Niranjan Vijayakumar, MD
Boston Children's Hospital
Boston, Massachusetts
Disclosure information not submitted.
Paula Levett, CCRN-K, MS, RN, MS
Nurse Practice Leader, PICU
University of Iowa Childrens Hospital, United States
Disclosure information not submitted.
Amanda Houston, MS, RN, CCRN-K
Clinical Practice Leader
University of Iowa Hospitals and Clinics, United States
Disclosure information not submitted.
Julie Isely
Staff Nurse
University of Iowa Hospitals and Clinics, United States
Disclosure information not submitted.
Howard Seigel
Senior Respiratory therapist
University of Iowa Hospitals and Clinics, United States
Disclosure information not submitted.
Madhuradhar Chegondi, MD
Clinical Associate Professor, Division of Pediatric Critical Care Medicine
University of Iowa Stead Family Childrens's Hospital
Iowa City, IA, United States
Disclosure information not submitted.
Title: Project BLUE: Implementing Bundle Limiting Unplanned Extubation in the Pediatric ICU (PICU)
Introduction: Invasive ventilation with an endotracheal tube (ETT) is a mainstay of critical management in the Pediatric Intensive Care Unit (PICU). Unplanned extubations (UE) refer to events where the ETT gets dislodged from its ideal position causing an inability to continue efficient respiratory support. UE can lead to significant morbidity and mortality, due to hypoxia and hemodynamic compromise. This quality improvement (QI) project aims to reduce UE events in our PICU.
Methods: This project is being conducted at our tertiary care PICU, a 28-bed unit accommodating patients 0-21 years old. The PICU admits a wide variety of surgical and medical cases, including complex congenital heart disease, heart/renal transplants, extracorporeal membrane oxygenation, or intensive trauma care. The core team was composed of physicians, nurses, respiratory therapists. This QI initiative rolled out in 2 parts, with the implementation of each intervention and continuous assessment in PDSA cycles, with the ability to provide real-time feedback.
The individual Interventions are,
Standardize taping method, tape, anatomical landmarks for depth of insertion and improving X-ray quality annotation with the depth of insertion. A monthly audit determined the quality of x-rays and adherence: scored for position of head/chin, clavicles, unobstructed chest view and ETT view, and annotation for a total score of 5.
Implementation of Airway maintenance safety checklist (AMSC): includes ETT characteristics, details of the tube insertion and expected complications of ETT loss (risk factors for cardiopulmonary compromise). Discuss extubation readiness on clinical rounds to shorten ventilator days.
OUTCOMES MEASURED:
UE rate per 100 ventilator days
Total ventilator days
Results: The pre-intervention analysis of the PICU UE rate was 0.8/100 ventilator days/year, compared to the national average of 0.6. The institutional goal was < 0.5. After stage 1, our rates fell to 0.5 in the first 6 months. Upon periodic assessment and educations our UE rate fell to 0.19 in the next 6 months (p = 0.03). Average ventilator days fell from 140.33 in the first 6 months to 93.00 in the second half (p < 0.01).
FUTURE COURSE: Stage 2: Improving safety culture and extubation readiness assessment using the AMSC, maintaining low UE rates and reducing ventilator days.