Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore.
Department of Quality Safety and Risk Management, KK Women's and Children's Hospital, Singapore.
Respir Care. 2022 Jul;67(7):833-841. doi: 10.4187/respcare.09680. Epub 2022 Apr 26.
There is currently no standardized way to determine suitability for extubation of pediatric ICU (PICU) patients, potentially resulting in prolonged duration of mechanical ventilation. We aimed to design and implement a protocol for screening all intubated PICU patients for extubation readiness.
We adopted the quality improvement (QI) Model for Improvement with Plan-Do-Study-Act (PDSA) cycles to achieve this aim. This QI project was conducted over 11 months in a multidisciplinary PICU. Outcome measures included the (1) development of a standardized extubation readiness test (ERT) that was acceptable and safe; (2) performance of ERT on > 80% of all mechanically ventilated subjects; and (3) maintenance or reduction in mechanical ventilation duration, extubation failure (non-elective re-intubation within 48 h of extubation), and need for rescue noninvasive ventilation (NIV). Balancing measures were to ensure (1) no compromise of the subject's clinical status; and (2) acceptability of the ERT workflow by medical, nursing, and respiratory therapist (RT) teams.
Four PDSA cycles were necessary to achieve the aims of this study. During the QI period, 438 subjects were admitted to the PICU. The ERT was championed by the RTs who conducted the test during office hours. ERT performance increased from 0% (baseline) to 90% (fourth PDSA cycle). Extubation failure rate after implementing ERT was reduced compared to baseline (4/31 [12.9%] vs 3/127 [2.4%], = .01), whereas need for rescue NIV (3/31 [9.7%] vs 10/127 [7.9%], = .74) and duration of mechanical ventilation (2 [1-7] d vs 1 [1-3] d, = .09) were unchanged. PICU length of stay was reduced after implementing ERT (5 [3-10] d vs 3 [1-6] d, = .01). No subject was destabilized as a result of ERT, and PICU staff found the workflow acceptable.
An acceptable and safe ERT protocol was implemented and found to improve outcomes in PICU subjects on mechanical ventilation.
目前尚无标准化方法来确定儿科重症监护病房（PICU）患者的拔管适宜性，这可能导致机械通气时间延长。我们旨在设计并实施一种筛选所有气管插管 PICU 患者以确定拔管准备情况的方案。
我们采用质量改进（QI）模型中的计划-执行-研究-行动（PDSA）循环来实现这一目标。这项 QI 项目在一个多学科的 PICU 中进行了 11 个月。结果测量包括：（1）制定一种可接受且安全的标准化拔管准备测试（ERT）；（2）对>80%的机械通气患者进行 ERT；（3）保持或减少机械通气时间、拔管失败（拔管后 48 小时内非计划性再插管）以及需要抢救性无创通气（NIV）的情况。平衡措施是确保（1）不影响患者的临床状况；（2）ERT 工作流程被医生、护士和呼吸治疗师（RT）团队接受。
为了实现本研究的目标，需要进行 4 个 PDSA 循环。在 QI 期间，有 438 名患者被收入 PICU。ERT 由 RT 主导，他们在办公时间进行测试。ERT 的实施率从 0%（基线）增加到 90%（第四个 PDSA 循环）。与基线相比，实施 ERT 后的拔管失败率降低（4/31 [12.9%]比 3/127 [2.4%]， =.01），而需要抢救性 NIV 的比例（3/31 [9.7%]比 10/127 [7.9%]， =.74）和机械通气时间（2 [1-7] d 比 1 [1-3] d， =.09）没有变化。实施 ERT 后，PICU 住院时间缩短（5 [3-10] d 比 3 [1-6] d， =.01）。没有患者因 ERT 而不稳定，PICU 工作人员发现工作流程可接受。
实施了一种可接受且安全的 ERT 方案，发现可改善机械通气的 PICU 患者的结局。
