Respiratory Therapist-Driven Extubation Readiness Testing in a Single Pediatric ICU

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.