Decreasing unplanned extubations: Utilization of the Penn State Children’s Hospital Sedation Algorithm

Popernack, Myra L.; Thomas, Neal J.; Lucking, Steven E.

doi:10.1097/01.ccm.0000105305.95815.91

Cited by 60 publications

(48 citation statements)

References 13 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…We found that lack of sedation of infants may contribute to unplanned extubations, which has been shown in PICU studies 13 as well as in other NICUs. Although sedation is a very important factor in PICUs, it is not without its own adverse effects.…”

Section: Discussionmentioning

confidence: 72%

Reducing Unplanned Extubations in the NICU

et al. 2014

View full text Add to dashboard Cite

BACKGROUND AND OBJECTIVES: Unplanned extubation can be a significant event that places the patient at risk for adverse events. Our goal was to reduce unplanned extubations to <1 unplanned extubation per 100 patient-intubated days. METHODS: All unplanned extubations in the NICU beginning in October 2009 were audited. Data collected included time of day, patient weight, and patient care activity at the time of the event. Bundles of potentially better practices were implemented in sequential Plan-Do-Study-Act cycles. Rates of unplanned extubation (number per patient-intubated day) for each month were analyzed by using control charts, and causes of unplanned extubation were analyzed by using Pareto charts. RESULTS: We found a significant decrease in the unplanned extubation rate after implementation of the first bundle of potentially better practices in May 2010 (2.38 to 0.41 per 100 patient-intubated days). Several more Plan-Do-Study-Act cycles were conducted to sustain this improvement. A persistent reduction in the unplanned extubation rate (0.58 per 100 patient-intubated days) began in February 2013. Causes included dislodgement during care and procedures and variation in the fixation of the endotracheal tube. The majority of events occurred in very low birth weight infants during the daytime shift. CONCLUSIONS: Unplanned extubations in the NICU can be reduced by education of staff and by implementing standard practices of care. Sustainability of any practice change to improve quality is critically dependent on culture change within the NICU. We suggest that the benchmark for unplanned extubation should be a rate <1 per 100 patient-intubated days.

show abstract

Section: Discussionmentioning

confidence: 72%

Reducing Unplanned Extubations in the NICU

et al. 2014

View full text Add to dashboard Cite

show abstract

“…Sedation as a method to minimize agitation was not as studied. On the other hand, there is evidence that a sedation/analgesia protocol significantly reduces the incidence of UE in both pediatric 25 and adult 26 patients.…”

Section: Discussionmentioning

confidence: 99%

Unplanned Extubation in the Neonatal ICU: A Systematic Review, Critical Appraisal, and Evidence-Based Recommendations

Reis²,

et al. 2012

View full text Add to dashboard Cite

SummaryOBJECTIVE: To update the state of knowledge on unplanned extubations (UEs) in neonatal ICUs. This review focuses on the following topics: incidence, risk factors, reintubation after UE, outcomes, and prevention. METHODS: The MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for relevant publications from January 1, 1950, through January 30, 2012. Fifteen articles were selected for data abstraction. The search strategy included the following key words: "unplanned extubation," "accidental extubation," "self extubation," "unintentional extubation," "unexpected extubation," "inadvertent extubation," "unintended extubation," "spontaneous extubation," "treatment interference," and "airway accident." Study quality was assessed using the Newcastle-Ottawa scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine's levels of evidence system. Studies with Newcastle-Ottawa scale score > 5 that included appropriate statistical analysis were deemed of high methodological quality. RESULTS: The overall mean Newcastle-Ottawa scale score was 3.5. UE rates ranged from 0.14 to 5.3 UEs/100 intubation days, or 1% to 80.8%. Risk factors included restlessness/agitation (13-89%), poor fixation of endotracheal tube (8.5-31%), tube manipulation at the time of UE (17-30%), and performance of a patient procedure at bedside (27.5-51%). One study showed that every day on mechanical ventilation increased the UE risk 3% (relative risk 1.03, P < .001). The association between birth weight/gestational age and UE is controversial. Reintubation rates ranged from 8.3% to 100%. There is still a gap of information about strategies addressed to reduce the incidence of UE. The best method of endotracheal tube securement remains a controversial issue. CONCLUSIONS: Despite numerous publications on UE, there are few studies assessing preventive strategies for adverse events and there is a lack of randomized clinical trials. Recommendations are proposed based on the current available literature.

show abstract

“…Although increasing sedation will decrease the risk of unplanned extubations, caution should be exercised in seeking low rates of unplanned extubations by excessive use of sedatives and neuromuscular blockers, which in turn can result in worse patient outcomes. Sedation algorithms (such as the Penn State Children's Hospital sedation algorithm) 13 or targeted sedation regimens (such as the RESTORE trial) 14 have the potential to balance the risk and benefits; however, whether their utilization will decrease the risk of unplanned extubations but not increase ventilator duration remains to be validated in independent studies. Use of restraints did not lead to any decrease in unplanned extubations in our project.…”

Section: Discussionmentioning

confidence: 99%

Plan to Have No Unplanned: A Collaborative, Hospital-Based Quality-Improvement Project to Reduce the Rate of Unplanned Extubations in the Pediatric ICU

et al. 2015

View full text Add to dashboard Cite

BACKGROUND: Although under-reported and understudied, unplanned extubations carry a significant risk of patient harm and even death. They are an important yardstick of quality control of care of intubated patients in the ICU. A unit-based risk assessment and multidisciplinary approach is required to decrease the incidence of unplanned extubations. METHODS: As part of a qualityimprovement initiative of Children's Hospital at Montefiore, all planned and unplanned extubations in a multidisciplinary 20-bed pediatric ICU were evaluated over a 12-month period (January to December 2010). At the end of 6 months, an interim analysis was performed, and high-risk patient groups and patient care factors were identified. These factors were targeted in the second phase of the project. RESULTS: Over this period, there were a total of 267 extubations, of which 231 (87%) were planned extubations and 36 (13%) were unplanned. A patient care policy targeting the risk factors was instituted, along with extensive nursing and other personnel education in the second phase. As a result of this intervention, the unplanned extubation rate in the pediatric ICU decreased from 3.55 to 2.59/100 intubation days. All subjects who had an unplanned extubation during nursing procedures or transport required re-intubation, whereas none of the unplanned extubations during ventilator weaning required re-intubation. CONCLUSIONS: A targeted approach based on unit-specific risk factors is most effective in quality-improvement projects. A specific policy for sedation and weaning can be very helpful in managing intubated patients and preventing unintended harm.

show abstract

Decreasing unplanned extubations: Utilization of the Penn State Children’s Hospital Sedation Algorithm

Abstract: Utilization of the PSCHSA resulted in a decreased number of unplanned extubations without increasing the length of PICU stay. Implementation of the PSCHSA is needed in other PICUs to validate these findings.

Cited by 60 publications

References 13 publications

Reducing Unplanned Extubations in the NICU

Reducing Unplanned Extubations in the NICU

Unplanned Extubation in the Neonatal ICU: A Systematic Review, Critical Appraisal, and Evidence-Based Recommendations

Plan to Have No Unplanned: A Collaborative, Hospital-Based Quality-Improvement Project to Reduce the Rate of Unplanned Extubations in the Pediatric ICU

Contact Info

Product

Resources

About