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Updated: Jan 4, 2026
A Structured Approach to Extubation in Mechanically Ventilated Rats
Published on: July 18, 2025
Achieving Sustainability in Reducing Unplanned Extubations in a Pediatric Cardiac ICU
Nina M Censoplano1, Cindy S Barrett1, Richard J Ing2
1Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Center, Children's Hospital Colorado, Aurora, CO.
Insights
A quality improvement initiative successfully maintained a low rate of unplanned extubations in a pediatric cardiac ICU. Younger, smaller patients requiring longer mechanical ventilation were at higher risk, highlighting the need for early identification and intervention.
Area of Science:
- Pediatric critical care medicine
- Quality improvement science
- Patient safety
Background:
- Unplanned extubation is a significant concern in pediatric cardiac intensive care units (ICUs).
- Previous quality improvement initiatives aimed to reduce unplanned extubations.
- Assessing the sustainability of these initiatives and identifying associated risk factors is crucial.
Purpose of the Study:
- To determine the incidence of unplanned extubations in a pediatric cardiac ICU.
- To evaluate the sustainability of a quality improvement initiative.
- To identify risk factors for unplanned extubations and analyze patient outcomes.
Main Methods:
- Retrospective chart review of intubated and mechanically ventilated patients in a pediatric cardiac ICU.
- Data collected from July 2011 to December 2017.
- Analysis of patient demographics, ventilation duration, interventions, and outcomes.
Main Results:
- The unplanned extubation rate was 0.4 per 100 ventilator days.
- Patients experiencing unplanned extubation were younger, weighed less, and required longer mechanical ventilation.
- Higher risk of cardiopulmonary resuscitation and in-hospital mortality was observed in patients with unplanned extubations.
- Contributing factors included poor endotracheal tube securement and inadequate sedation.
Conclusions:
- A low rate of unplanned extubation is sustainable despite increased patient volume and acuity.
- Early identification of high-risk patients can further decrease the incidence of unplanned extubation.
- Continued quality improvement efforts are essential for patient safety in pediatric cardiac ICUs.
Objectives:
To determine the incidence of unplanned extubations in a pediatric cardiac ICU in order to prove sustainability of our previously implemented quality improvement initiative. Additionally, we sought to identify risk factors associated with unplanned extubations as well as review the overall outcome of this patient population.
Design:
Retrospective chart review.
Setting:
Pediatric cardiac ICU at Children's Hospital of Colorado on the Anschutz Medical Center of the University of Colorado.
Patients:
Intubated and mechanically ventilated patients in the cardiac ICU from July 2011 to December 2017.
Interventions:
None.
Measurements And Main Results:
A total of 2,612 hospitalizations for 2,067 patients were supported with mechanical ventilation. Forty-five patients had 49 episodes of unplanned extubations (four patients > 1 unplanned extubation). The average unplanned extubation rate per 100 ventilator days was 0.4. Patients who had an unplanned extubation were younger (0.09 vs 5.45 mo; p < 0.001), weighed less (unplanned extubation median weight of 3.0 kg [interquartile range, 2.5-4.5 kg] vs control median weight of 6.0 kg [interquartile range, 3.5-13.9 kg]) (p < 0.001), and had a longer length of mechanical ventilation (8 vs 2 d; p < 0.001). Patients who had an unplanned extubation were more likely to require cardiopulmonary resuscitation during their hospital stay (54% vs 18%; p < 0.001) and had a higher likelihood of in-hospital mortality (15% vs 7%; p = 0.001). There was a significant difference in surgical acuity as denoted by The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score and patients with an unplanned extubation had a higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category (p = 0.019). Contributing factors associated with unplanned extubation were poor endotracheal tube tape integrity, inadequate tube securement, and/or inadequate sedation. A low rate of unplanned extubation was maintained even in the setting of increasing patient complexity and an increase in patient volume.
Conclusions:
A low rate of unplanned extubation is sustainable even in the setting of increased patient volume and acuity. Additionally, early identification of patients at higher risk of unplanned extubation may also contribute to decreasing the incidence of unplanned extubation.
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