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Appropriate use criteria for endotracheal suction interventions in mechanically ventilated children: The RAND/UCLA development process

Open AccessPublished:December 16, 2021DOI:https://doi.org/10.1016/j.aucc.2021.10.006

      Abstract

      Objectives

      Endotracheal suction is an invasive airway clearance technique used in mechanically ventilated children. This article outlines the methods used to develop appropriate use criteria for endotracheal suction interventions in mechanically ventilated paediatric patients.

      Methods

      The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop paediatric appropriate use criteria. This included the following sequential phases of defining scope and key terms, a literature review and synthesis, expert multidisciplinary panel selection, case scenario development, and appropriateness ratings by an interdisciplinary expert panel over two rounds. The panel comprised experts in the fields of paediatric and neonatal intensive care, respiratory medicine, infectious diseases, critical care nursing, implementation science, retrieval medicine, and education. Case scenarios were developed iteratively by interdisciplinary experts and derived from common applications or anticipated intervention uses, as well as from current clinical practice guidelines and results of studies examining interventions efficacy and safety. Scenarios were rated on a scale of 1 (harm outweighs benefit) to 9 (benefit outweighs harm), to define appropriate use (median: 7 to 9), uncertain use (median: 4 to 6), and inappropriate use (median: 1 to 3) of endotracheal suction interventions. Scenarios were than classified as a level of appropriateness.

      Conclusions

      The RAND Corporation/University of California, Los Angeles Appropriateness Method provides a thorough and transparent method to inform development of the first appropriate use criteria for endotracheal suction interventions in paediatric patients.

      Keywords

      1. Introduction

      Endotracheal suction (ETS) is a mainstay secretion management technique for mechanically ventilated children worldwide. Despite its importance and frequency of application, ETS is an invasive and potentially harmful intervention. Observational studies in critically ill children have demonstrated that approximately 25% of ETSs
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      Adverse events and practice variability associated with paediatric endotracheal suction: an observational study.
      contribute to postsuction complications including oxygen desaturation,
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      A bedside decision tree for use of saline with endotracheal tube suctioning in children.
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      • Charles K.
      • et al.
      Normal saline and lung recruitment with pediatric endotracheal suction: a pilot, factorial, randomized controlled trial.
      cardiovascular interactions,
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      • Copnell B.
      Endotracheal suctioning of the critically ill child.
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      Endotracheal suction in high risk patients.
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      Patterns of instability associated with endotracheal suctioning in infants with single-ventricle physiology.
      and ventilator-associated infection.
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      • Ware R.S.
      • Charles K.
      • et al.
      Normal saline and lung recruitment with pediatric endotracheal suction: a pilot, factorial, randomized controlled trial.
      ,
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      Investigation into the effect of closed-system suctioning on the frequency of pediatric ventilator-associated pneumonia in a developing country.
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      Ventilator associated pneumonia in children.
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      Ventilator associated pneumonia: evolving definitions and preventive strategies.
      and prolonged paediatric intensive care unit (PICU) admission which in turn increase the likelihood of PICU-acquired complications and impact survivorship.
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      PICU-acquired complications: the new marker of the quality of care.
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      Cost associated with pediatric delirium in the ICU.
      Internationally, ETS practice lacks standardisation, with the variable use of ETS interventions (e.g., normal saline instillation, preoxygenation, postoxygenation) likely contributing to the high incidence of complications.
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      • Woods C.R.
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      • Boone M.C.
      • Calhoun A.W.
      • Montgomery V.L.
      • et al.
      A bedside decision tree for use of saline with endotracheal tube suctioning in children.
      ,
      • Tume L.
      Endotracheal suction in high risk patients.
      ,
      • Schults J.
      • Mitchell M.L.
      • Cooke M.
      • Schibler A.
      Efficacy and safety of normal saline instillation and paediatric endotracheal suction: an integrative review.
      However, clinical decision-making regarding ETS intervention use in the PICU is complex. The heterogeneous nature of the PICU population and the high-acuity environment mean decisions must be made quickly, often in high-stake situations by nurses with relatively little critical care experience (i.e., < 12–24 months). These decisions are further complicated by a lack of clear guidelines, to help inform the decision-making process. This results in a heavy reliance on a clinician's own clinical experience and judgement.
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      • Cooke M.
      • Long D.
      • Mitchell M.
      “When no-one’s looking,” the application of lung recruitment and normal saline instillation with paediatric endotracheal suction: an exploratory study of nursing practice.
      Use of historical ETS practices such as ad hoc use of saline or lung recruitment may not be the best way to optimise ventilation strategies, improve oxygenation, or to prevent suction-related complications. Given the widespread variability and uncertainty regarding ETS best practice in the PICU, clinicians and patients would benefit from improved clinical guidance regarding the appropriateness (and inappropriateness) of ETS interventions. This guidance could be used to support clinical decision-making at the bedside, reduce variation in care and harmful practices, and improve outcomes for children and their families.
      In response to the need for improved guidance regarding the use of ETS interventions in the delivery of high-quality care, we undertook a process to determine the appropriate use of ETS interventions for paediatric patients. The resulting resource will be referred to as The Paediatric AirWay Suction (PAWS) appropriateness guide for ETS interventions.

