Wide Variation in Unplanned Extubation Rates Related to Differences in Operational Definitions

Abstract

Objectives: Unplanned extubation (UE) rate is a patient safety metric for which there are varied and inconsistently interpreted definitions. We aimed to test the sensitivity of UE rates to the application of different operational definitions. Methods:We analyzed neonatal intensive care unit (NICU) quality improvement data on UE events defined inclusively as "any extubation that was not performed electively, or not previously intended for that time." Unplanned extubations were classified as involving an endotracheal tube (ETT) that was either objectively "dislodged" or "removed" without proof of prior dislodgement. We used descriptive statistics to explore how UE rates vary when applying alternate UE definitions.Results: For 33 months, 241 UEs were documented, 70% involving dislodged tubes and 30% ETTs removed by staff. Among dislodged ETTs, only 9% were found completely externalized, whereas 77% were at an adequate depth but in the esophagus. Thirteen percent of events occurred outside the NICU and 13% were initially unreported. The overall UE rate was 4.9/100 ventilator days. If the least inclusive definition was used (i.e., counting only "self-extubations" by patients, requiring reintubation, and occurring within the NICU), 83% of UEs would have been excluded. Conclusions:Most UEs in our NICU population involved staff either removing ETTs from the trachea or partly removing them after internal dislodgement. In settings where ETTs removed by staff are not counted, UE rates may be substantially lower and associated risks underestimated. An inclusive, patient-centric operational definition along with a standardized classification would allow benchmarking, while enabling targeted approaches to minimize locally predominant causes of UEs.

Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

“…Consequently, we prevented many UEs that were avoidable, thus decreasing the harm and discomfort associated with physiologic destabilization and reintubation, even when ETTs are removed by staff. Our inclusive definition and classification scheme ensure that these events are not overlooked, as they might be when neonatologists exclude intentional but non-elective extubations [ 23 ], although an inclusive definition may result in significantly higher observed UE rates [ 24 ]. No significant reduction in the frequency of dETT UEs was observed, which may be a result of a lack of standardization on which tests of change to carry out across centers, differing levels of experience and expertise with the QI methodology, or other center differences in the processes that influence the rate of UEs not captured in our work.…”

“…A further limitation of this study was the inability of all the centers to reliably capture UEs occurring in NICU patients when located outside of the NICU-proper (e.g., in the delivery room, operating room, in-hospital transit, or inter-facility transport); however, these events accounted for 11% of UEs at the RPC with the most fastidious reporting methods, which would not account for the differences in the results among the centers. Finally, one other limitation of this project and any project seeking to reduce UEs within NICUs is the lack of a standard definition for UE [ 1 , 23 , 24 ]. Although our collaborative intentionally adopted a broad, inclusive definition shared by all participating RPCs at the outset of the project, the likely differences between our definition and the definition utilized by other institutions make benchmark comparisons difficult.…”

Synergizing Safety: A Customized Approach to Curtailing Unplanned Extubations through Shared Decision-making in the NICU

“…An UE was defined as unintended dislodgement of the ETT from the trachea in an infant receiving mechanical ventilation. 20 The team developed and implemented interventions to mitigate UE, and regular audits were performed to identify potential areas for improvement.…”