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Updated: Aug 6, 2025
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
Quality improvement project to reduce unplanned extubations in a paediatric intensive care unit
Joyce Caroline Dinelli Ferreira1, Milena Siciliano Nascimento2, Simone Brandi3
1Departamento de Qualidade e Segurança, Hospital Israelita Albert Einstein, São Paulo, Brazil.
Insights
Implementing innovative endotracheal tube fixation and restraint protocols in a pediatric ICU eliminated unplanned extubations for over two years. This quality improvement initiative significantly enhanced patient safety and reduced healthcare costs.
Area of Science:
- Pediatric Intensive Care
- Healthcare Quality Improvement
- Patient Safety
Background:
- Unplanned extubation is a frequent adverse event in mechanically ventilated children.
- Reducing unplanned extubations is a key safety goal in pediatric intensive care units (ICUs).
Purpose of the Study:
- To decrease the rate of unplanned extubation in a pediatric ICU by 66% (from 2.02 to 0.7).
Main Methods:
- A quality improvement project utilizing the Institute for Healthcare Improvement's model.
- Interventions included improved endotracheal tube fixation, positioning evaluation, physical restraint protocols, sedation monitoring, family engagement, and a prevention checklist.
- The Plan-Do-Study-Act methodology was employed for testing and implementation.
Main Results:
- The project successfully reduced the unplanned extubation rate to zero.
- This zero-event rate was sustained for 743 days (over two years).
- Significant cost savings were estimated at US$179,540.41 over two years.
Conclusions:
- A focused quality improvement project can effectively eliminate unplanned extubations in pediatric ICUs.
- Innovations in endotracheal tube fixation and restraint models were critical to success.
- Sustained zero-event rates demonstrate the long-term impact of implemented safety strategies.
Background:
Unplanned extubations are recurrent adverse events in mechanically ventilated children and have been the focus of quality and safety improvement in paediatric intensive care units (ICUs).
Local Problem:
To reduce the rate of unplanned extubation in the paediatric ICU by 66% (from 2.02 to 0.7).
Methods:
This is a quality improvement project that was conducted in a paediatric ICU of a private hospital at the quaternary level. All hospitalised patients who used invasive mechanical ventilation between October 2018 and August 2019 were included.
Interventions:
The project was based on the Improvement Model methodology of the Institute for Healthcare Improvement to implement change strategies. The main ideas of change were innovation in the endotracheal tube fixation model, evaluation of the endotracheal tube positioning, good practices of physical restraint, sedation monitoring, family education and engagement and checklist for prevention of unplanned extubation, with Plan-Do-Study-Act, the tool chosen to test and implement ideas for change.
Results:
The actions reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 2 years, totalling 743 days without any event. An estimate was made comparing cases with unplanned extubation and controls without the occurrence of this adverse event, which resulted in savings of R$955 096.65 (US$179 540.41) during the 2 years after the implementation of the improvement actions.
Conclusion:
The improvement project conducted in the 11-month period reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 743 days. Adherence to the new fixation model and the creation of a new restrictor model, which enabled the implementation of good practices of physical restraint were the ideas of change that had the greatest impact in achieving this result.
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