Unplanned extubation in a paediatric intensive care unit: impact of a quality improvement programme

Abstract

SummaryUnplanned tracheal extubation is an important quality issue in current medical practice as it is a common occurrence in paediatric intensive care units. We have assessed the effectiveness of a continuous quality improvement programme in reducing the incidence of unplanned extubation over a 5-year period. After a 2-year baseline period, we developed action plans to address the issues identified. Following implementation of the programme, the overall incidence of unplanned extubation decreased from 2.9 unplanned extubations per 100 intubated patient days in the first year to 0.6 in the last year (p = 0.0001). This reduction was the result of a decrease in unplanned extubation in children younger than 2 years of age. Although mortality was similar to that of children who did not experience an unplanned extubation, those with an unplanned extubation had a significantly longer duration of mechanical ventilation, longer stay in the intensive care unit, and longer hospital stay. We found that the implementation of a continuous quality improvement programme is effective in reducing the overall incidence of unplanned extubations.

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

“…[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%. 10,15,16,20 This suggests that restraints do not prevent self-extubation.…”

“…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%. 10,15,16,20 This suggests that restraints do not prevent self-extubation. Moreover, they can contribute to agitation, 10 and are discouraged unless necessary due to other safety concerns.…”

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

“…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.…”

“…Thus, stability during the post-intervention period is required to rule out extraneous trends and to convincingly document that the intervention is responsible for the performance. 3 We have previously demonstrated significant improvement in unplanned extubation rates after a sustained collaborative effort from 2002 until 2007. 3 During the last 8 y, we were able to maintain lower unplanned extubation rates, below the recommended benchmark, with ongoing reassessment, reinforcement, and reeducation applying interventions based on the PDSA (Plan, Do, Study, Act) cycle (Fig.…”

Impacto de una intervención de mejora de calidad sobre la incidencia de extubaciones no planeadas en una unidad de cuidados intensivos pediátricos

“…1 La ENP aumenta la morbimortalidad de los pacientes de la UCIP y los expone a las complicaciones de la intubación e n d o t r a q u e a l d e e m e r g e n c i a cuando se requiere la reintubación, prolongando el tiempo de VM y de permanencia en la UCIP. [2][3][4][5][6] Los programas de mejora continua de la calidad para disminuir la incidencia de las ENP han demostrado que, a través de la capacitación del personal de la UCIP, la identificación d e l o s p a c i e n t e s d e r i e s g o , l a estandarización de procedimientos de atención y cuidado, y el desarrollo de protocolos de sedación y analgesia y destete de la VM, es posible disminuir la incidencia de ENP. 1,2,[7][8][9][10] Los objetivos del presente estudio fueron conocer las causas de las ENP para diseñar una intervención de mejora de la calidad destinada a disminuir su incidencia y evaluar la eficacia de esa intervención.…”