Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit.

OBJECTIVE Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs. METHODS Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program. RESULTS From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation. CONCLUSIONS We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.

[1]  Y. Amoateng-Adjepong,et al.  Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. , 2001, Chest.

[2]  F. Kapadia.  Effect of unplanned extubation on outcome of mechanical ventilation. , 2001, American journal of respiratory and critical care medicine.

[3]  F. Kapadia,et al.  Airway accidents in intubated intensive care unit patients: An epidemiological study , 2000, Critical care medicine.

[4]  Andrés Esteban,et al.  Accidental removal of endotracheal and nasogastric tubes and intravascular catheters , 2000, Critical care medicine.

[5]  J. Ménard,et al.  Unplanned extubation: risk factors of development and predictive criteria for reintubation. , 1998, Critical Care Medicine.

[6]  R. Lewis,et al.  Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries , 1997, Pediatric pulmonology.

[7]  J. C. Lee,et al.  Effectiveness of a continuous quality improvement program aiming to reduce unplanned extubation: A prospective study , 1996, Intensive Care Medicine.

[8]  R. Cane,et al.  Unplanned endotracheal extubation in the intensive care unit. , 1996, Journal of clinical anesthesia.

[9]  U. Ruttimann,et al.  PRISM III: an updated Pediatric Risk of Mortality score. , 1996, Critical care medicine.

[10]  J. Mickell,et al.  UNPLANNED EXTUBATION IN PEDIATRIC PATIENTS: INCIDENCE AND RELATED FACTORS , 1993 .

[11]  J. Tibballs,et al.  Complications of endotracheal intubation and mechanical ventilation in infants and children , 1992, Critical care medicine.

[12]  C. Newth,et al.  Factors affecting accidental extubations in neonatal and pediatric intensive care patients , 1990, Critical care medicine.

[13]  J. Georgitis,et al.  Predictability and consequences of spontaneous extubation in a pediatric ICU , 1985, Critical care medicine.

[14]  J. Orlowski,et al.  Complications of airway intrusion in 100 consecutive cases in a pediatric ICU , 1980, Critical care medicine.

[15]  D. Shannon,et al.  Endotracheal tube displacement in the newborn infant. , 1977, The Journal of pediatrics.

[16]  P. Reilly,et al.  Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. , 2000, The Journal of trauma.

[17]  T. Voepel-Lewis,et al.  The FLACC: a behavioral scale for scoring postoperative pain in young children. , 1997, Pediatric nursing.

[18]  D. Notterman,et al.  A PROSPECTIVE EVALUATION OF UNPLANNED ENDOTRACHEAL EXTUBATIONS IN A PEDIATRIC INTENSIVE CARE UNIT (PICU) , 1994 .

[19]  P. P. O'Rourke,et al.  Complications of mechanical ventilation in a children's hospital multidisciplinary intensive care unit. , 1990, Respiratory care.