Atul Vats, MD, FAAP,FCCM
Pediatric Intensivist
Emory University School of Medicine, United States
Disclosure information not submitted.
Evan Orenstein, MD
Associate Professor Hospitalist
Emory University, United States
Disclosure information not submitted.
Christopher Fritzen, PA
Physician Assistant
Children's Healthcare of Atlanta, Georgia, United States
Disclosure information not submitted.
Karen Walson, MD, FAAP
Pediatric Intensivist
Scottish Rite Hospital Childrens Healthcare of Atlanta, United States
Disclosure information not submitted.
Pinar Keskinocak, PhD
Professor
Georgia Institute of Technology, United States
Disclosure information not submitted.
Regina Lunde
Director, Pulmonary Services
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Clara Hopkins-Bailey
Manager, Respiratory Care
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Colleen Mosley
Process Improvement Specialist
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Janice Owen, RN
RN
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Lihinie DeAlmeida, MD
Pediatric Intensivist
Emory Critical Care, United States
Disclosure information not submitted.
Stephanie Sparacino, RRT
RRT
Childrens Healthcare of Atlanta, United States
Disclosure information not submitted.
Leah McKay
Senior Clinical Information Specialist
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Tal Senior
BI Requirments Analyst-Clinical
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Patrick Spafford, MD
Pediatric Intensivist
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Shanelle Clarke, MD
Cardiac Intensivist
Sibley Heart Center, United States
Disclosure information not submitted.
Shannon Hamrick, MD
Neonatologist
Emory Children's Center, United States
Disclosure information not submitted.
Michael Mallory, MD
Chief of Medicine
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Rajit (Raj) Basu, MD, MS, FCCM
Posy and Jon Krehbiel Professor, Division Head of Critical Care Medicine
n/a
Disclosure information not submitted.
Priyamvada Chaudhary, MD
Pediatric Intensivist
Childrens Healthcare of Atlanta, United States
Disclosure information not submitted.
Stephanie Jernigan, MD
Chief of Medicine
Children's Healthcare of Atlanta, United States
Disclosure information not submitted.
Title: Clinical decision support improves unplanned extubation risk charting and stakeholder engagement
INTRODUCTION: Situation awareness can help clinicians prevent unplanned extubations (UEs). We hypothesized that (1) an alert for respiratory therapists (RTs) in 5 ICUs (2 pediatric, 2 neonatal, 1 cardiac) would improve UE risk charting and communication between stakeholders and (2) a second alert notifying MDs about patients at high risk for UE in a 36 bed PICU would improve achieving appropriate levels of sedation for high UE risk patients.
Methods: A quarternary care pediatric healthcare system convened RTs, nurses, MDs, and quality and process improvement specialists to improve compliance with UE risk1 charting and enhance stakeholder engagement. Clinical decision support was implemented in the electronic health record to (1) alert RTs when UE risk charting was not complete in a timely fashion for an intubated pediatric patient and (2) encourage MDs in one PICU to order a sedation behavioral scale (SBS) of ≤-2 and avoid sedation holidays in high UE risk patients. Key data tracked include: UE incidence per 100 vent days, UE risk charting compliance, extubation readiness assessment, SBS for high UE risk patients, and CAP-D (delirium) scores.
Results: From April 2021 through July 2021, the RT alert fired 9,294 times and the MD BPA fired 173 times. Compliance with UE risk charting improved from 82% at baseline to 91% (P< 0.001), and sedation at SBS ≤-2 for high-risk patients improved from 39% to 77% (P< 0.001). There was no change in the number of patients receiving a sedation holiday (88% to 89%, P=0.99). The UE rate center line remained static at 0.55/100-vent days, and the frequency of CAP-D scores >9 trended down (35% to 20%, P=0.06). Though not statistically significant, extubation readiness assessment was noted to increase from 89.2% to 91.1%
Conclusions: An RT alert improved compliance with UE risk charting for all intubated pediatric patients. Extubation readiness charting was noted to improve, as well. A pilot MD-facing alert was associated with increase compliance of an SBS of ≤-2 for all high UE risk pediatric patients with no increase in CAP-D scores. Sedation holiday incidence was not impacted. Further study is warranted to see if these changes in behavior and culture have an impact on overall UE rates.
1Pediatr Crit Care Med 2017; 18:661-666.