Department of Pediatrics, University of Rochester, Rochester, New York.
Pediatrics. 2024 Sep 1;154(3). doi: 10.1542/peds.2023-062930.
Failed extubations are associated with pulmonary morbidity in hospitalized premature newborns. The objective of this study was to use quality improvement methodology to reduce failed extubations through practice standardization and integrating a real-time extubation success calculator into the electronic medical record (EMR).
A specific, measurable, achievable, relevant, and time-bound aim was developed to reduce failed extubations (defined as reintubation <5 days from primary extubation) by 50% among infants <32 weeks' gestational age (GA) or <1500 g birth weight by December 31, 2022. Plan-do-study-act cycles were developed to standardize postextubation respiratory support and integrate the EMR-based calculator. Outcome measures included extubation failure rates. Balancing measures included days on mechanical ventilation and number of patients intubated <3 days. Process measures were followed for guideline compliance. Statistical process control charts were used to track time-ordered data and detect special cause variation.
We observed a reduction in failed extubations from 10.3% to 2.3%, with special cause variation noted after both plan-do-study-act cycle #1 and #2. Special cause variation was detected in both GA subgroups: <28 weeks' GA (22.0%-8.6%) and ≥28 weeks' GA (4.6%-0.3%). Additionally, the average number of infants intubated <3 days increased (60.2%-73.6%), whereas average ventilator days decreased (10.8-7.0). Finally, the time from infants' extubation score reaching threshold (≥60%) to extubation decreased (14.1-6.4 days) after launching the EMR-integrated calculator.
Practice standardization and implementation of an EMR-based real-time clinical decision support tool improved extubation success, promoted earlier extubation, and reduced ventilator days in premature newborns.
在住院的早产儿中，拔管失败与肺部发病率有关。本研究的目的是使用质量改进方法，通过规范实践并将实时拔管成功率计算器整合到电子病历（EMR）中，来降低拔管失败率。
制定了一个具体、可衡量、可实现、相关且有时限的目标，即在 2022 年 12 月 31 日前，将胎龄<32 周或出生体重<1500 克的婴儿的拔管失败率（定义为初次拔管后<5 天重新插管）降低 50%。制定了计划-执行-研究-行动循环，以规范拔管后的呼吸支持并整合基于 EMR 的计算器。结果测量包括拔管失败率。平衡措施包括机械通气天数和<3 天内插管的患者人数。遵循指南的依从性的过程测量。使用统计过程控制图来跟踪有序数据并检测特殊原因变化。
我们观察到拔管失败率从 10.3%降至 2.3%，在执行完第 1 次和第 2 次计划-执行-研究-行动循环后，均发现特殊原因的变化。在<28 周的 GA（22.0%-8.6%）和≥28 周的 GA（4.6%-0.3%）两个 GA 亚组中均检测到特殊原因的变化。此外，<3 天内插管的婴儿平均数量增加（60.2%-73.6%），而呼吸机使用天数减少（10.8-7.0）。最后，在启动 EMR 整合的计算器后，婴儿的拔管评分达到阈值（≥60%）到拔管的时间缩短（14.1-6.4 天）。
规范实践和实施基于 EMR 的实时临床决策支持工具可提高早产儿的拔管成功率，促进更早拔管，并减少呼吸机使用天数。
