manager. With the assistance of the physician champion, updates were conducted for the PICU intensivists. The inclusion of the ERA checklist orders at the initiation of intubation assisted with collaboration at the bedside and ERA. Changing the culture from acceptance of reintubations to one of nonacceptance of reintubations was accomplished with the assistance of the physician champion and the PICU medical director. Supporting the culture of collaboration for extubation readiness involved the nurse manager with the team members proactively identifying patients ready for an ERA trail.
Extubation Failures
RECOMMENDATIONS AND LESSONS LEARNED
The creation of the PICU ERA checklist was accomplished by recognizing and coordinating a multidisciplinary team of stakeholders. Each team member brought a specific skill set and focus that contributed to the overall creation and success of the ERA. Commitment to the team process, such as attending meetings, and fulfilling assigned responsibilities are essential agreements that need to be presented early in the process. Another lesson learned was to conduct an evaluation of the cultural norms of the PICU as part of the initial assessment survey process. The implementation of the ERA trial revealed a long-standing perception and cultural norm that failed extubations were to be expected and demonstrated proactive mechanical ventilator management from the physician perspective. These perceptions and cultural norms were challenges that needed to be addressed. Sharing current literature that supported the reduction of failed extubations and the potential harms associated with reintubations changed these beliefs and fostered adoption by the physician champion and the medical director of the PICU. The third lesson learned was the importance of assigning responsibility for staff education and implementation early in the project. Not having someone designated to deliver staff education can be a barrier to the adoption of a new tool. By collaborating with the department-designated educators, staff education for the ERA trial and implementation was eventually accomplished. Team members developed consensus as to who was responsible for staff education and began face-to-face promotion of the ERA trial with department educators. Physician education and follow through was assigned to the physician champion and included promotion of the new practice and performance feedback. The fourth lesson learned was the value of a trial period to test the appropriateness of the criteria and determine how to fit the ERA assessment into the existing work flow. To better assist the trial period, clarity of roles and expectations of the team members would have improved the introduction of the ERA into the work flow. The team created the ERA to be adapted for the electronic medical record. However, the transition from the paper trial to the electronic medical record was delayed because of the lack of information technology department representatives on the team at the outset. This delay slowed the operationalization of the ERA into the work flow including order entry and documentation of the assessment. Early inclusion of personnel from the information technology department would have enhanced the efficiency and adoption of the ERA. SUMMARY
The reduction of failed extubations in the PICU from 2.47 per 1000 ventilator days to 0.80 per 1000 ventilator days is attributed to the increased collaboration among care providers, use of the ERA checklist, and implementation of the ERA checklist into the work flow. The resulting protocol can now be used to identify and prepare children with nonchronic conditions for extubation. The inclusion of the ERA into the electronic medical record, the clarification of roles and expectations, and a culture shift related to nonacceptance of failed extubations changed and improved patient care. The use of an evidence-based practice approach in addressing failed extubations for children without previous lung injury and/or neuromuscular conditions created a model for sustained practice change. Inclusion of multidisciplinary stakeholders in the creation, implementation, and evaluation of the ERA checklist enhanced the evidence-based competencies of team members and contributed to other positive outcomes of the project.
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An additional and unexpected benefit of this evidence-based practice project included increased collaboration among care providers that will assist in future evaluation of extubation readiness in children, potentially including those with previous lung disease and/or neuromuscular conditions and new quality improvement initiatives in many other areas of PICU patient care. REFERENCES
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