Reducing Unplanned Extubations in a Pediatric Intensive Care Unit: A Systematic Approach

Abstract

Objective. To prospectively determine the rate of unplanned extubations and contributing factors and determine whether a targeted intervention program would be successful in decreasing the rate of unplanned extubations. Design. Prospective, observational study. Setting. A 10-bed Pediatric Intensive Care Unit (PICU). Patients. All intubated pediatric patients during two time periods: September 1, 2000–March 31, 2001 and November 1, 2001–April 30, 2002. Interventions. After determining the rate and causes of unplanned extubation, a program was developed consisting of education and a formalized endotracheal tube taping policy. Data were then collected after implementation of the program. Measurements and Main Results. Prior to the implementation of the program, there were 10 (14.7%) unplanned extubations for a rate of 6.4 unplanned extubations per 100 ventilated days. Of the ten unplanned extubations, reintubation was required in 2 (20%). Inadequate sedation, poor taping, and improper position of the endotracheal tube were the items most frequently cited as causing an unplanned extubation. Following the program, there were two (3.4%) unplanned extubations for 1.0 unplanned extubations per 100 ventilated days. Neither patient required reintubation. There were no significant differences (P > .05) in age, weight, endotracheal tube size, or duration of intubation in the two time periods. However, there was a significant decrease in both the number (P = .03) and the rate (P = .04) of unplanned extubations after the implementation of the quality improvement program. Conclusions. The rate of unplanned extubation in a PICU can be decreased with a quality improvement program that targets the institution's specific needs.

Reducing Unplanned Extubations in the NICU

“…Factors that contribute to unplanned extubations include method of fixation of endotracheal tubes; procedures such as weighing and suctioning; and agitation of the patient, resulting in rapid movement of the head. 2,8 Although benchmark data exist for PICUs in terms of unplanned extubations 11 , there are no such national data on unplanned extubations for NICUs. After noting what appeared to be a high incidence of unplanned extubations in our NICU during the last 3 months of 2009, we began the present quality improvement project with the aim of reducing unplanned extubations by developing a bundle of potentially better practices implemented in successive Plan-DoStudy-Act (PDSA) cycles.…”

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.…”

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

“…3,5 La incidencia observada en la UCIP del HGNPE durante los primeros 6 meses de estudio fue de 2,30 por 100 días de VM, similar a la informada por otros estudios en la etapa previa a la aplicación de una intervención para disminuir su ocurrencia. 2,4,7,13 No hay consenso acerca de la incidencia aceptable de ENP. Una tasa igual a cero puede ser deseable, pero al mismo tiempo, peligrosa.…”

“…Tras su aplicación, la incidencia de ENP disminuyó de 2,9 por 100 días de VM a 0,6 por 100 días de VM (p= 0,0001). Rachman y cols., 4 luego de incorporar un programa de mejora continua que incluía la capacitación del personal, la estandarización de la fijación del TET y el monitoreo de la fijación del TET, también observaron una disminución de la incidencia de ENP de 6,4 por 100 días de VM a 1 por 100 días de VM (p= 0,04).…”

“…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.…”