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

Abstract

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.

Multidisciplinary interventions and continuous quality improvement to reduce unplanned extubation in adult intensive care units

“…This increase can be attributed to the hospital's having moved some experienced critical care nurses to support a newly set-up branch hospital, which decreased the quality of care in the ICU of our hospital's main branch ICU. Other studies [5,16–18] report similar findings in different populations. Fontanez-Nieves et al [16] reported a significant reduction of UE from 16.1 to 4.5/100 ventilator-days in neonates using the methods with 3 PDCA cycles over 20 months; Tripathi et al [5] reported a reduction in a pediatric ICU (PICU) from 3.55 to 2.59/100 intubation days after implementing a patient care policy targeting the risk factors, followed by extensive nursing and other personnel education over 12 months; Merkel et al [17] found a significant decrease in 3 years in the rate of UE in a neonatal intensive care unit (NICU) after bundles of potentially better practices had been implemented following sequential PDSA cycles; and Rachman and Mink [18] also reported that the effect of the quality improvement program to reduce UE had been successfully maintained even 9 years after implementation in the PICU.…”

“…Fontanez-Nieves et al [16] reported a significant reduction of UE from 16.1 to 4.5/100 ventilator-days in neonates using the methods with 3 PDCA cycles over 20 months; Tripathi et al [5] reported a reduction in a pediatric ICU (PICU) from 3.55 to 2.59/100 intubation days after implementing a patient care policy targeting the risk factors, followed by extensive nursing and other personnel education over 12 months; Merkel et al [17] found a significant decrease in 3 years in the rate of UE in a neonatal intensive care unit (NICU) after bundles of potentially better practices had been implemented following sequential PDSA cycles; and Rachman and Mink [18] also reported that the effect of the quality improvement program to reduce UE had been successfully maintained even 9 years after implementation in the PICU. In summary, our findings and those of other studies [5,16–18] indicate that a multidisciplinary quality improvement program can effectively reduce UE in the ICU, and the effect can be maintained and even improved 15 years after the sequential introduction of different interventions.…”

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

“…We read with great interest the article by Tripathi et al 1 recently published in RESPI-RATORY CARE assessing the impact of a quality-improvement project on the incidence of unplanned extubations. By carrying out this quality-improvement project, they were able to decrease the rate of unplanned extubations from 3.55 to 2.59 per 100 intubation days.…”

“…After the implementation of their qualityimprovement program, the rate of unplanned extubations/100 intubation days dropped from 3.55 to 2.59. 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).…”

Comparison of Flow Resistance Characteristics and Placement of Two Endotracheal Tubes

“…5 There are several quality improvement studies in pediatric and adult populations when using different interventions, which showed decreased unplanned extubation rates in the hospital. [6][7][8][9][10] Despite these studies, no interventions have been shown consistently to be effective in preventing unplanned extubations, which remains a significant hospital-acquired condition with high health-care cost. 11,12 There are a wide variety of endotracheal tubes (ETT) available from different manufacturers, such as tubes with a suction port above the cuff or silver-impregnated tubes to decrease the colonization of the ETT.…”