      2. Methods

      2.1 Design

      Using the RAND Corporation/University of California, Los Angeles (RAND/UCLA) Appropriateness Method,
      • Fitch K.
      • Bernstein S.J.
      • Aguilar M.D.
      • Burnand B.
      • LaCalle J.
      • Lazaro P.
      we developed appropriate use criteria for ETS interventions in mechanically ventilated children across Australia and New Zealand. Appropriateness refers to the relative weight of the benefits and harms of an intervention.
      • Fitch K.
      • Bernstein S.J.
      • Aguilar M.D.
      • Burnand B.
      • LaCalle J.
      • Lazaro P.
      The method balances the best available scientific evidence with the collective judgement of experts to form a statement regarding the appropriateness of using a procedure.
      • Fitch K.
      • Bernstein S.J.
      • Aguilar M.D.
      • Burnand B.
      • LaCalle J.
      • Lazaro P.
      The appropriate procedure is evidence based, is individualised to the patient, is cost-effective, and achieves expert consensus. This method is valuable for the current study given the limited availability of high-quality evidence surrounding paediatric ETS interventions.
      • Schults J.A.
      • Mitchell M.L.
      • Cooke M.
      • Long D.
      • Ferguson A.
      • Morrow B.
      • et al.
      Endotracheal suction interventions in mechanically ventilated children: an integrative review to inform evidence-based practice.
      The Appropriateness Method has been used to develop appropriate use criteria internationally and across health disciplines,
      • Ullman A.J.
      • Bernstein S.J.
      • Brown E.
      • Aiyagari R.
      • Doellman D.
      • Faustino V.
      • et al.
      The Michigan appropriateness guide for intravenous Catheters in pediatrics: miniMAGIC.
      • Saag K.G.
      • Teng G.G.
      • Patkar N.M.
      • Anuntiyo J.
      • Finney C.
      • Curtis J.
      • et al.
      American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis.
      • McAlindon T.E.
      • Bannuru R.R.
      • Sullivan M.
      • Arden N.
      • Berenbaum F.
      • Bierma-Zeinstra S.M.
      • et al.
      OARSI guidelines for the non-surgical management of knee osteoarthritis.
      with a number of apropirate use criteria implemented in clinical practice, including for advanced diagnostic imaging
      • Hussey P.S.
      • Timbie J.W.
      • Burgette L.F.
      • Wenger N.
      • Nyweide D.
      • Kahn K.
      • et al.
      Appropriateness of advanced diagnostic imaging ordering before and after implementation of clinical decision support systems.
      and transthoracic echocardiography.
      • Salik J.R.
      • Sen S.
      • Picard M.H.
      • Weiner R.B.
      • Dudzinski D.
      The application of appropriate use criteria for transthoracic echocardiography in a cardiac intensive care unit.
      The RAND/UCLA Appropriateness Method involves sequential phases, detailed in Fig. 1. Ethical approval to undertake the study was obtained from Griffith University Human Research Ethics Committee (GU REF: 2019/916). All expert panel members provided written informed consent before panel participation.
      Figure 1
      Fig. 1RAND/UCLA Appropriateness Method phases.

