117 - Reducing Unplanned Extubations with a Standardized Extubation Readiness Testing Protocol

Publication Number: 117.6146

Beatriz Teppa Sanchez, Johns Hopkins All Children's Hospital, SAINT PETERSBURG, FL, United States; Gretchen Thompson, JHACH, St Petersburg, FL, United States; Nathan P. Dean, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States; Eric Newcomer, Johns Hopkins All Children’s Hospital, San Francisco, CA, United States

Background: Unplanned extubations (UE) are a hospital acquired condition associated with prolonged duration mechanical ventilation, prolonged intensive care unit stay, additional financial cost and risk of cardiovascular collapse. During fiscal year 2023 the PICU experienced 21 UEs, up from 11 the previous year. After evaluating the potential causes, the group decided to implement a standardized extubation readiness test (ERT) protocol.

Objective: By implementing this process, our goal is to reduce UEs from 1.2 to 0.5 per 100 ventilator days by December 2024 and maintain for 6 months.

Design/Methods: As part of this protocol, every patient is screened at 6 am. Patients with ICU stays > 72 hours, low ventilator settings (Positive End Expiratory Pressure (PEEP) 6 cmH20 or less, oxygen requirement less than 50%), spontaneous respiratory effort and hemodynamically stable, undergo a spontaneous breathing trial with PEEP of 5 cmH2O and Pressure Support of 0 cmH2O for 30 minutes. Success occurs when there is no apnea, stable oxygen requirement, and appropriately breath tidal volume. Patients are to be extubated within 24 hours of the successful ERT. Outcome measure is the rate of UEs per 100 ventilator days. To evaluate the efficacy of our intervention we monitored compliance with extubations per protocol, the percentage of eligible patients undergoing ERT, and the percentage of ERTs with the correct settings. For balancing measures, we monitored the number of patients who passed ERT trials, and the number of patients who remained extubated 24 hours after extubation.

Results: During the initial implementation, only 50% of patients meeting ERT criteria were extubated. With staff education, compliance increased to a new centerline of 75% starting in December of 2023. Initially 67% of eligible patients underwent ERT, but during the last 6 months 85% of patients underwent ERT. 74% of ERTs were done with the correct settings. 90% of patients undergoing ERT at the correct settings met criteria for extubation, and 95% of patients with a successful ERT remained extubated at 24 hrs.
Improve: Prior to initiation of the standardized ERT protocol our UE rate was 1.2 per 100 ventilator days. After implementation of the protocol the UE rate dropped to 0.3 per 100 ventilator days, with only 5 events occurring during fiscal year 24.

Conclusion(s): The implementation of a standardized ERT protocol can be an effective and safe initiative to reduce rates of unplanned extubation in Critically Ill Children.

Figure 1
Outcome Measure: Unplanned Extubation per 100 Vent Days (u- Chart)

Figure 2
Process Measure: Compliance with extubation Protocol (P-Chart)

Figure 3
Balancing Measure: (A) Percentage of patients remaining extubated after successful ERT and (B) Percentage of patients with successful ERT with appropriate settings

Figure 1
Outcome Measure: Unplanned Extubation per 100 Vent Days (u- Chart)

Figure 2
Process Measure: Compliance with extubation Protocol (P-Chart)

Figure 3
Balancing Measure: (A) Percentage of patients remaining extubated after successful ERT and (B) Percentage of patients with successful ERT with appropriate settings