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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, 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
Nursing Services
Pharmacy Services
^|| Pediatrics, University of Michigan Health System, Ann Arbor, Michigan

	ABSTRACT

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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 • LOS_ICU, length of stay in the intensive care unit • LOI, length of intubation • AWD, airway days • NMB, neuromuscular blockade

Improving the quality of patient care is an important priority for the health care industry. Recent reports have focused attention on the reduction of adverse events as an essential component of the health care improvement initiative. To maximize patient safety, health care practitioners must identify potential adverse events and cultivate an open and constructive system for reporting, analyzing, and addressing the factors that contribute to such events.

Unplanned extubation (UEX) represents an adverse event that poses risks to patients who require artificial airways. The use of artificial airways is a common practice in critical care units, and the affixation of these devices can be problematic. The sudden, unexpected dislodgement of an artificial airway subjects the patient to potential harm and even death. In recent years, a variety of investigations in adult populations have explored the incidence, factors, and consequences associated with UEX as well as the factors and consequences associated with reintubation after UEX. Previous investigators have reported a reduction of UEX of adult patients after implementation of a UEX monitoring and provider education program.^1–3 Little information is available regarding the incidence of and patient conditions related to UEX and subsequent reintubation in infants and children.

We assembled a multidisciplinary team to investigate UEX in our pediatric intensive care unit (PICU). Following our institution's model for continuous quality improvement (CQI), "Plan–Do–Check–Act," we initiated a program of prospective monitoring of UEX in our PICU to determine the rate of UEX among pediatric patients and to develop strategies for improvement. We followed UEXs over several years to detect trends in the rate of UEX among our patients.

	METHODS

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The PICU at the University of Michigan Health System is a 16-bed, tertiary care facility in which medical and general surgical patients are treated. Periodically, patients from a separate pediatric cardiothoracic intensive care unit are accommodated in the PICU as well. From July 1, 1996, to June 30, 2001, all patients who were admitted to the PICU and required an artificial airway (orotracheal, nasotracheal, or tracheostomy tube) were monitored prospectively for incidents of UEX. We defined an UEX as 1) an unscheduled event in which an airway was observed, directly or radiographically, to be completely dislodged from the trachea or 2) a sudden loss of bilateral breath sounds that could not be reestablished by suctioning or advancement of the airway. Airway dislodgment was then confirmed by direct or radiographic observation or by the absence of exhaled carbon dioxide assessed via capnometry.

The preferred route of intubation at our institution is oral, and the vast majority of patients were orally intubated and received mechanical ventilation (MV). After each UEX, a respiratory therapist completed a data collection form that captured the patient's demographic characteristics such as age, gender, diagnosis, and service, as well as clinical factors that may have contributed to the UEX and subsequent reintubation, if required. For the overall population of PICU patients who required an airway, demographic characteristics such as age, gender, service, Pediatric Risk of Mortality Score,⁴ length of mechanical ventilation (LOMV), and length of stay in the intensive care unit (LOS_ICU) were captured in a separate PICU population quality assurance program and used to compare features of children with and without UEX.

We categorized the length of intubation (LOI) before the UEX as short (<24 hours), intermediate (24–672 hours), or long (>672 hours). To correspond with a previously published investigation,⁵ we classified patients as sedated when a sedative had been administered within 2 hours of the UEX. The use of restraints was documented as "yes" when restraints were in place at the time of the UEX or "no" when restraints were not in place at the time of the UEX because the patient did not meet the institutional criteria for use of restraints or because the caregiver had removed the restraints temporarily to reposition or transfer the patient. Patients were documented as reintubated when reinsertion of the airway was required within 24 hours of the UEX. The primary indication for reintubation was recorded as "airway" (stridor, secretions, wheezing) or "nonairway" (hypoxemia, hypercapnia, apnea, hemodynamic instability).

A multidisciplinary CQI team was assembled to collect data and report to the Pediatric Critical Care Joint Practice Committee. After institutional review board approval by the University of Michigan Health Center, the data analysis was conducted in 4 phases, following the steps outlined in our institution's CQI model: "Plan–Do–Check–Act." During phase I ("Plan"), from July 1, 1996, to June 30, 1998 (fiscal years 1997 and 1998), the team quantified and benchmarked the incidence of UEX, conducted a root-cause analysis of associated factors, and developed 2 action plans to address the issues identified. In phase II ("Do"), from July 1, 1998, to June 30, 1999 (fiscal year 1999), the action plans were implemented. A provider education program was the first action plan initiated by the CQI team. Periodic in-services and newsletters, emphasizing low patient age as the greatest risk factor for UEX, were instituted for the medical, nursing, and respiratory therapy staffs. The second action plan implemented by the CQI team was a protocol-directed weaning plan designed to expedite weaning and extubation among patients who were ready for unassisted breathing.

