A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units

Asitha D L Jayawardena; Zelda J Ghersin; Luis Jose Guzman; Jose A Bonilla; Susana Abrego; Alejandra Aguilar; Daniel Ramos; Evelyn Zablah; Kevin Callans; Megan Macduff; Makara Cayer; Thomas Q Gallagher; Mark G Vangel; Mark H Peikin; Phoebe H Yager; Christopher J Hartnick

doi:10.1016/j.ijporl.2021.110857

A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units

Int J Pediatr Otorhinolaryngol. 2021 Oct:149:110857. doi: 10.1016/j.ijporl.2021.110857. Epub 2021 Jul 28.

Authors

Asitha D L Jayawardena¹, Zelda J Ghersin², Luis Jose Guzman³, Jose A Bonilla⁴, Susana Abrego⁵, Alejandra Aguilar⁶, Daniel Ramos⁴, Evelyn Zablah⁷, Kevin Callans⁸, Megan Macduff⁹, Makara Cayer¹⁰, Thomas Q Gallagher¹¹, Mark G Vangel¹², Mark H Peikin¹³, Phoebe H Yager², Christopher J Hartnick¹⁴

Affiliations

¹ Children's Minnesota, Department of Otolaryngology, Minneapolis, MN, USA; Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA.
² Massachusetts General Hospital, Pediatric Intensive Care Unit, Boston, MA, USA.
³ Benjamin Bloom Hospital, Pediatric Intensive Care, San Salvador, El Salvador.
⁴ Benjamin Bloom Hospital, Department of Otolaryngology San Salvador, El Salvador.
⁵ Benjamin Bloom Hospital, Pediatric Anesthesia, San Salvador, El Salvador.
⁶ Benjamin Bloom Hospital, Respiratory Therapy, San Salvador, El Salvador.
⁷ Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; The Benjamin Harry Peikin Foundation, Boston, MA, USA.
⁸ Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA; Massachusetts General Hospital for Children, Boston, MA, USA.
⁹ Massachusetts General Hospital, Department of Respiratory Care Services, Boston, MA, USA.
¹⁰ Massachusetts Eye and Ear Infirmary, Department of Anesthesia, Boston, MA, USA.
¹¹ 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.
¹² Massachusetts General Hospital, Department of Radiology, Boston, MA, USA.
¹³ The Benjamin Harry Peikin Foundation, Boston, MA, USA.
¹⁴ Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA. Electronic address: christopher_hartnick@meei.harvard.edu.

PMID: 34343831
DOI: 10.1016/j.ijporl.2021.110857

Abstract

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.

Keywords: Airway extubation; Child mortality; Developing countries; Global health; Medical education; Pediatric intensive care units.

MeSH terms

Airway Extubation*
Airway Management
Child
Curriculum
Humans
Intensive Care Units
Intensive Care Units, Pediatric
Intubation, Intratracheal*