Effectiveness of a continuous quality improvement program aiming to reduce unplanned extubation: A prospective study

Abstract

The implementation of a concerted CQI program is effective in reducing the overall incidence of unplanned endotracheal extubation.

Unplanned extubations: making progress using CQI

“…This unacceptably high incidence has not changed appreciably over the past two decades, despite repeated documentation of the problem and its potentially devastating consequences [1]. Dr. Chiang and colleagues [3] present convincing evidence that by applying straightforward, well-conceived changes to practice patterns, the incidence of unplanned extubation (UE) can be cut in half. Their work provides an important step in solving the problem and, in so doing, should serve as a impetus for clinicians to develop their own continuous quality improvement (CQI) programs.…”

“…Chiang and co-workers [3] identified the major components of their CQI program as: 1) the standardization of procedures for securing endotracheal tubes, 2) encouragement of active communication between staff and patients, including preoperative education, to help manage discomfort and improve the patients' understanding of UE, 3) the development of guidelines for the use of sedatives, analgesics and psychotropic agents, 4) the standardization of the use of physical restraints, and 5) the avoidance of undue delay of elective extubation, similar to other recommendations [1]. Importantly, they organized a multi-disciplinary CQI task force, implemented educational courses and continuously assessed progress and problems.…”

“…Improved ET tube stabilization is probably important. It is of interest that Chiang et al [3] found virtually all of the improvement to occur in orally intubated patients. In the first trimester the incidence density was 4.6 cases/100 MV days, which translates to an extraordinarily high 20-25% UE rate.…”

“…This fell steadily to 1.7 and 1.0 cases/100 MV days in subsequent trimesters. Chiang et al [3] used twill tape to secure their ET tubes. Previous comparative studies have found twill tape to be similar to adhesive tape as far as tube movement, ease of use, and oral hygiene [4].…”

“…In contrast to orotracheal intubation, the UE incidence was remarkably stable and acceptably low (in the 1.4-1.2 cases/100 MV days range) for nasally intubated patients throughout the program [3]. Why not just routinely use nasotracheal placement?…”