We are excited to present the second edition of the PCCM Global Critical Care Article of the Month! Every 2 months, a team of pediatric intensive care experts from WFPICCS selects one outstanding paper from Pediatric Critical Care Medicine, the Official Journal of WFPICCS, to spotlight key advances, emerging evidence, and perspectives shaping our field.
This initiative aims to foster continuous learning and reflection, encouraging our global community to engage with the latest research that informs and improves the care of critically ill children worldwide.
The selected Article for April 2026 is Nurse-Led Care Bundle for Reducing Unplanned Extubations: Single-Center PICU Experience in India, 2022–2023
Expert commentary by Lokesh Tiwari
Why This Question Matters?
Unplanned extubation (UPE) remains one of the most common and potentially preventable adverse events in pediatric intensive care units (PICUs). UPE can result in hypoxemia, aspiration, airway trauma, emergency reintubation, prolonged mechanical ventilation, longer ICU stay, and increased healthcare costs.1 UPE often arises from modifiable system and process failures rather than solely from disease progression. Consequently, UPE has become an important patient safety indicator and quality metric in critical care units worldwide. Over the past two decades, several institutions have reported success with sedation protocols, standardized tube fixation techniques, handling checklists, and multidisciplinary safety bundles. Much of this evidence originates from high-income settings with favourable staffing ratios, advanced monitoring systems, and established quality-improvement infrastructure.2,3 Whether similar gains can be achieved in resource-constrained settings remains an important question for pediatric critical care globally.
In this context, the study by Kaushal and colleagues deserves attention. Rather than introducing expensive technology or additional personnel, the authors focused on a deceptively simple question: Can a nurse-led, context-specific quality improvement bundle reduce unplanned extubations using resources already available at the bedside?4
What Did This Study Add?
The authors conducted a prospective quality improvement project in a 15-bed multidisciplinary PICU in India. Following a root-cause analysis and Pareto assessment, the team identified inadequate sedation, insecure tube fixation, and procedural handling as the dominant contributors to UPEs. Four sequential Plan-Do-Study-Act (PDSA) cycles were then implemented, followed by a sustainability phase.4
The intervention bundle included standardized YY-method endotracheal tube fixation, routine Comfort-B sedation assessment, structured protocols for high-risk procedures, real-time UPE documentation, staff education, and continuous feedback. Importantly, no additional staffing, equipment, or external funding was required. Across 421 intubated children and 3556 ventilator days, the UPE rate decreased from 1.9 to 1.3 events per 100 intubated patient-days, representing a 31.6% reduction. The final PDSA cycle recorded no UPEs, and low rates were maintained during the sustainability period. Process measures improved substantially, with sedation-score documentation increasing from approximately 65% to 98%, YY fixation compliance reaching nearly 100%, and documentation practices becoming almost universal.
Beyond Tape and Sedation: The Real Story Is Reliability
At first glance, this appears to be a study about tube fixation techniques and sedation scoring. However, the more important lesson may be that successful prevention of UPEs depends less on any individual intervention and more on creating reliable systems of care. One of the most interesting aspects of the study is the use of local root-cause analysis before designing the intervention. Rather than importing a bundle developed elsewhere, the investigators first identified the dominant contextual causes of UPE within their own unit. More than 80% of events were attributable to a small number of modifiable factors, particularly inadequate sedation and loose fixation. The resulting bundle, therefore, targeted the problems that mattered most in the local setting.
This reflects a broader principle of quality improvement: successful interventions are rarely copied wholesale from one institution to another.5 Instead, they are adapted to local workflows, staffing patterns, patient populations, and resource constraints. The greatest strength of this work may therefore be its demonstration of how global evidence can be translated into locally relevant practice.
Why the Nurse-Led Model Matters
Unplanned extubation is fundamentally a bedside event. The day-to-day activities that influence tube security, sedation assessment, repositioning, transport, and procedural handling are largely performed by nursing staff. One of the most important contributions of this study is the central role assigned to nurses in identifying risks, implementing preventive practices, and sustaining change, rather than the specific choice of sedation score or fixation technique. The intervention empowered nurses to become active leaders in airway safety.
This finding has broader implications. In an era when discussions of patient safety increasingly focus on advanced monitoring systems, artificial intelligence, and digital infrastructure, this study serves as a timely reminder that many adverse events remain preventable through consistent execution of basic care processes. Technology can support safety, but it cannot replace vigilance, communication, teamwork, and accountability.
What Can PICUs Around the World Learn?
The YY fixation method and individual bundle component have been known to physicians for a long time.6 The most transferable lesson from this work is the methodology for identifying problems and implementing solutions. The study also reinforces the value of incremental change. The four PDSA cycles allowed repeated testing, feedback, and refinement. Process compliance improved steadily over time, and the most substantial reduction in UPEs occurred after these practices became embedded within routine care. In many ways, the observed decline in UPE rates may be viewed as a consequence of improved process reliability rather than any single intervention.
For PICUs in low- and middle-income countries, the message is particularly encouraging. Resource limitations are frequently cited as barriers to patient safety initiatives. Yet this study demonstrates that meaningful improvements can be achieved without additional staffing, sophisticated technology, or external funding. The study highlights the role of leadership, engagement, education, measurement, and accountability in the PICU.
What the Study Does Not Tell Us
As with many quality improvement studies, several important questions remain unanswered. The single-centre design limits generalizability, and the absence of a concurrent control group limits the definitive role of the reported intervention. Furthermore, important outcomes such as reintubation rates, ventilator-associated pneumonia, duration of mechanical ventilation, ICU length of stay, and mortality were not reported, which may be more important to patients and healthcare systems than UPE alone.
The sustainability phase was relatively short, and longer-term follow-up will be necessary to determine whether gains persist over years rather than months. In addition, the baseline UPE rate in this unit was already lower than that reported in several other LMIC settings, which may influence the magnitude of improvement achievable elsewhere. Nevertheless, these limitations should be interpreted within the context of QI research, where the primary objective is to improve care in local clinical settings rather than establish definitive causal relationships.
Take-Home Message
Kaushal and colleagues remind us that preventing unplanned extubation is not simply a matter of securing an endotracheal tube. It is a matter of securing reliable systems of care. Through a nurse-led, locally adapted quality improvement program, the authors achieved a meaningful reduction in UPEs without additional resources, technology, or staffing.
References
Children: Impact on Hospital Cost and Length of Stay. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2015;16(6):572-575.
- Klugman D, Melton K, Maynord PO, et al. Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children. JAMA Pediatr. 2020;174(6):e200268.
- Melton K, Lee A, Macartney J, et al. Reducing Pediatric Unplanned Extubation: A National Quality Improvement Collaborative. Pediatrics. 2025;155(5):e2024068304.
- Kaushal S, Nagi M, Saini R, Nallasamy K, Bansal A. Nurse-Led Care Bundle for Reducing Unplanned Extubations: Single-Center PICU Experience in India, 2022–2023. Pediatr Crit Care Med. 2026;27(3):307-315.
- Inata Y, Nakagami-Yamaguchi E, Ogawa Y, Hatachi T, Takeuchi M. Quality Assessment of the Literature on Quality Improvement in PICUs: A Systematic Review. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2021;22(6):553-560.
- Fitzgerald RK, Davis AT, Hanson SJ, National Association of Children’s Hospitals and Related Institution PICU Focus Group Investigators. Multicenter Analysis of the Factors Associated With Unplanned Extubation in the PICU. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2015;16(7):e217-223.
