Improving Compassionate Extubation Practices in the Pediatric Intensive Care Unit.

Abstract

Background: This study was conducted in a free-standing pediatric academic institution in the pediatric intensive care unit (PICU) and cardiothoracic intensive care unit (CTICU), focusing on children with planned compassionate extubation (CE). Prior to the study, variability in CE practices led to inconsistencies in care and communication.

Objectives: Implement and assess the efficacy of a protocol to ensure consistent symptom management, enhance documentation, and promote communication among providers during CE events.

Methods: Pre and post quality improvement project with implementation of a CE protocol in February 2022, including (1) a checklist to standardize orders, documentation, medical management, and provider availability around the time of CE and (2) a post-extubation staff debriefing tool. The study was carried out by a multidisciplinary team composed of providers, nurses, respiratory therapists, palliative care specialists, and a child life specialist. The improvement team evaluated CE events for a 12 month period before (January-December 2020) and for 12 months after (February 2022-January 2023) the intervention roll-out date via manual chart review and Research Electronic Data Capture surveys of staff members who participated in the CE. The primary outcome was the compliance with best practices surrounding documentation and clinical interventions at the time of CE. Secondary outcomes included staff satisfaction with the CE process and rate of debriefings.

Results: There were 18 pre-intervention events and 26 post-intervention CE events that underwent chart review. 53 surveys were reviewed, 20 pre-intervention and 33 post-intervention. There was a significant increase in the appropriate placement of extubation orders (6% prior to protocol, 69% at study conclusion), improvement in timely advance care plan documentation (89% prior to protocol, 100% at study conclusion), and increase in cessation of vasoactive infusions at the time of extubation (78% prior to protocol, 100% at study conclusion). The rates of debriefs remained similar before and after protocol implementation (65% and 67% respectively). Overall, the protocol was well received by ICU staff, over 90% of staff surveys showed positive feedback on patient and provider comfort during CE.

Conclusions: A CE protocol improved documentation and communication around pediatric end-of-life care. Future improvements should focus on exploring the barriers to post-extubation debriefings.