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 and is an important quality indicator in pediatric critical care. The objective of this review was to comprehensively synthesize literature published on quality improvement (QI) practices implemented to reduce the rate of unplanned extubations in critically ill children. Methods We included original, primary research on quality improvement interventions to reduce the rate of unplanned extubations in pediatric critical care. A search was conducted in MEDLINE (Ovid), Embase, and CINAHL from inception through April 29, 2021. Two reviewers independently screened citations in duplicate using pre-determined eligibility criteria. Data from included studies were abstracted using a tool created by the authors, and QI interventions were categorized using the Behavior Change Wheel. Vote counting based on the direct of effect was used to describe the effectiveness of quality improvement interventions. Study quality was assessed using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Results were presented as descriptive statistics and narrative syntheses. Results Thirteen studies were included in the final review. Eleven described primary QI projects; two were sustainability studies that followed up on previously described QI interventions. Under half of the included studies were rated as high-quality. The median number of QI interventions described by each study was 5 [IQR 4–5], with a focus on guidelines, environmental restructuring, education, training, and communication. Ten studies reported decreased unplanned extubation rates after the QI intervention; of these, seven had statistically significant reductions. Both sustainability studies observed increased rates that were not statistically significant. Conclusions This 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 registration This review was registered on PROSPERO (CRD42021252233) prior to data extraction