      2.2 Context and applicability

      The PAWS guideline focused on defining the appropriateness of interventions that are most commonly applied during ETS in mechanically ventilated children in intensive care, across Australia and New Zealand. These geographical locations were chosen to reflect current collaborations and the need to generate recommendations that would take into account varying care contexts across these locations. The PAWS included critically ill paediatric patients from birth to 18 years of age. We did not seek to provide appropriate recommendations for preterm neonates admitted to neonatal intensive care units or special care after birth as this cohort requires a specialist approach and consideration of differing lung pathology and mechanics. Included patient populations (e.g., general, cardiovascular, severe traumatic brain injury, respiratory and specialist patient populations) were included to represent the diversity amongst key PICU service users across Australia and New Zealand.
      ETS interventions included in the PAWS are representative of the most common adjunct interventions used within Australia and New Zealand; as such we intentionally excluded practices that are not specifically utilised in these healthcare settings (e.g., lignocaine installation).
      • Argent A.C.
      Endotracheal suctioning is basic intensive care or is it?: commentary on article by Copnell et al. on page 405.
      ,
      • Argent A.C.
      Endotracheal lidocaine installation, endotracheal suction, and intracranial pressure in patients with traumatic brain injury—assessing the impact∗.
      This decision was made with the support of the expert panel. We also sought to provide guidance on important clinical questions surrounding ETS practice that were current areas of uncertainty, irrespective of evidence availability or quality.

