This document summarizes evidence regarding nurse to patient ratios in pediatric intensive care units (PICUs) and the impact on unplanned extubations. Two studies found higher rates of unplanned extubations were associated with nursing shortages and nurse to patient ratios above 1:1 for intubated pediatric patients. The document proposes piloting an acuity-based staffing model in one PICU with intubated patients having a 1:1 ratio to decrease extubation rates and improve outcomes. It outlines assembling a team, communicating the vision, empowering staff involvement, and assessing results to anchor the new approach.

1. Staffing the Pediatric Intensive Care Unit Marti George, RN University of Wisconsin Green Bay

2. Caring for intubated pediatric patients For pediatric patients in an intensive care setting, is there a difference in unplanned extubations with nurse to patient ratio of 1:1 as compared to a nurse to patient ratio of 1:2?

3. Summary of Evidence Source #1 daSilva, P., & de Carvalho, W. (2010). Unplanned extubation in pediatric critically ill patients: A systemic review and best practice recommendations, Pediatric Critical Care Medicine, 11(2). Purpose A systemic literature review to update the state of knowledge of unplanned extubations in the pediatric population

4. Summary of Evidence Source #1 cont. Sample 11 total articles based on pediatric studies involving unplanned extubations 9 prospective cohort studies 1 retrospective and prospective cohort study 1 case-control study Design Systemic review

5. Summary of Evidence Source #2 Ream, R., Mackey, K., Leet, T., Green, C., Andreone, T., Loftis, L., & Lynch, R. (2007). Association of nursing workload and unplanned extubations in a pediatric intensive care unit, Pediatric Critical Care Medicine, 8(4), 366-371. Purpose To estimate nursing workload from the patient acuity level assigned to patients in a pediatric intensive care unit and to determine its influence on unplanned extubations.

6. Summary of Evidence Source #2 cont. Sample Purposive sampling of 2139 nursing shifts with 1,919 admissions to the PICU over a 2 year period 739 PICU patients (39%) received mechanical ventilatory support 40 unplanned extubations of 40 individual patients (n=40) Shifts with unplanned extubations (n=40) Shifts without unplanned extubations (n=2153)

7. Summary of Evidence Source #2 cont. Design Prospective cohort study Independent Variables: Patient acuity level (using a hospital acuity scoring system) Patient / nurse ratio Dependent Variable: Unplanned extubations

8. Summary of Evidence Source #2 cont. Measurement Data collected from the PICU database, respiratory therapy department database (therapist hours and intubated patients per shift), and nursing department records. (staffing, patient census, and patient acuity level). Monthly reports from risk management and shift reports were reviewed for unplanned extubations

9. Summary of Evidence Other Sources of Evidence American Academy of Pediatrics. (2004). Clinical report: Guidelines and levels of care for pediatric intensive care units. Pediatrics, 114(4), 1114-1125. This clinical report provides guidelines for care of patients in the pediatric intensive care unit. It covers personnel, hospital services, hospital facilities, training, medications and monitoring.

10. Summary of Evidence Other Sources of Evidence Society of Pediatric Nurses (2007). Position statement: Safe staffing for pediatric patients. Pensacola, FL.: Author This position statement provides guidelines and addresses nurse staffing and education based on patient needs for pediatric patients in an inpatient setting.

11. Summary of Evidence Conclusions Incidence of unplanned extubation is higher in the pediatric population. Nursing staff shortage was associated with unplanned extubation. Nurse-to-patient ratio of 1:1 is recommended. Continuous quality improvement team Development of appropriate data tracking tools and data collection

12. Summary of Evidence Conclusions Future studies are recommended to further explore the work environment in the PICU and adverse events. Staffing ratios should take into account not only patient acuity mix but also nursing skill mix.

13. Innovation Change staffing in the pediatric intensive care unit to acuity based and make intubated patients a 1:1 staffing ratio.

14. Stakeholders identified Patients Staff nurses Support staff Physicians Hospital Parents Family

15. Policy and procedures identified as needed or updated Staffing policy - include an acuity based model Staffing policy - how to achieve 1:1 ratio in case of short staffing. Education policy - address the care of intubated pediatric patients.

16. Kotter’s Phases of Change Model Project Name Pilot- Trial staffing in the pediatric intensive care unit by acuity, making intubated pediatric patients 1:1 Establish Urgency Develop a presentation for staff meeting to show the relationship between staffing and unplanned extubations, including statistics and outcomes.

17. Kotter’s Phases of Change Model Create Coalition Assemble a team- a staff nurse from each shift on pilot unit, unit director, nurse manager, charge nurse, respiratory therapist and unit medical director. Develop Vision How does this affect nurses, support staff, physicians, families, budget. Vision statement: Decrease unplanned extubation rates, improve patient outcomes improving staff, physician and family satisfaction.

18. Kotter’s Phases of Change Model Communicate Vision Poster presentation for break room detailing how staffing will be handled to accommodate new staffing ratio and acuity. Email presentation to all involved. Empower Action Weekly team meetings for first month and then monthly to review staff responses and suggestions. Suggestion box placed in unit where staff can voice concerns or recommendations and may do so anonymously if needed.

19. Kotter’s Phases of Change Model Generate Short-term Wins Present unplanned extubation data monthly compared to previous months, along with staff, physician, and family satisfaction. Post information in break room, department newsletter, and hospital newsletter Consolidate Gains/Produce More Expand pilot to one additional unit after six months, using staff from original unit as change champions and support for new unit.

20. Kotter’s Phases of Change Model Anchor Approaches Discuss ongoing results and concerns at quarterly staff meetings for two years. Team will continue to keep track of extubation rates and circumstances.