In phase III ("Check"), from July 1, 1999, to June 30, 2000 (fiscal year 2000), we evaluated trends in our data and implemented enhancements of the 2 action plans. A third action plan was also introduced. Sedation practices were standardized by implementing a protocol to direct the titration of dose and frequency of intravenous sedation of intubated patients according to pain and sedation assessment scores (FLACC⁶ and Ramsey⁷ scales). In phase IV ("Act"), from July 1, 2000, to June 30, 2001 (fiscal year 2001), the incidence of UEX was again evaluated and information was shared with clinical providers.

A standardized rate of UEX using the method described by Little et al⁵ was calculated. This method relates the number of UEXs to the length of risk exposure by reporting UEXs per 100 airway days (AWD). Data are presented as median values with 25th and 75th quartiles for nonparametric data and as mean values with standard deviations for normally distributed data. The Mann-Whitney U test was used to compare continuous data. The ² test and ² for trend tests were used to compare categorical data. A statistical software package (SPSS 10.0 for Windows, SPSS Inc, Chicago, IL) and Epi Info 2000 (www.cdc.gov) were used. Statistical significance was defined as P < .05.

	RESULTS

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During our 5-year observation period, a total of 2192 patients required 13 630 AWD. From this population, 141 (6%) patients experienced 164 UEXs. A total of 124 (88%) patients experienced a single episode of UEX, 13 (9%) children experienced 2 UEXs each, 2 (1%) children experienced 3 UEXs each, and 2 (1%) children experienced 4 UEXs each.

Table 1 compares the demographic and clinical characteristics of the children who experienced UEXs with children who had airway control and did not have a UEX for the entire study period. The median age of children in the UEX group was significantly younger (0.9 vs 3.3 years), and the UEX children were more frequently on the medical service (77% vs 68%). These observations prompted us to calculate the annual standardized rates of UEX for children by age groups (Fig 1) and the overall standardized rates of UEX for both services. We found no difference in the overall mean rates of UEX (1.3 vs 1.1 UEX per 100 AWD) of children on the medical and surgical services, respectively. Severity of illness scores (Pediatric Risk of Mortality Score III 12-hour predicted mortality)⁴ were similar; however, the median LOMV was twice as long (6 vs 3 days; P < .001) in the UEX group, and the median LOS_ICU was also significantly longer (8 vs 4 days; P < .001).

View larger version (17K): [in this window] [in a new window]   Fig 1. Unplanned extubations per 100 AWD. *P < .05 2 for trend. FY, fiscal year.

Factors associated with the occurrence of UEX are listed in Table 2. During the 5-year monitoring period, a total of 122 (74%) of the UEXs originated from a patient-related activity. At the time of their UEX, 75 (46%) patients were weaning from MV and 62 (38%) patients were described as agitated.

	DISCUSSION

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Despite similar predicted mortality scores (at admission to the PICU), we found that the patients with UEXs had significantly longer LOMV than patients without UEXs. Investigators have suggested that UEX may be responsible for prolonging LOMV and LOS_ICU; however, the evidence is conflicting and inconclusive. Chevron et al⁸ reported a significantly shorter LOMV and LOS_ICU for UEX patients compared with non-UEX control subjects. Because the reintubation rate of the UEX patients was low (37%), they theorized that UEX served to expedite the weaning and extubation process. Our findings and our reintubation rate (52%) are similar to information reported by Epstein et al,⁹ who compared 75 UEX patients with 150 matched, non-UEX control subjects. They observed a reintubation rate of 56% and theorized that complications from the UEX and reintubation, along with a tendency of caregivers to increase sedation after a UEX, may have prolonged LOMV and LOS_ICU. Conversely, Boulain¹⁰ reported no difference in LOMV between UEX and non-UEX patients despite a reintubation rate of 61% in their UEX patients.

From another perspective, it could be argued that it is not UEX that prolongs LOMV; it may be that a long LOMV, made necessary by the patient's underlying illness, produces more UEXs simply by exposing the patient to a longer period of risk. We cannot determine which argument explains our finding of prolonged LOMV among pediatric patients with UEX.