      2.3 Definition of key terms

      ETS: The artificial aspiration of respiratory secretions from the distal end of an endotracheal tube to maintain airway patency and facilitate ventilation and oxygenation.
      • Schults J.A.
      • Mitchell M.L.
      • Cooke M.
      • Long D.
      • Ferguson A.
      • Morrow B.
      • et al.
      Endotracheal suction interventions in mechanically ventilated children: an integrative review to inform evidence-based practice.
      ,
      • Morrow B.
      • Argent A.
      A comprehensive review of pediatric endotracheal suctioning: effects, indications, and clinical practice.
      Invasive mechanical ventilation: Ventilatory support (assistance to breathing) delivered by invasive means (oral or nasal endotracheal tube) including conventional mechanical ventilation and high-frequency oscillation ventilation. For the purposes of following the PAWS guideline, this included positive pressure ventilation modes and continuous positive airway pressure.
      • Lema-Zuluaga G.L.
      • Fernandez-Laverde M.
      • Correa-Varela A.M.
      • Zuleta-Tobon J.
      As-needed endotracheal suctioning protocol vs a routine endotracheal suctioning in Pediatric Intensive Care Unit: a randomized controlled trial.
      We excluded children receiving mechanical ventilation via a tracheostomy tube owing to their unique considerations.
      Populations: Population definitions including age and subspecialty populations are outlined in Table 1.
      Table 1Population categories.
      Demographic itemDefinition
      Age
      • Jacobs J.P.
      • O’Brien S.M.
      • Pasquali S.K.
      • Gaynor J.
      • Mayer J.
      • Karamlou T.
      • et al.
      The society of thoracic surgeons congenital heart surgery database mortality risk model: Part 2-clinical application.
      ,
      NeonateFrom full-term to less than ≤30 days of age
      InfantAged between >31 days and 12 months
      ChildAged between >12 months and 11 years
      AdolescentAged between >11 years and 18 years
      Patient population
      Critically illPaediatric patients receiving care in an intensive care setting.
      General paediatric
      Includes patients admitted for the following reasons: neurologic or neuromuscular diagnosis, gastrointestinal, metabolic, malignancy, technology dependency, renal or urologic, haematologic or immunologic, other congenital or genetic defect, transplantation, mental health/behavioural
      Specialty population
      Cardiovascular
      A patient who has been admitted for medical or surgical treatment of an underlying congenital cardiac condition or acquired cardiovascular disease.
      Subspecialty populations
      • Rosenzweig E.B.
      • Abman S.H.
      • Adatia I.
      • Beghetti M.
      • Bonnet D.
      • Haworth S.
      • et al.
      Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management.
      ,
      • Lindstrom S.J.
      • Pellegrino V.A.
      • Butt W.W.
      Extracorporeal membrane oxygenation.
      • i.
        Low-risk and stable haemodynamics after cardiac surgery, e.g., low risk: atrial septal defect, ventricular septal defect, coarctation repair, stage II and III single-ventricle pathway;
      • ii.
        High-risk and/or unstable haemodynamics after cardiac surgery, e.g., high risk: stage 1 single-ventricle pathway, systemic-to-pulmonary artery shunts, pulmonary artery band, neonatal repair of truncus arteriosus, transposition of the great arteries;
      • iii.
        High-risk cardiovascular conditions, patients with severe cardiac conditions with a high degree of instability, e.g., known cardiac dysfunction, cardiomyopathy;
      • iv.
        Pulmonary hypertension, high blood pressure that affects the arteries in your lungs and the right side of the heart; and
      • v.
        Extracorporeal membrane oxygenation is a technique that involves oxygenation of blood outside the body and provides support to selected patients with severe respiratory or cardiac failure.
      Specialty population
      Severe traumatic brain injury
      • Araki T.
      • Yokota H.
      • Morita A.
      Pediatric traumatic brain injury: characteristic features, diagnosis, and management.
      Including the following primary reasons for admission: Primary TBI (skull fractures and intracranial injury) or secondary TBI (diffuse cerebral swelling), e.g., severe TBI (these are the ones we intubate for neurological reasons not because of other injuries)
      Subspecialty populations
      Specialty population
      Respiratory
      A pathological condition that effects the lungs and other parts of the respiratory system that facilitate gas exchange and respiration
      Subspecialty populations
      Additional patient populations
      • Jardine E.
      • Wallis C.
      Core guidelines for the discharge home of the child on long-term assisted ventilation in the United Kingdom. UK Working Party on Paediatric Long Term Ventilation.
      • Sterni L.M.
      • Collaco J.M.
      • Baker C.D.
      • Carroll J.L.
      • Sharma G.D.
      • Brozek J.L.
      • et al.
      An official American thoracic society clinical practice guideline: pediatric chronic home invasive ventilation.
      • Nixon G.
      • Edwards E.
      • Cooper D.
      Ventilatory support at home for children: a consensus statement from the Australasian paediatric respiratory group.
      • a.
