(Screen 1 - 6:00 PM Saturday) Best Practice Peri-Extubation Bundle Derived from High-Performing CICUs Reduces Neonatal Extubation Failure After Cardiac Surgery

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Abstract: Introduction/Objectives
Extubation failure after neonatal cardiac surgery is independently associated with poor clinical outcomes including morbidity and mortality. There is a wide variation in risk-adjusted neonatal extubation failure rates across centers participating in the Pediatric Cardiac Critical Care Consortium (PC4). Recognizing higher-than-expected extubation rates in center-specific PC4 data, we aimed to implement a quality improvement bundle to improve this outcome. Utilizing practices from high-performing PC4 centers, we aimed to create and implement a best practices bundle at our institution and evaluate its effect on extubation success in neonatal postoperative cardiac surgical patients.

Methods
Utilizing the PC4 registry, we identified five CICUs with lower than expected neonatal extubation failure rates with the balancing metric of expected or better than expected duration of postoperative mechanical ventilation. These centers were surveyed using a structured telephone interview regarding neonatal extubation practices including: use of spontaneous breathing or extubation readiness trials, steroids, post-extubation respiratory support, criteria utilized for extubation readiness, and criteria for high-risk extubations. These data underwent qualitative content analysis to create a peri-extubation bundle of best practices. Inclusion criteria for bundle implementation included patients < 60 days of age undergoing an index cardiac surgical procedure. Patients were excluded if they had a tracheostomy or were extubated within 6 hours of the operation. Extubation failure was defined as reintubation within 48 hours of extubation except for planned procedures. After bundle component training for unit staff, implementation occurred on January 2, 2022. The neonatal extubation failure rate for 6 months preintervention was calculated and compared to the neonatal extubation failure rate in the 6 months after bundle implementation.

Results:
During the preintervention time period, there were 27 extubations in 26 patients. Three patients failed extubation (11.1%). During the postintervention period, there were 27 extubations in 23 patients with 1 extubation failure (3.7%) resulting in 66.7% relative reduction in extubation failures after bundle implementation.

Conclusions
A peri-extubation bundle, derived from best practices at high performing CICUs, to standardize extubation practice decreases neonatal extubation failures. This is the first study on extubation practice to utilize data from high-performing CICUs to create a peri-extubation bundle. Furthermore, this study demonstrates the utility of transparency in data-sharing to improve outcomes in pediatric CICU patients.