Evidence-Based Practice presentation presented at the Pacific Institute for Nursing (PIN) conference

1. Extubation Readiness in the
PICU
Creating a Guideline
Kolea Chong RN, BSN, CCRN
Susan Bankhead, MSN, CCRN, CNML

2. No Financial Disclosures to
Note
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3. Objectives
• Decrease failed extubations
• Develop assessment tool for extubation
readiness for PICU patients with non-chronic
lung/musculoskeletal conditions
• Increase nursing and RT comfort/satisfaction
and collaboration
• Standardize multi-disciplinary team approach to
extubation
• Develop a culture of evidence based practice

4. Our Beginnings
• 2010
– EBP workshop (Hawaii State Center for Nursing)
• Introduction to the Iowa Model of EBP
– PICO development
– Based on Triggers
– To decrease the need for reintubation and
improve staff collaboration in the extubation
process for intubated PICU patients with non-
chronic lung conditions by implementing a
weaning readiness assessment score/tool
which includes acceptable ventilator settings,
sedation level and ability to protect airway prior
to extubation
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5. 5

6. Triggers
• 4 failed extubations in past 12 month prior to project
• Traumatic physically and psychologically to patients and
parents
• Lack of agreement/collaboration among caregivers about
when a patient is ready for extubation
• No standardized approach or criteria for extubation
• Decisions not necessarily based on evidence
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7. Team Formation
• Multidisciplinary team approach
• Physician Champion
• Nursing
• Respiratory
• Pharmacy
• Management
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8. Is There
a Sufficient
Research
Base?
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
Pilot the Change in Practice
1. Select Outcomes to be Achieved
2. Collect Baseline Data
3. Design Evidence-Based
Practice (EBP) Guideline(s)
4. Implement EBP on Pilot Units
5. Evaluate Process & Outcomes
6. Modify the Practice Guideline
Base Practice on Other
Types of Evidence
1. Case Reports
2. Expert Opinion
3. Scientific Principles
4. Theory
Conduct
Research
Yes No
= a decision Point
The Iowa Model of
Evidence Based Practice to Promote Quality
Care

9. Literature?
• Pediatric literature limited
– RTC not necessarily done for children
– Adult studies translated to pediatric care
• Fit to the settings
• Levels of Evidence
– One guideline non pediatric
– 2 extubation readiness tools used by other hospital
PICU
– 7 articles Pediatric based
• 1 level II
• 2 level VI
• 4 level VII
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10. Nursing/RT Staff Survey
• 66% of staff indicated varied practice for
extubation
• 33% of staff indicated multidisciplinary
collaboration during extubation process
• 83% of staff indicated an extubation
readiness tool would be helpful
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11. Our Tool
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13. Paper Trial of Extubation
Protocol
• >1 year of trial
• Multiple extubations delayed due to
criteria not met
• During Trial period - 0 failed extubations
when protocol followed
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14. Is Change
Appropriate for
Adoption in
Practice?
Continue to Evaluate
Quality of Care and
New Knowledge
No Yes
Institute the Change in Practice
Monitor and Analyze Structure,
Process, and Outcome Data
- Environment
- Staff
- Cost
- Patient and Family
Disseminate Results
= a decision Point
DO NOT REPRODUCE WITHOUT PERMISSION
REQUESTS TO:
Marita Titler, PhD, RN
Office of Nursing Research
The University of Iowa Hospitals and Clinics
Iowa City, IA 52242-1009
Revised: April 1998 © UIHC
Titler, M.G., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp Reimer, T.,
& Goode, C. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing
Clinics of North America, 13(4):497-509.

15. Electronic Implementation
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16. Electronic Implementation
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17. Lessons Learned
• Consider the culture of the unit:
– “If we don’t have failed extubations we are not
doing our job.”
– Communicate….
• Frequently
• Follow-up
• Have set team meetings: time & place
• Point persons are vital
• Identify the roles
• Time frames and deadlines
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18. More Lessons Learned
• Trialing takes time (piloting the change)
• Expect Multiple changes
– 3 revisions to paper form of extubation readiness
protocol
• Acknowledge the set backs
• Connect with IT early
• How do we operationalize this?
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19. Clinical Results
• Extubation Readiness tool is part of the
PICU standard order set for intubation
• No failed extubation to date for those
patients meeting criteria!!
• Staff survery showed increased feelings of
collaboration and consistency in practice
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21. Nurse/RT Survey Results
Post Protocol Implementation
• 0% of staff indicated varied practice for
extubation (prevously 66%)
• 68% of staff indicated multidisciplinary
collaboration during extubation process
(previously 33%)
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22. Contact
• Kolea Chong RN, BSN, CCRN
– Kolea.chong@kapiolani.org
– Kapiolani Medical Center for Women & Children
• Susan Bankhead MSN, CCRN, CNML
– Susan.bankhead@kapiolani.org
– Kapiolani Medical Center for Women & Children
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23. References
Baumeister, B.L., El-Khatib, M., Smith, P.G., Blumer, J.L. (1997) Evaluation of predictors of weaning
of mechanical ventilation in pediatric patients. Pediatric Pulmonology, 24(5): 344-52.
Farias, J.A., Alia, I., Esteban, A., Golubicki, A.N., Olazarri, F.A. (1998) Weaning from Mechanical
Ventilation In Pediatric Intensive Care Patients. Intensive Care Medicine, 24(10); 1070-5.
MacIntyre, N.R., Cook, D.J., Ely, E.W., Epstein, S.K., Fink, J.B., Heffner, J.E., et al (2002) Evidence-
Based Guidelines for Weaning and Discontinuing Ventilatory Support. Respiratory Care, 47(1):
69-89.
Meade, M.O., Ely, E.W. (2002) Protocols to Improve the Care of Critically Ill Pediatric and Adult
Patients. JAMA, 228(20): 2601-03
Newth, C.J., Venkataraman, S., Willson, D.F., Meert, K.L., Harrison, R., Dean, J.M. et.al (2009)
Weaning and extubation readines in pediatric patients. Pediatric Critical Care Medicine, 10(1): 1-
11.
Titler, M.G., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp
Reimer, T., & Goode, C. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality
Care. Critical Care Nursing Clinics of North America, 13(4):497-509.
Venkataraman, S.T., Khan, N., Brown, A. (2000) Validation of predictors of extubation success and
failure in mechanically ventilated infants and children. Critical Care Medicine, 28(8): 2991-2996.
Wratney, A.T., Cheifetz, I.M. (2006) AARC Clinical Practice Guideline; Removal of the Endotracheal
Tube-2007 Revision and Update. Respiratory Care, 52(1): 81-93.
Wratney, A.T., Cheifets, I.M. (2006) Extubation Criteria in Infants and Children. Respir Care Clin N
Am., 12(3); 469-81.
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24. • This EBP project was generously supported, in
part, by the Hawaii State Center for Nursing
• This project was supported by grant number
R13HS017892 from the Healthcare Research
and Quality. The content is solely the
responsibility of the authors and does not
necessarily represent the official views of the
Agency for Healthcare Research and Quality.
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