        Patients requiring long-term ventilation: any child who, when medically stable, continues to require a mechanical aid for breathing (3 months after the institution of ventilation), after an acknowledged failure to wean, or a slow wean, 3 months after the institution of ventilation. Including children who require invasive ventilation in the home
      • b.
        Patients requiring ventilation for palliative support: ventilatory support provided with a focus on palliation of symptoms and to facilitate quality of life in children with a life-limiting condition.
      • c.
        Patients requiring ventilation for transport: ventilatory support provided with a focus on the transportation of the patient to another location or healthcare facility.
      ICP, intracranial pressure; TBI, traumatic brain injury.
      Clinical indications for ETS were categorised into two classifications:
      • Davies K.
      • Monterosso L.
      • Bulsara M.
      • Ramelet A.
      Clinical indicators for the initiation of endotracheal suction in children: an integrative review.
      • Davies K.
      • Monterosso L.
      • Leslie G.
      Determining standard criteria for endotracheal suctioning in the paediatric intensive care patient: an exploratory study.
      • Davies K.
      • Bulsara M.K.
      • Ramelet A.S.
      • Monterosso L.
      Reliability and criterion-related validity testing (construct) of the Endotracheal Suction Assessment Tool (ESAT(c)).
      nonrespiratory indications such as routine or proactive/preprocedural indications (e.g., pre-extubation, before transfer) and respiratory indications, that is a change in the patient's respiratory status (e.g., decreased air entry, visible/audible secretions, change in tidal volume, peak inspiratory pressure, or end tidal CO2).
      ETS interventions: A range of ETS treatments which are used to support secretion clearance via the endotracheal tube are defined in Table 2.
      Table 2Endotracheal suction interventions.
      • Schults J.A.
      • Cooke M.
      • Long D.A.
      • Schibler A.
      • Ware R.S.
      • Charles K.
      • et al.
      Normal saline and lung recruitment with pediatric endotracheal suction: a pilot, factorial, randomized controlled trial.
      ,
      • Rosenzweig E.B.
      • Abman S.H.
      • Adatia I.
      • Beghetti M.
      • Bonnet D.
      • Haworth S.
      • et al.
      Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics and management.
      • Lindstrom S.J.
      • Pellegrino V.A.
      • Butt W.W.
      Extracorporeal membrane oxygenation.
      • Araki T.
      • Yokota H.
      • Morita A.
      Pediatric traumatic brain injury: characteristic features, diagnosis, and management.
      • Rangel-Castilla L.
      • Gopinath S.
      • Robertson C.S.
      Management of intracranial hypertension.
      • Rath G.P.
      • Dash H.H.
      Anaesthesia for neurosurgical procedures in paediatric patients.
      ANZICS
      The statement on death and organ donation.
      Pediatric Acute Lung Injury Consensus Conference Group
      Pediatric acute respiratory distress syndrome: consensus recommendations from the pediatric acute lung injury consensus conference.
      InterventionDefinition
      PresuctionInterventions to facilitate optimisation of the endotracheal suction event, typically applied immediately preceding the suction
      PreoxygenationThe deliberate increase in the FiO2 before the endotracheal suction.
      PrebaggingDisconnection of ETT from ventilator circuit to anaesthetic bag and ventilation delivered using anaesthetic bag, also referred to a bag-ETT ventilation.
      MAP manipulationIncrease in mean airway pressure before endotracheal suction in children receiving HFOV.
      Suction procedureBreaking of the ventilator-ETT circuit or the intention to commence suction using a closed system.
      Normal saline instillation0.9% saline solution (sodium chloride) instilled into the endotracheal tube during the suction.
      Open suctionOpen-suction system requiring the disconnection of the patient from the mechanical ventilator to mechanically aspirate secretions.
      Closed suction
      Inline suction system.
      The mechanically aspiration of secretions occurring while patient remains connected to the mechanical ventilator using an inline suction system.
      Deep suctionSuction to the point of resistance (i.e., carina)
      PostsuctionInterventions to facilitate optimisation of the endotracheal suction event, typically applied immediately after the suction
      PostoxygenationThe deliberate increase in FiO2 after the completion of the endotracheal suction
      PostbaggingDisconnection of ETT from ventilator circuit to anaesthetic bag and ventilation delivered using anaesthetic bag, also referred to a bag-ETT ventilation.
      PEEP manipulationA deliberate treatment to increase pulmonary pressure and maximise alveolar recruitment and gas surface exchange area. For this project, PEEP manipulation refers to increasing the baseline PEEP, for example, by a factor of 2 (e.g., 5–10 cm H20) or incremental PEEP where incremental increases in PEEP are involved followed by incremental decreases to return to baseline.
      ETT, endotracheal tube; FiO2, fraction of inspired oxygen; HFOV, high-frequency oscillation ventilation; H2O, centimetres of water; MAP, mean airway pressure; PEEP, positive and spiritual pressure.
      a Inline suction system.

