Nurse staffing and unplanned extubation in the pediatric intensive care unit

To determine the association between unplanned extubations and years of nurse experience and nurse-to-patient ratio in the pediatric intensive care unit (PICU).

Case-control study.

University-affiliated children's hospital PICU.

Unplanned extubations were identified from January 1999 through December 2002. Three control patients for each of the patients experiencing an unplanned extubation were selected on three matching factors: age, intubation duration, and severity of illness as defined by the Pediatric Risk of Mortality (PRISM) III.

None.

Fifty-five of 1,004 intubated patients (5.5%) experienced an unplanned extubation during the 4-yr period. A conditional logistic regression analysis was used to evaluate the association between a patient's risk of an unplanned extubation and the nurse's years of PICU experience and nurse-to-patient ratio. Factors associated with unplanned extubations included the documentation of patient agitation (odds ratio, 2.99; 95% confidence interval, 1.14, 7.86) and a nurse-to-patient ratio of 1:2 (one nurse caring for two patients) relative to a nurse-to-patient ratio of 1:1 (odds ratio, 4.24; 95% confidence interval, 1.00, 19.10). Years of PICU nursing experience, patient restraints, and the method of sedation delivery (continuous infusion vs. intermittent bolus) were not associated with unplanned extubations.

Pediatric patients are more likely to experience an unplanned extubation when being cared for by a nurse assigned to two patients compared with a nurse caring for one patient. To provide safe patient care, health care policymakers and hospital administrators should consider the nurse-to-patient ratio and its potential association with adverse events in hospitalized children.