(324) Implementation of a Compassionate Extubation Protocol in the Pediatric Intensive Care Unit

Sunday, January 21, 2024

2:30 PM – 3:30 PM MT

Location: Connections Central - RST 16

First Author(s)

Elizabeth Rinaldi

n/a

Co-Author(s)

DB

Debbie Brostoff, MSN, MSN, CPNP-AC/PC

Nurse Practitioner
Children's Hospital Los Angeles, United States
Sabrina F. Derrington, MD, MA Bioethics (she/her/hers)

Associate Professor of Pediatrics; Director, CHLA Center for Bioethics
Childrens Hospital Los Angeles
La Canada Flt, California
Jenny Kingsley, MD, MA, HEC-C,

n/a
Los Angeles, California
RH

Robin Horak, MD

Physician
Boston Children's Hospital, United States
MB

Maria Batsis, MD

Fellow Physician
Children's Hospital Los Angeles, United States
Justin Jones, MD

Fellow Physician
Children's Hospital Los Angeles
Los Angeles, California, United States
Daniel Nigri, MD (he/him/his)

Pediatric Critical Care Medicine Fellow
Childrens Hopital Los Angeles
Los Angeles, California
DL

Debra Lotstein, MD, MPH

Physician
Children's Hospital Los Angeles, United States
Meredith Winter, MD

Assistant Professor of Clinical Pediatrics
Childrens Hospital Los Angeles
Los Angeles, California, United States

Introduction: Compassionate extubation (CE) is the withdrawal of ventilatory support as a part of cessation of life-sustaining therapies in the intensive care unit (ICU). Impediments to providing a smooth and comfortable CE include inadequate preparation and communication and lack of appropriate orders in the medical chart. To overcome these challenges, our institution implemented a CE protocol as a part of a quality improvement initiative in the pediatric and cardiothoracic ICUs.

Methods: A multidisciplinary team consisting of nurses, nurse practitioners, critical care and palliative care physicians, respiratory therapists, and a child life specialist performed a needs assessment, identified areas for targeted improvement, and implemented a protocol using Plan-Do-Study-Act (PDSA) cycles. The protocol included a CE checklist, a set of guiding end-of-life principles, and a standardized debrief form. Objective outcomes included time to death after extubation, presence of orders and documentation, and timely cessation of additional life-sustaining therapies such as vasopressors and maintenance fluids. Subjective outcomes from staff included self-reported comfort and perception of patient comfort during CE. Process outcomes included frequency of checklist and debrief form utilization. Outcome data were collected via chart review and staff surveys.

Results: Data was collected on 44 patients in the ICUs, with 18, 14, and 12 patients assessed in the pre-intervention cycle, PDSA cycle 1, and PDSA cycle 2 respectively. Frequency of extubation orders improved from 22% pre-intervention to 92% after PDSA cycle 2. Frequency of advance care plan orders improved from 83% to 100%. Vasoactive medications were discontinued and fluids were stopped or decreased at the time of extubation in 100% of patients after PDSA cycle 2, as compared to 89% and 94% respectively pre-intervention. Time to death was not hastened despite more frequent discontinuation of life-sustaining therapies. At the end of PDSA cycle 2, staff reported improved patient comfort, improved medical plan for comfort, and improved communication.

Conclusions: Implementation of a CE protocol improved the rates of documentation of and compliance with end-of-life procedures. Hospital staff reported greater perceived patient comfort and improved team communication.