Approach to unplanned extubations in a pediatric intensive care unit

An unplanned extubation is defined as an extubation that occurs at a time other than that planned for the procedure. It may result in life-threatening complications such as laryngospasm, pulmonary or cardiac failure. Quality improvement initiatives have targeted an unplanned extubation rate of 0% in pediatric intensive care units.

To determine if a targeted approach specific to local practices and unit culture could decrease the incidence of and, ultimately, eliminate unplanned extubations in our tertiary care PICU.

This study used a mixed methods design involving three phases. Phase 1 involved the retrospective collection of data on all unplanned extubations from September 2011 to August 2013. Phase 2 involved development of a quality improvement program and Phase 3 involved prospective collection of data on all unplanned extubations from January to August 2014.

There were 12 unplanned extubations in Phase 1 resulting in a rate of 0.9 per 100 patient ventilator days. The majority of unplanned extubations occurred in children less than one year of age (66.6%, 8/12), and during the nightshift (91.7%). In addition, 25% of events occurred during chest radiographs. Forty-one per cent of patients who had an unplanned extubation required re-intubation and one of the seven children who remained extubated required non-invasive airway support. Staff concerns included inadequate sedation, loose endotracheal tubes and frequent manipulation of endotracheal tubes. Following Phase 2 and a more comprehensive tracking method, we recorded 10 unplanned extubations with a rate of 0.9 per 100 patient ventilator days, but there were no unplanned extubations in patients less than a month of age or during chest radiographs and only four unplanned extubations occurred during the nightshift (40%).

Our initiatives were successful in decreasing the unplanned extubations associated with certain high-risk factors in our unit, but not in decreasing our overall unplanned extubation rate. We have identified several issues to target for our next round of audit and feedback. While it is important to learn from studies that show a decrease in unplanned extubation rates, we think that it is equally important to understand why others do not achieve their desired goals, as these studies may provide support and ideas for other units struggling with the same issues.