Published online September 1, 2004
PEDIATRICS Vol. 114 No. 3 September 2004, pp. 628-632 (doi:10.1542/peds.2003-0735-L)
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Continuous Quality Improvement: Reducing Unplanned Extubations in a Pediatric Intensive Care Unit

Roxanne Sadowski, BA, RRT*, Ronald E. Dechert, DrPH, RRT*, Kenneth P. Bandy, BS, RRT*, Julie Juno, RN, BSN{ddagger}, Varsha Bhatt-Mehta, PharmD, FCCP§,||, Joseph R. Custer, MD||, Frank W. Moler, MD|| and Susan L. Bratton, MD, MPH||

* Departments of Critical Care Support Services
{ddagger} Nursing Services
§ Pharmacy Services
|| Pediatrics, University of Michigan Health System, Ann Arbor, Michigan

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.

Key Words: endotracheal intubation • unplanned extubation • self-extubation • accidental extubation • reintubation • pediatric intensive care unit • length of stay • quality assurance

Abbreviations: UEX, unplanned extubation • PICU, pediatric intensive care unit • CQI, continuous quality improvement • MV, mechanical ventilation • LOMV, length of mechanical ventilation • LOSICU, length of stay in the intensive care unit • LOI, length of intubation • AWD, airway days • NMB, neuromuscular blockade

Accepted Mar 12, 2004.


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