      2.4 Evidence review and synthesis

      An integrative review of the literature
      • Schults J.A.
      • Mitchell M.L.
      • Cooke M.
      • Long D.
      • Ferguson A.
      • Morrow B.
      • et al.
      Endotracheal suction interventions in mechanically ventilated children: an integrative review to inform evidence-based practice.
      was undertaken to summarise the available scientific evidence surrounding ETS interventions in mechanically ventilated children. The review was undertaken using high-quality methods
      • Whittemore R.
      • Knafl K.
      The integrative review: updated methodology.
      including an extensive, systematic search of electronic databases (Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, EBSCO, CINAHL, and clinical trial registries). Search strings were developed with the assistance of a health librarian and included Medical Subject Heading and key words. After the integrative review, a review and critical appraisal of current ETS clinical guidelines
      • Schults J.
      • Cooke M.
      • Long D.
      • Mitchell M.
      Normal saline and lung recruitment with pediatric endotracheal suction: a review and critical appraisal of practice recommendations.
      was undertaken. A systematic search for ETS clinical practice guidelines
      National Health and Medical Research Council
      Australian clinical practice guidelines: NHMRC, Australian government.
      ,
      in children (aged <18 years) was conducted in CINAHL, Medline, PubMed, Embase, and Google Scholar. Two independent assessors evaluated each included guideline, using the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument.
      • Brouwers M.C.
      • Kerkvliet K.
      • Spithoff K.
      The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.
      ,
      • Brouwers M.C.
      • Kho M.E.
      • Browman G.P.
      • Burgers J.
      • Cluzeau F.
      • Feder G.
      • et al.
      AGREE II: advancing guideline development, reporting and evaluation in healthcare.
      Results of the integrative review and critical appraisal were synthesised, summarised, and provided to expert panellists before undertaking appropriateness ratings in round 1.

      2.5 Panel of clinical experts

      Australian and New Zealand experts were invited to be a part of a panel to assess and rate potential ETS interventions. Acknowledged lead researchers in the field of respiratory medicine/PICU as well as clinical experts (currently practising) in paediatrics, intensive care medicine, anaesthetics, physiotherapy, nursing, neonatology, neuro and cardiac intensive care, and infectious disease as voting panellists (n = 12), thus ensuring the resulting criteria were applicable across diverse range of PICU populations. A parent representative
      • Bell S.K.
      • Roche S.D.
      • Mueller A.
      • Dente E.
      • O’Reilly K.
      • Sarnoff B.
      • et al.
      Speaking up about care concerns in the ICU: patient and family experiences, attitudes and perceived barriers.
      ,
      • Menzies J.C.
      • Morris K.P.
      • Duncan H.P.
      • Marriot J.F.
      Patient and public involvement in Paediatric Intensive Care research: considerations, challenges and facilitating factors.
      (parent of three children with Australian PICU experience, providing a parent perspective) was also invited as a nonvoting panellist member to ensure the consumer voice was central to all discussions. In addition, the parent representative led a discussion on the lived experience of a PICU family at the beginning of the panel. As per RAND/UCLA methods, nonvoting attendees, including panel facilitators (methodologist Professor Amanda Ullman, Australia) and support staff were also present. Panel representation is outlined in Table 3.
      Table 3Panel representatives.
      NamePaediatric specialtyLocationHospital and/or university affiliations
      Voting panellists
      P1Victoria, Australia
      P2Victoria, Australia
      P3Tasmania, Australia
      P4Western Australia, Australia
      P5Western Australia, Australia
      P6Auckland, New Zealand
      P7Queensland, Australia
      P8Queensland Australia
      P9New South Wales, Australia
      P10New South Wales, Australia
      P11Western Australia, Australia
      P12Queensland, Australia
      Nonvoting panellists
      NV 1Queensland, Australia
      NV 2Queensland, Australia
      NV 3Queensland, Australia
      NV4Queensland, Australia
      Parent representativeQueensland, Australia
      CNC, clinical nurse consultant; MD, medical doctor; NEd, nurse educator; PICU, paediatric intensive care unit; PhD, Doctor of Philosophy; PT, physiotherapist; RN, registered Nurse. +mixed population.

