Abstract
Background:
Unplanned extubations (UE) can result in immediate airway management complications, hemodynamic instability, increased length of stay (LOS), and, increased ventilator days (VD). UEs in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days.1 Risk factors, such as age, gender, increased salivary secretions, intubation duration, nursing attentiveness, endotracheal tube fixation method, and sedation have all been referenced in the literature. After reviewing our practices in 2019 with a UE rate of 0.56/100 VD, we created a multidisciplinary subgroup with a goal UE rate of 0/100 VD. We focused our efforts on standardizing a process for evaluating UE in our PICU using the Solutions for Patient Safety (SPS) workgroup as a source of information.
Methods:
In an IRB approved retrospective analysis, data was analyzed from 1/1/2019 to 4/30/2020 for number of UEs per 100 VD. After review in 12/2019 changes to our UE bundle included three major changes that were implemented 1/1/2020. First an immediate swarm event post UE with the providing team (RN, RT and MD) using a standard Event Review Form. A visual bundle card was created and education to multidisciplinary teams regarding ETT management in the PICU was completed. Lastly, an ETT management education and elements included; standardized ETT securement process, 2 RT ETT securement process, “Two on the Tube” during patient mobility, and increased awareness for RNs on ETT securement verification.
Results:
UE rate from 2019 was compared to available data from 2020. The UE rate for the first 17 weeks in 2019 was 0.83/100 VD and in the same time in 2020, UE rate was 0.38/100 VD. For 2019 (1/1-12/31), PICU UE rate was 0.56/100 VD (7/1,257). The current PICU UE rate (17 weeks) is 0.36/100 VD (2/527). See Figure 1 for detailed week-to-week data.
Conclusions:
By implementing UE swarms, adding visual bundle elements, and providing multidisciplinary education in our PICU the UE rate decreased 54.21% (Q1 2019 vs. Q1 2020). Our goal is still 0/100 VD and we will continue with continuous improvement initiatives and bundle modifications to achieve this standard in our PICU. Further studies must be done to evaluate the effectiveness of these types of interventions in other patient populations. 1. Klugman D, et al. Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children. JAMA Pediatr 2020 Apr 13:e2DD268
Graph 1 displays the rate of unplanned extubations per 100 endotracheal tube days.
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