Quality Improvement Interventions to Prevent Unplanned Extubations in Pediatric Critical Care: A Systematic Review

Abstract Background An unplanned extubation is the uncontrolled and accidental removal of a breathing tube. The health impact of an unplanned extubation ranges from minimal to life-threatening, but this is an important quality indicator in pediatric critical care. ObjectiveTo comprehensively synthesize literature published on quality improvement (QI) practices implemented to reduce the rate of unplanned extubations in critically ill children. Methods Data Sources and Study Selection: A search was conducted in MEDLINE, Embase, and CINHAL from inception through April 29, 2021. Two reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data Extraction and Data Synthesis: Data from included studies were abstracted using a tool created by the authors, and QI interventions were categorized using the Behavior Change Wheel. Study quality was assessed using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Results were presented as descriptive statistics and narrative syntheses. ResultsTwelve studies were included in the final review. Ten described primary QI projects; two were sustainability studies that followed up on previously described QI interventions. Half of the included studies were rated as high-quality. The median number of QI interventions described by each study was 4.5 [IQR 4-5], with a focus on guidelines, environmental restructuring, education, training, and communication. Nine studies reported decreased unplanned extubation rates after the QI intervention; of these, six had statistically significant reductions. Both sustainability studies observed increased rates that were not statistically significant. ConclusionsThis review provides a comprehensive synthesis of QI interventions to reduce unplanned extubation. With only half the studies achieving a high-quality rating, there is room for improvement when conducting and reporting research in this area. Findings from this review can be used to support clinical recommendations to prevent unplanned extubations, and support patient safety in pediatric critical care. Systematic Review RegistrationThis review was registered on PROSPERO (CRD42021252233) prior to data extraction.