The initiation of our effort to identify the rate of UEX in our PICU led us to address the question of what an acceptable rate of UEX is. Ideally, one might argue that the rate of UEX should be 0. However, if that rate is achieved by using excessive sedation or overly aggressive extubation, then other factors such as LOMV and patient morbidity and mortality could be compromised. We examined the range of UEX rates reported by other PICUs (0.11–2.4)^5,11–17 and set a rate of 2.0 UEXs per 100 AWD as our goal. In the first 2 years of our program, a consistent annual baseline rate of 1.5 UEXs per 100 AWD was observed. During this time, we identified opportunities for improvement and adopted the rate of 1.5 UEXs as our internal benchmark against which to compare our future performance. We focused our initial efforts to reduce UEX on 2 groups of patients: those with the highest occurrence rate of UEX (younger patients) and those with a low reintubation rate (weaning patients).

Before our data collection effort, we suspected that younger patients experienced a higher UEX rate than older ones, and our results supported this clinical impression. We observed that children younger than 5 years were consistently more likely to experience UEX than older patients. Our data support the findings of Scott et al,¹⁸ who reported that young patient age was the best predictor of UEX. In that study, no patient over the age of 5 years experienced a UEX. Todres et al¹⁹ examined the movement of endotracheal tubes in 16 infants who ranged in weight from 0.91 to 3.14 kg. Roentgenographic examination of each infant when held in full flexion (to simulate positioning for lumbar puncture) and full extension (to simulate supine lifting) demonstrated a range of movement from 7 to 28 mm (mean: 14.3 mm). The extent of movement was comparable to that found in adults; however, this distance was more likely to lead to airway displacement in children because of the shorter tracheal length. Additional factors, such as the use of uncuffed tubes in younger patients, combined with the lack of cognitive and emotional maturity to accept and tolerate an artificial airway, are likely to contribute to a higher rate of UEX in younger patients as well. Our provider education program emphasized the increased vulnerability of younger children to UEX, and the most significant reduction in the rate of UEX occurred specifically in this population.

As in adult reports,^9,20–22 a significant proportion of the UEX in our population occurred in patients who were weaning at the time of the event. These patients experienced a low risk for reintubation similar to the published reports of reintubation risk in adult weaning UEX patients (15%–30%).^9,20,21 These observations led us to believe that a significant number of our patients would benefit from an expedited weaning process. Results from the weaning protocol program demonstrated a decrease in the overall time required to wean and extubate PICU patients, and we theorize that this decrease contributed to the overall reduction of UEX rates in the subsequent years. However, we were not able to quantify precisely the weaning protocol's contribution to the reduction of UEX. To calculate the most accurate indicator of UEX incidence in weaning patients, ie, UEX per 100 AWD, it would have been necessary to stratify all patients with airway control into weaning versus nonweaning groups and record AWD for each. Theoretically, a standardized incidence rate could have been calculated for each and every risk factor associated with UEX, but to do so would have required a level of data collection that we did not consider feasible.

In the course of our investigation, we identified several factors associated with a high risk for reintubation after UEX. The association between large amounts of secretions and reintubation is somewhat intuitive and has been reported in adult, non-UEX populations.²³ Children who had recently received sedation, those with prolonged courses of respiratory failure, and those whose UEX was associated with caregiver activity were also more likely to require reintubation. As expected, we observed a 100% risk of reintubation for patients who received NMB. We tracked NMB patients as a separate category because of our concern that they are at high risk for severe complications. We think that the UEX of NMB patients, as well as any UEX associated with caregiver activity, must be considered preventable, and we highlight this in the provider education program.

Our study highlights both the utility and the complexity of using UEX data to enhance the quality of care in a PICU. Because we did not randomize our program against a control group and because of the unfeasibility of computing a standardized rate for each risk factor associated with UEX, we cannot credit the program as wholly and directly responsible for the reduction in UEX that we observed. We recognize that, over time, variations in patient characteristics such as severity of illness, LOMV, and age distribution as well as alterations in patient care practices would also affect the rate of UEX. Monitoring these factors was beyond the focus of our investigation. In our experience, the UEX monitoring program was useful for providing a "snapshot" of patient conditions at the time of an adverse event. As such, it provided a forum for doctors, nurses, respiratory therapists, pharmacists, and radiology technicians to collaborate in a dynamic and constructive analysis of the many aspects of care that contribute to the maintenance of artificial airways. Prompted by the UEX monitoring program, we speculate that the ongoing enhancements of many factors, such as staff education, staff-to-patient workloads, and management protocols, also contributed to reducing UEXs in our PICU.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
UEX among children in a PICU is associated with longer LOMV and LOS_ICU, and a CQI program of monitoring and analysis of UEX contributed to a reduction of this complication rate over 5 years. Patients who are at high risk for UEX are children who are younger than 5 years. A substantial number of UEXs occur in children while they are weaning from MV, and those children are at low risk for subsequent reintubation.

