An Interdisciplinary Initiative to Reduce Unplanned Extubations in Pediatric Critical Care Units

Kaufman, Jon; Rannie, Michael; Kahn, Michael G.; Vitaska, Matthew; Wathen, Beth; Peyton, Chris; Judd, Jerrold; Quinby, Zachary; Cruz, Eduardo M. da; Dobyns, Emily L.

doi:10.1542/peds.2011-2642

Cited by 27 publications

(18 citation statements)

References 13 publications

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“…7,11,13 Approximately 50% of these patients will require re-intubation (range of 10 -78%). [6][7][8]11,13,15,16 Based upon the literature, successful strategies for the prevention of unplanned extubations include standardized protocols for securing the tracheal tube, 15,[17][18][19][20] titration of sedation, [15][16][17]21 weaning patients off mechanical ventilation, 16,20 tube suctioning, patient hygiene, and transport. 15 Although it may seem intuitive that restraining patients might prevent self-extubations, the rate of patients in restraints at the time of unplanned extubation is roughly 60%.…”

Section: Unplanned Extubationsmentioning

confidence: 99%

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

et al. 2016

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. Once each organization had its dataset of ventilator-related adverse events, reviewers read the narrative descriptions of each event and classified it according to the developed common taxonomy. RESULTS: A Pennsylvania Patient Safety Authority, FDA, and UHC search provided 252, 274, and 700 relevant reports, respectively. The 3 event types most commonly reported to the UHC and the Pennsylvania Patient Safety Authority's Patient Safety Reporting System databases were airway/breathing circuit issue, human factor issues, and ventilator malfunction events. The top 3 event types reported to the FDA were ventilator malfunction, power source issue, and alarm failure. CONCLUSIONS: Overall, we found that (1) through the development of a common taxonomy, adverse events from 3 reporting systems can be evaluated, (2) the types of events reported in each database were related to the purpose of the database and the source of the reports, resulting in significant differences in reported event categories across the 3 systems, and (3) a public-private collaboration for investigating ventilator-related adverse events under the P5S model is feasible.

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Section: Unplanned Extubationsmentioning

confidence: 99%

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

et al. 2016

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“…Despite a growing body of single-center observational studies of UE and quality improvement studies to reduce UE, [12][13][14][15][16] to our knowledge, no pediatric multicenter efforts to reduce UE have been published to date. We describe a multiinstitutional national quality improvement intervention led by Children's Hospitals Solutions for Patient Safety (SPS) across 43 volunteer hospitals to reduce UEs in all hospitalized patients with an aim to reduce the absolute rate of UEs by 40% over a 2-year period.…”

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confidence: 99%

Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children

et al. 2020

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IMPORTANCE Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events.OBJECTIVE To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events. DESIGN, SETTING, AND PARTICIPANTSThis multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children's hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study.INTERVENTIONS Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses. MAIN OUTCOMES AND MEASURESThe main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level.RESULTS Among the 43 children's hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days.CONCLUSIONS AND RELEVANCE This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.

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“…Tripathi et al 1 have not provided the statistical significance of this improvement. It is noteworthy to highlight that compared with contemporary qualityimprovement studies with 50 -80% improvement, 3,4,6 a 27% improvement in the unplanned extubation rate is disappointing, since the final unplanned extubation rate remained higher than in other contemporary studies (range: 0.29 -1.5/100 intubation days) 3,4,[6][7][8][9] and also higher than the benchmark reported as acceptable in the literature (Ͻ1/100 intubation days). 10 In fact, the 2 largest studies in the pediatric literature have recently supported this recommendation achieving an incidence of 0.74 11 and 0.77 12 unplanned extubations per 100 intubation days.…”

Section: To the Editormentioning

confidence: 74%

Reducing Unplanned Extubations in the Pediatric ICU: Are We Seeing the Whole Picture?

2015

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An Interdisciplinary Initiative to Reduce Unplanned Extubations in Pediatric Critical Care Units

Abstract: Through accurate tracking, multiple practice changes, and promoting transparency of efforts and data, an interdisciplinary team reduced the number of unplanned extubations in both ICUs. This reduction has been sustained throughout the postintervention monitoring period.

Cited by 27 publications

References 13 publications

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children

Reducing Unplanned Extubations in the Pediatric ICU: Are We Seeing the Whole Picture?

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