A Quality Improvement Initiative to Decrease Duration of Mechanical Ventilation in a Tertiary PICU

Introduction: Prolonged mechanical ventilation (MV) has been associated with ventilator-induced lung injury, neuromuscular weakness, and increased length of stay. Our quality improvement (QI) initiative aimed to protocolize extubation readiness testing in order to decrease the duration of MV in patients admitted to the PICU at Nicklaus Children’s Hospital.


Methods: Extubation readiness testing guidelines were created after reviewing published literature (PDSA 1: March to December 2023). PICU staff, including nurses, respiratory therapists, residents, fellows, and attending physicians, were educated and encouraged to follow these guidelines (PDSA 2: May to July 2024). Data was collected from the Virtual Pediatric Systems from January 2023 to July 2025, including demographic data, length of PICU stay (LOS), length of MV, and admission PRISM score for patients 1 month to 21 years who were intubated for more than 3 days. The guidelines were implemented in August 2024 (PDSA 3: August to December 2024). We stratified patients based on their PRISM score. We compared the duration of MV, length of ICU stay, and extubation failure rates before and after guideline implementation (PDSA 4: January to July 2025) and evaluated the data with run charts, chi-square, and Mann-Whitney U tests. Extubation failure was defined as reintubation within 48 hours. Local IRB approved the project.


Results: The median length of MV at baseline was 8.3 days, which decreased to 7.1 days post-intervention. The reduction in length of MV was higher in the subgroups with PRISM 6-10 (9.6 days vs 7.3 days) and PRISM 11-15 (8.2 days vs 5 days). The reduction in LOS was higher in the subgroup with PRISM 6-10 (26.4 days vs 16.5 days). Extubation failure rates (balancing measure) did not change significantly after guideline implementation (2.04% vs 3.03%; p=0.66).


Conclusions: Implementation of extubation readiness guidelines decreases the length of MV without increasing the extubation failure rate. Patients with higher PRISM scores benefit the most from the intervention. We will continue to perform PDSA cycles to sustain the gains from the interventions.