Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries

Abstract

Accidental extubation is a potentially serious event for pediatric or neonatal patients with respiratory failure, especially in clinical settings in which personnel capable of performing reintubation may not be readily available. Thus the rate of accidental extubation in small intensive care units that operate without 24‐hour in‐house physician availability may be an important quality assurance indicator. The objectives of this study were to determine the accidental extubation rate at a single small pediatric intensive care unit (PICU) and compare it with published reports. This study was carried out in a six‐bed PICU at Washoe Medical Center in Reno, Nevada, with a relatively low level of patient acuity, as measured by PRISM score and the frequency of intubation, and without 24‐hour in‐house physician availability. All intubated patients admitted during the 5‐year period from January 1, 1989 to December 31, 1993 were included. The primary outcome measure was the occurrence of accidental extubation. We observed only two accidental extubations in 1,749 intubated‐patient‐days (IPD) (0.114 accidental extubations/100 IPD [95% confidence interval 0.014–0.413 accidental extubations/100 IPD]). This rate of accidental extubation was compared with data in published reports from neonatal intensive care units (NICUs) and PICUs, which ranged from 0.14 accidental extubations/100 IPD to 4.36 accidental extubations/100 IPD. The dependence of the observed accidental extubation rate on unit size and institutional experience with intubated patients, as measured by the average number of intubated patients, was examined. We found no evidence that the accidental extubation rate is higher in smaller units or units with less institutional experience. Low rates can be achieved in small units with low acuity. Pediatr. Pulmonol. 1997; 23:424–428. © 1997 Wiley‐Liss, Inc.

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

“…The hypothesized primary mechanism for this decrease was increased diligence to the details of patient care. In the following 5 yrs, that level reached a stable but unacceptable plateau (0.44 to 0.63 per 100 intubated patient days), which was superior to or equal with published data (3)(4)(5)(6)(7)(8). However, the decision was made that improvements in patient management were necessary to further decrease the unplanned extubation rate because the critical care team considered even a single unplanned extubation as unacceptable due to the potentially dangerous results.…”

Impact of team building using a novel technique (planned experimentation) to standardize endotracheal tube taping practice in the NICU

“…While 10 UE per 1,000 ventilated days fall within general national averages for pediatrics, we acknowledge that this rate is unacceptably high for infants [5,[8][9][10] . A Pareto analysis of factors associated with unplanned extubations over 12 months identified loose tape as an important preventable reason for UEs (see Figure 1).…”

Incidência e fatores de risco para a extubação acidental em uma unidade de terapia intensiva neonatal

“…3,5,12,13,[22][23][24][25] However, we identified only a few publications analyzing, in the neonatal age group, incidence and circumstances accompanying AE, 2,8-10 total AV time, 2 length of hospital stay and mortality in extubated patients, 2 association between types of fixation and AE, 10 and one intervention study to reduce AE. 11 The extubation density obtained in this study is higher than that reported in previous studies, 2,8-11 and, in some months, unacceptably high rates were observed, revealing the need for the implementation of an effective intervention.…”

“…3 In neonatal intensive care units in the United States, AE is the fourth most common adverse event. 4 AE or unplanned extubation is defined as every unexpected or nonelective extubation 5 3 Helymar da Costa Machado 4 in the diagnosis of this event, such as: tube displacement, presence of vocalization, sudden and unexplained air escape, gastric distension, radiologic evidence of endotracheal tube malpositioning, 5 sudden cyanosis or desaturation, and absence of respiratory movements or breathing. 2 AE may require urgent reintubation in less controlled situations, often with repeated attempts, increasing the risk of laryngeal injury, and the consequent stridor, 6 and physiologic changes such as hypoxemia and increased blood and intracranial pressure.…”

“…In these units, incidence ranges from 0.72 to 4.8 AE per 100 patient-days ventilated, 2,[8][9][10][11] values that are higher than those found in pediatric intensive care units (0.11-2.7/100 patientdays). 5,8,[12][13][14] Given the importance of this potentially preventable adverse effect, AE rate has been used as an indicator in the assessment of the quality of medical care. 15 Taking into consideration AE-associated morbidity, 2 it seems important that neonatal units establish the incidence of this adverse event and be informed about associated risk factors in order to be capable of identifying the need to implement interventions and measure their results.…”