      2.6 Clinical scenario development

      Fig. 2 outlines the conceptual framework used to develop the clinical scenarios and appropriate use criteria. The conceptual framework utilised patient and clinical characteristics to inform the iterative development of clinical scenarios for specific patient and subspecialty populations. The clinical scenarios were informed by the results of the integrative review, appraisal of the guidelines, and the expertise of panellists, within the boundaries and scope of the project. Clinical scenarios were divided into the following sections: patient population, mode of ventilation, clinical indication for ETS, and patient age. Suction interventions were categorised into presuction, the suction event, and postsuction interventions. Subspecialty populations were also included. Developed clinical scenarios underwent a process of internal review by the investigators and expert panellists and external review by independent international PICU experts to ensure the scenarios reflected the predefined aims of the project.
      Figure 2
      Fig. 2Conceptual framework for the development of clinical scenarios of appropriateness and preference. The conceptual framework developed for the Paediatric AirWay Suction (PAWS) guideline was based on existing conceptual frameworks developed by The Michigan Appropriateness Guide for Intravenous Catheters
      • Chopra V.
      • Flanders S.A.
      • Saint S.
      • Woller S.
      • O’Grady N.
      • Safdar N.
      • et al.
      The Michigan appropriateness guide for intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method.
      and Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics appropriate use criteria.
      • Ullman A.J.
      • Chopra V.
      • Brown E.
      • Kleidon T.
      • Cooke M.
      • Rickard C.
      • et al.
      Developing appropriateness criteria for pediatric vascular access.

      2.7 Round 1 appropriateness rating

      As per the RAND/UCLA Appropriateness Method, round 1 appropriateness rating involved independent review of the document without interaction with other panel members. Voting panellists received the literature review, clinical scenarios, definition of terms, and guide for rating scenarios via email. Panellists were instructed to familiarise themselves with the literature review and the process of rating clinical scenarios using a Microsoft Excel® spreadsheet. For each scenario, panel members were asked to rate the appropriateness by considering the benefit-to-harm ratio on a scale of 1–9, where 1 indicates harms outweighs benefit and 9 signifies that benefits outweigh harm. The ratings were completed and distributed electronically and returned to their investigator group via email. A maximum of three follow-up emails were sent to ascertain missed ratings. The overall ratings for round 1 for each indication were summarised descriptively as a median, frequency, range, and interquartile range (IQR). As recommended by the RAND/UCLA method, indications were classified into three levels of appropriateness:
      • 1.
        Appropriate: panel median score of 7–9, without disagreement;
      • 2.
        Uncertain/neutral: panel median score of 4–6, or with disagreement regardless of median; and
      • 3.
        Inappropriate: panel median score of 1–3, without disagreement.
      Disagreement existed if ≥ four panelists rated in each extreme (1–3 and 7–9).
      • Fitch K.
      • Bernstein S.J.
      • Aguilar M.D.
      • Burnand B.
      • LaCalle J.
      • Lazaro P.