	ACKNOWLEDGMENTS

 
We acknowledge and thank the respiratory care practitioners in the Department of Critical Care Support Services and the nurses in the PICU for assistance in the meticulous data collection required for this study.

	FOOTNOTES

 
Accepted Mar 12, 2004.

Reprint requests to (R.S.) Department of Critical Care Support Services, University of Michigan Health System, 200 East Hospital Dr, F5815 Box 0208, Ann Arbor, MI 48109. E-mail: rsadowsk{at}umich.edu

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

1. Chiang AA, Lee KC, Lee JC, et al. Effectiveness of a continuous quality improvement program aiming to reduce unplanned extubation: a prospective study. Intensive Care Med. 1996;22 :1269 –1271[Medline]
2. Carrion MI, Ayuso D, Marcos M, et al. Accidental removal of endotracheal and nasogastric tubes and intravascular catheters. Crit Care Med. 2000;28 :63 –66[CrossRef][ISI][Medline]
3. Christie JM, Dethlefsen M, Cane RD. Unplanned endotracheal extubation in the intensive care unit. J Clin Anesth. 1996;8 :289 –293[CrossRef][ISI][Medline]
4. Pollack MM. PRISM III. An updated pediatric risk of mortality score. Crit Care Med. 1996;24 :743 –752[CrossRef][ISI][Medline]
5. Little LA, Koenig JC, Newth CJL. Factors affecting accidental extubations in neonatal and pediatric intensive care patients. Crit Care Med. 1990;18 :163 –165[ISI][Medline]
6. Merkel SI, Voepel-Lewis T, Sayevitz JR, et al. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23 :293 –297[Medline]
7. Hall JB, Schmidt GA, Wood LDH. Control of anxiety and pain. In: Principles of Critical Care. New York, NY: McGraw-Hill; 1992:74
8. Chevron V, Menard JF, Richard JC, et al. Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med. 1998;26 :1049 –1053[CrossRef][ISI][Medline]
9. Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med. 2000;161 :1912 –1916[Abstract/Free Full Text]
10. Boulain T, the Association des Reanimateurs du Centre-Ouest. Unplanned extubations in the adult intensive care unit: a prospective multicenter study. Am J Respir Crit Care Med 1998;157(suppl) :1131 –1137
11. Benjamin PK, Thompson JE, O'Rourke PP. Complications of mechanical ventilation in a children's hospital multidisciplinary intensive care unit. Respir Care. 1990;35 :873 –878[Medline]
12. Frank BS, Lewis RJ. Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries. Pediatr Pulmonol. 1997;23 :424 –428[Medline]
13. Hagner MJ, Woods K, Pyles L, et al. Inadvertent extubation in PICU [abstract]. Crit Care Med. 1994;22 :A154
14. McCready M, Greenwald BM, Scolavino J, et al. A prospective evaluation of unplanned endotracheal extubations in a pediatric intensive care unit (PICU) [abstract]. Crit Care Med. 1994;22 :A154
15. Metz RI, Mickel JJ. Unplanned extubation in pediatric patients: Incidence and related factors [abstract]. Crit Care Med. 1993;21(suppl) :S155
16. Orlowski JP, Ellis NG, Amin NP, et al. Complications of airway intrusion in 100 consecutive cases in a pediatric ICU. Crit Care Med. 1980;8 :324 –331[Medline]
17. Rivera R, Tibballs J. Complications of endotracheal intubation and mechanical ventilation in infants and children. Crit Care Med. 1992;20 :193 –199[ISI][Medline]
18. Scott PH, Eigen H, Moye LA, et al. Predictability and consequences of spontaneous extubation in a pediatric ICU. Crit Care Med. 1985;13 :228 –232[Medline]
19. Todres ID, deBros F, Kramer SS, et al. Endotracheal tube displacement in the newborn infant. J Pediatr. 1976;89 :126 –127[CrossRef][ISI][Medline]
20. Razek T, Gracias V, Sullivan D, et al. Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation. J Trauma. 2000;48 :466 –469[Medline]
21. Betbese AJ, Perez M, Bak E, et al. A prospective study of unplanned extubation intensive care unit patients. Crit Care Med. 1998;26 :1180 –1186[CrossRef][ISI][Medline]
22. Kapadia FN, Bajan KB, Raje KV. Airway accidents in intubated intensive care unit patients: an epidemiological study. Crit Care Med. 2000;28 :659 –664[CrossRef][ISI][Medline]
23. Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001;120 :1262 –1270[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (5) Citing Articles via Google Scholar Google Scholar Articles by Sadowski, R. Articles by Bratton, S. L. Search for Related Content PubMed PubMed Citation Articles by Sadowski, R. Articles by Bratton, S. L. Related Collections Office Practice

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