A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units international journal of pediatric Otorhinolaryngology,International Journal of Pediatric Otorhinolaryngology

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A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units international journal of pediatric Otorhinolaryngology
International Journal of Pediatric Otorhinolaryngology ( IF 1.5 ) Pub Date : 2021-07-28 , DOI: 10.1016/j.ijporl.2021.110857
Asitha D L Jayawardena ₁ , Zelda J Ghersin ₂ , Luis Jose Guzman ₃ , Jose A Bonilla ₄ , Susana Abrego ₅ , Alejandra Aguilar ₆ , Daniel Ramos ₄ , Evelyn Zablah ₇ , Kevin Callans ₈ , Megan Macduff ₉ , Makara Cayer ₁₀ , Thomas Q Gallagher ₁₁ , Mark G Vangel ₁₂ , Mark H Peikin ₁₃ , Phoebe H Yager ₂ , Christopher J Hartnick ₁₄

Affiliation

Children's Minnesota, Department of Otolaryngology, Minneapolis, MN, USA; Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA.
Massachusetts General Hospital, Pediatric Intensive Care Unit, Boston, MA, USA.
Benjamin Bloom Hospital, Pediatric Intensive Care, San Salvador, El Salvador.
Benjamin Bloom Hospital, Department of Otolaryngology San Salvador, El Salvador.
Benjamin Bloom Hospital, Pediatric Anesthesia, San Salvador, El Salvador.
Benjamin Bloom Hospital, Respiratory Therapy, San Salvador, El Salvador.
Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; The Benjamin Harry Peikin Foundation, Boston, MA, USA.
Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; Massachusetts General Hospital for Children, Boston, MA, USA.
Massachusetts General Hospital, Department of Respiratory Care Services, Boston, MA, USA.
Massachusetts Eye and Ear Infirmary, Department of Anesthesia, Boston, MA, USA.
Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Department of Otolaryngology-Head and Neck Surgery, Pediatric Otolaryngology, 601 Children's Lane, 2nd Floor, Norfolk, VA, 23507, USA.
Massachusetts General Hospital, Department of Radiology, Boston, MA, USA.
The Benjamin Harry Peikin Foundation, Boston, MA, USA.
Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA.

Introduction

Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU.

Methods

This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was $1.32 per child. PICU mortality was evaluated as an exploratory outcome.

Results

Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28–0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17–0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24–0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is $30.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44.

Conclusion

This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.

中文翻译：

减少资源匮乏儿科重症监护病房意外拔管的低成本教育干预国际儿科耳鼻喉科杂志

介绍

在低收入儿科重症监护病房 (PICU) 中，意外拔管 (UE) 的情况比高收入同行要差几个数量级。此外，很大一部分 (20%) 的 UE 会导致不稳定事件或心脏衰竭，从而对发病率和死亡率产生负面影响。由于安全气道管理的原则是普遍的，我们假设包括提供低成本带套囊的气管插管 (ETT) 和 ETT 胶带在内的多学科教育干预包将降低非计划拔管 (UE) 的发生率有资源的 PICU。

方法

这是一项前后干预研究，旨在评估萨尔瓦多 PICU 中插管儿科患者的 UE，经过多学科教育努力并提供低成本的一次性材料。实施了多学科（耳鼻喉科医师、重症监护医师、麻醉师、呼吸治疗师和护士）教育课程，包括动手培训、通过床边二维码随时可用的在线视频模块以及前后测试。干预材料的费用为每名儿童 1.32 美元。PICU 死亡率被评估为探索性结果。

结果

957 名（干预前 859 名，干预后 98 名）患者符合纳入标准。具有一种或多种 UE 的患者在干预后从 29.4% 显着降低至 17.3%（p = 0.01；CI：0.28–0.88），优势比为 0.51。带套囊 ETT 的使用从 12 % 增加到 36 %（p < 0.001；CI：0.17–0.44；OR：3.74）并且带套囊 ETT 的使用与 UE 减少相关，优势比为 0.40（p < 0.001；置信区间：0.24–0.66）。最后，儿科死亡率从 26.7 % 下降到 22.4 % 4.3 %，这相当于需要治疗以防止 23 名单身儿童死亡。因此，每预防死亡的 ICER 为 30.7 美元，每残疾调整生命的 ICER 为 30.7年 (DALY) 为 0.44 美元。