      2.8 Round 2 appropriateness rating

      After round 1 appropriateness ratings, panellists were invited to a face-to-face meeting at the Centre for Children's Health Research, Brisbane, Queensland, Australia. Owing to COVID-19 restrictions, the round 2 meeting was also offered online using Microsoft Teams®. The panel discussion was moderated by a RAND/UCLA methodology expert (Professor Ullman) and scientific content experts (Dr Schults, Associate Professor Long), without voting. Sessions were structured to encourage discussion and debate regarding uncertain clinical practices and ratings where disagreement occurred. Clinical scenarios that were rated neutral or uncertain were also revisited. During this discussion, panellists recommended modifications to indications and definitions resulting in a reduction in the final number of clinical scenarios and improvement in the clarity of ratings. After this discussion, clinical scenarios were rerated independently by voting panellists using the Microsoft Excel® document. Round 2 data were then analysed and reclassified into the three levels of appropriateness with disagreement and agreement (≥10 panellists rating in the three-point median) described. A maximum of three follow-up emails were made in an attempt to ascertain missing responses after round 2 ratings.

      3. Discussion

      This study is the first of its kind to be undertaken across Australia and New Zealand and will translate evidence and clinical expertise into ETS intervention appropriate use criteria for PICU clinicians. Although many steps are being taken to establish research as a standard of care in the PICU,
      • Zimmerman J.J.
      • Anand K.J.S.
      • Meert K.L.
      • Willson D.
      • Newth C.
      • Harrison R.
      • et al.
      Research as a standard of care in the PICU.
      many routine practices, such as ETS, lack clinical trial data to support the safe and effective use of associated interventions. In the absence of this evidence, the RAND/UCLA Appropriateness Method represents a reliable method to systematically assess variation in the use of procedures, by defining the appropriateness of these procedures, within clinical situations.
      • Lawson E.H.
      • Gibbons M.M.
      • Ko C.Y.
      • Shekelle P.
      The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures.
      The new appropriateness guidelines can inform large-scale collaborative and bedside efforts to reduce inappropriate ETS intervention use and related adverse events. It will also support the appropriate use of suction interventions, as well as identify areas of clinical practice requiring further research. Future research could explore the acceptability, application, and efficacy of the developed appropriate use recommendations across varying health contexts.

      4. Limitations

      The current COVID-19 pandemic required a modification to the RAND/UCLA methods to accommodate round 2 appropriateness ratings via an online platform. This may impact the result of the study, both in recommendations (e.g., increased use of closed suction) and panellist participation (the online platform may lead to reduced panellist discussion when compared with in-person meetings).
      • Fitch K.
      • Bernstein S.J.
      • Aguilar M.D.
      • Burnand B.
      • LaCalle J.
      • Lazaro P.

      5. Conclusion

      Using the outlined, rigorous methodology, the resulting appropriate use criteria may be a valuable clinical resource to support practice decisions across a broad range of contexts. Such guidance can be used to reduce suction intervention variation across diverse paediatric critical care practice settings.

      Funding

      This research was independently developed with support from the Australian College of Critical Care Nurses and the Children's Hospital Foundation .

      CRediT authorship contribution statement

      Jessica A Schults: Conceptualisation, Funding acquisition, Methodology, Investigation, Writing – original draft, Visualisation. Karina Charles: Methodology, Investigation, Resources, Data curation, Writing – original draft, Visualisation, Project administration. Debbie Long: Conceptualisation, Funding acquisition, Methodology, Writing – review & editing. Simon Erikson: Investigation, Validation, Writing – review & editing. Georgia Brown: Investigation, Validation, Writing – review & editing. Michaela Waak: Investigation, Validation, Writing – review & editing. Lyvonne Tume: Conceptualisation, Methodology, Validation, Writing – review & editing. Lisa Hall: Conceptualisation, Funding acquisition, Methodology, Writing – review & editing. Amanda J Ullman: Conceptualisation, Funding acquisition, Methodology, Validation, Writing – review & editing.

      Conflict of Interest

      The authors have no conflicts of interest to declare.

      Acknowledgements

      The authors gratefully acknowledge Mr Scott Moore for his contribution to the study database and Professor Schibler for his support.

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