528 - Refining Extubation Readiness Testing Performance with Respiratory Therapist Driven Weaning (REPoRT)

Publication Number: 1507.528

Mandar S. Kulkarni, Washington University in St. Louis School of Medicine, Creve Coeur, MO, United States; Colleen Everett, Washington University in St. Louis School of Medicine, St. Louis, MO, United States; Michael A. Kramer, Washington University in St. Louis School of Medicine, Saint Louis, MO, United States; Lisa M. Cracchiolo, St. Louis Children's Hospital, Saint Louis, MO, United States; Michelle Marty, St. Louis Children's Hospital, Highland, IL, United States; Sara Malone, Washington University in St Louis, Saint Louis, MO, United States; John C. Lin, Washington University in St. Louis School of Medicine, St. Louis, MO, United States

Background: Prolonged duration of mechanical ventilation (MV) has been shown to increase morbidity in critically ill children. Protocolized use of Spontaneous Breathing Trials (SBT) in daily practice has been proven to decrease duration of MV in critically ill adults and has been associated with shorter duration of MV in children. Despite this, there is significant heterogeneity among PICUs in implementation of protocolized extubation readiness testing (ERT) screening and performance.

Objective: To evaluate acceptability, fidelity, and workflow of current ERT guidelines and to assess performance of daily SBT screening.

Design/Methods: REPoRT evaluated fidelity of the current guideline through retrospective chart review on all intubated patients over a 3-month period from October to December 2024. Respiratory therapist (RT) knowledge/perspectives of the existing ERT guidelines were assessed using anonymous surveys of PICU RTs. Self-identified RT volunteers participated in semi-structured interviews to develop a workflow map of current practice, to identify facilitators and barriers, and to solicit input on methods to improve ERT screening, performance, and communication. Direct observations of RTs performing ERTs quantified the time required for each task in the workflow map.

Results: Retrospective chart review of 117 patients showed low adherence to daily ERT documentation (Table 1). 26 PICU RTs were surveyed using Likert Scale questions to assess knowledge, adherence, acceptability, and feasibility (Figure 1). Respondents reported having good knowledge of the current pathway, but with variability in adherence. 7 semi-structured interviews involving 10 RTs were also used to build a workflow map (Figure 2) of the protocol. Identified barriers to performance included confusion in documentation and lack of a standing ERT order. Direct observations of ERT performance by bedside RTs allowed triangulation of the workflow and quantification of the time required for each discrete task. To date, 3 observations have been completed with at least 12 observations planned. Analysis of retrospective data, qualitative interview coding, and direct observations is ongoing.

Conclusion(s): While performance of daily ERTs has good acceptability amongst PICU bedside RTs, there are significant barriers to daily practice which include confusion in documentation, lack of clarity in provider preference, and low adherence to daily safety screening. More nuanced understanding of workflow processes, quantification of time required for each step, and identification of rate limiting steps may inform development of more effective ERT processes.

Patient Characteristics and Primary Outcomes of Retrospective Review
Units are specified next to the given parameter. Values in parentheses represent either the percentage of the total cohort (N = 116) or the Interquartile Range 25% - 75%.

Survey Responses organized by Domain
Survey responses complied as Agree (Strongly Agree or Agree) and Neutral/Disagree (Neutral, Disagree, Strongly Disagree). Survey questions are listed with Letters corresponding to the domain being tested. Questions are as follows:

K1 - I am familiar with our ERT protocol, K2 - I understand that our ERT protocol consists of a safety screen and the ERT itself, K3 - I know where to document the results of the safety screen, K4 - I know where to document the results of the ERT.

A5 - I always perform a safety screen on every patient, A6 - if a safety screen is passed, I ask a provider if a ERT is desired, A7 - I always perform an ERT if the safety screen is passed, A8 - I always tell the nurse about the ERT, A9 - I always document the results of a passed ERT, A10 - I always document the results of a failed ERT, A11 - I always communicate the results of an ERT with a provider.

Ac 12 - Doing standardized ERTs helps patient's extubate quicker, Ac 13 - Performing standardized ERTs takes too much time, F14 - My typical clinical workload prevents me from doing daily ERTs.

Workflow Map of ERT Process
Tasks are organized by profession with arrows indicating the general order of tasks being completed. Tasks in Green are those which require interfacing with the EHR, Tasks in Blue require face to face or phone communication with another profession, and takes in purple require direct observation or interaction with the patient.