Article Text

Download PDFPDF
Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis
  1. Paulo Sergio Lucas da Silva1,
  2. Maria Eunice Reis2,
  3. Daniela Farah3,
  4. Teresa Raquel M Andrade3,
  5. Marcelo Cunio Machado Fonseca3
  1. 1Department of Pediatrics, Municipal Civil Servant Hospital, Sao Paulo, Brazil
  2. 2Division of Neonatology, Santa Joana Hospital and Maternity, Sao Paulo, Brazil
  3. 3Health Technologies Assessment Center, Federal University of Sao Paulo Paulista School of Medicine, Sao Paulo, Brazil
  1. Correspondence to Dr Paulo Sergio Lucas da Silva, Department of Pediatrics, Municipal Civil Servant Hospital, Sao Paulo, Brazil; psls.nat{at}terra.com.br

Abstract

Objective To assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children.

Design Systematic review according to the Cochrane guidelines and meta-analysis using random-effects modelling.

Methods We searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Cochrane and SciELO databases from inception until April 2021. We conducted a quality appraisal for each study using the Newcastle–Ottawa Scale and Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0 checklist.

Main outcome The primary outcome measure was UE rates per 100 intubation days.

Results We screened 10 091 records and finally included 11 studies. Six studies were pre/post-intervention studies, and five were interrupted time-series studies. The methodological quality was ‘good’ in 70%, and the remaining as ‘fair’ (30%). The most frequently used implementation strategies were staff education (100%), root cause analysis (100%), and audit and feedback (82%). Key bundle care components comprised identification of high-risk patients, endotracheal tube care and sedation protocol. Not all studies fully completed the SQUIRE V.2.0 checklist. Meta-analysis revealed a reduction in UE rate following the introduction of care bundles (rate ratio: 0.40 (95% CI: 0.19 to 0.84); p=0.02), which equates to a 60% reduction in UE rates.

Conclusions We found that identifying high-risk patients, endotracheal tube care and protocol-directed sedation are core elements in care bundles for preventing UEs. However, there are several methodological gaps in the literature, including poor evaluation of adherence to bundle components. Future studies should address these gaps to strengthen their validity.

  • qualitative research
  • nursing care
  • therapeutics

Data availability statement

No data are available.

Statistics from Altmetric.com

Data availability statement

No data are available.

View Full Text

Footnotes

  • Contributors PSLdS conceptualised and designed the study, carried out the initial analyses, conducted literature search, collected the data, drafted the initial manuscript and approved the final manuscript as submitted. MER, DF and TRMA carried out the initial analyses, conducted literature search, collected the data, drafted the initial manuscript and approved the final manuscript as submitted. MCMF reviewed the literature, designed the data collection instruments, and coordinated and supervised data collection, critically reviewed the manuscript and approved the final manuscript as submitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.