"Our first concern for the children in the pediatric intensive care unit is their safety," said Steven E. Lucking, M.D., chief, division of pediatric critical care, Penn State Children's Hospital. "Unplanned dislodging, or extubations, of breathing tubes, can cause serious injury including damage to the airway."
A 10-year study, recently published in Pediatric Critical Care Medicine, showed that a process called the Penn State Children's Hospital Sedation Algorithm, developed by Myra Popernack, R.N. C.C.R.N., pediatric critical care nurse, and Lucking and used by a team of nurses, respiratory therapists and physicians in the pediatric intensive care unit, resulted in a significant decrease in unplanned extubations without increasing the length of stay for patients in the pediatric intensive care unit.
When children are critically ill and need help with breathing, they may be placed on mechanical ventilation, which means that tubes are placed down their throats and machines regulate their respiration. During mechanical ventilation, sedatives are used to keep the children comfortable and to try to prevent the tubes from being deliberately or inadvertently removed by the patient, an event termed, unplanned or accidental extubation.
The Penn State Children's Hospital Sedation Algorithm sets six target behavior goals for ventilated children, such as "awake" or "arouses to light stimulation," and corresponding medication recommendations to achieve those desired behaviors. This goal-setting, based on objective criteria, allows for more consistency in the child's care across staffing shifts and ensures that each child is given adequate medication to ensure appropriate alertness and comfort level while, at the same time, preventing removal of breathing tubes.
From July 1991 to June 1996, before making any additional changes to the standard of care, the team tracked total ventilation days, incidence of unplanned extubations, diagnosis of patients who self-extubated, and patient outcomes.
"This data showed that steps we'd already taken to decrease rates of accidental extubation were working. Our levels were below those in published data from other pediatric ICUs, however, we felt that even a single unplanned extubation was unacceptable due to the potentially dangerous result," Popernack said. "Our goal was - and is - to eliminate unplanned extubations completely."
So based on the first five years of data, the team proposed that a standard process, or algorithm, of goal-directed sedation may further reduce the incidence of unplanned extubations in critically ill pediatric patients. The goals of the algorithm were to address patient safety during mechanical ventilation, create guidelines for individual patients that would allow nurses more autonomy in caring for the patients, and facilitate communication between nurses and physicians as well as between medical staff from different shifts.
The algorithm established six levels of sedation, each based on alertness of the child and the amount of ventilator support required. For example, the goal for Level 1 is, "Awake and interactive with the environment." The "action" then details the types of medications that should be considered for that child, based on their individual needs, to maintain the appropriate level of alertness.
Along with the levels, a protocol was established for using the algorithm. When a child was placed on a ventilator, the desired level was established by the patient's medical team and prescribed by physician order. The nurses administered physician-prescribed medications to achieve the desired goal. In collaboration with the nurses, the respiratory therapists were responsible for identifying changes in patient status that deviated from the goal. An evaluation and adjustments were made daily or more frequently if necessary and all elements of the patient's care were documented and communicated to the family and among medical staff.
Starting in 1996 after implementation of the algorithm, unplanned extubation rates were tracked for five years. The data showed that unplanned extubations dropped from between 0.44 and 0.63 per 100 intubated patient days before use of the algorithm, to between 0 and 0.19 per 100 intubated patient days for the four years after mandatory use of the algorithm. Length of stay in the pediatric intensive care unit did not increase, suggesting that the tools used in the algorithm did not lead to increased ventilator days.
"This data shows that with coordinated care and well-defined guidelines that are communicated among caregivers, we can improve care for our pediatric patients," Lucking said. "We'd like for the Penn State Children's Hospital Sedation Algorithm to be implemented in other pediatric intensive care units to validate these findings."
In addition to Lucking and Popernack, study authors included Neal J. Thomas, M.D., assistant professor of pediatrics, Penn State College of Medicine.