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Published on: August 2, 2024
Outcomes of Unplanned Extubations in a Large Children's Hospital
Cheryl L Dominick1, Brooke N Blanke2, Emily M Simmons2
1Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. defalco@chop.edu.
Insights
Unplanned extubation (UE) is common in pediatric ICUs, with significant adverse events and variable re-intubation rates. Interventions are needed to reduce these occurrences and improve patient safety.
Area of Science:
- Pediatric Critical Care Medicine
- Healthcare Quality Improvement
- Patient Safety
Background:
- Unplanned extubation (UE) is the unintentional removal of an endotracheal tube (ETT), potentially causing instability and requiring re-intubation.
- Quality improvement initiatives are crucial for identifying factors contributing to UEs and mitigating adverse outcomes.
- Understanding UE patterns across different pediatric intensive care units (ICUs) is essential for targeted interventions.
Purpose of the Study:
- To investigate the occurrence, contributing factors, and clinical outcomes of UEs in pediatric ICU (PICU), cardiac ICU (CICU), and neonatal ICU (NICU).
- To hypothesize and analyze differences in UE incidence and outcomes across these specialized pediatric ICUs.
- To inform the development of targeted quality improvement interventions to minimize UEs.
Main Methods:
- A 5-year retrospective review (January 2016-December 2021) of UEs across PICU, CICU, and NICU at a large academic children's hospital.
- Utilized a prospective database and electronic medical records, with data extracted by respiratory therapists.
- Employed consensus-based definitions for contributing factors and adverse events, ensuring data consistency.
Main Results:
- A total of 408 UEs were reported in 339 subjects, with the neonatal ICU (NICU) accounting for the majority (80%).
- Common causes included routine nursing care (18%), ETT retaping (16%), and patient handling (3.9%).
- Adverse events such as desaturation (<80% in 33%) and bradycardia (22.8%) were frequent, with cardiac arrest in 12%; 67% required re-intubation within 72 hours, varying significantly by unit (PICU 62%, CICU 35%, NICU 71%).
Conclusions:
- Unplanned extubations are a significant concern in pediatric ICUs, associated with adverse events and requiring re-intubation.
- Re-intubation rates within 72 hours following UE were substantial (<70%) and demonstrated significant variability across the PICU, CICU, and NICU.
- These findings underscore the need for unit-specific quality improvement strategies to reduce UE incidence and associated complications.
Background:
Unplanned extubation (UE) is defined as unintentional dislodgement of an endotracheal tube (ETT) from the trachea. UEs can lead to instability, cardiac arrest, and may require emergent tracheal re-intubation. As part of our hospital-wide quality improvement (QI) work, a multidisciplinary committee reviewed all UEs to determine contributing factors and evaluation of clinical outcomes to develop QI interventions aimed to minimize UEs. The objective was to investigate occurrence, contributing factors, and clinical outcomes of UEs in the pediatric ICU (PICU), cardiac ICU (CICU), and neonatal ICU (NICU) in a large academic children's hospital. We hypothesized that these would be substantially different across 3 ICUs.
Methods:
A single-center retrospective review of UEs in the PICU, CICU, and NICU was recorded in a prospective database for the last 5 y. Consensus-based standardized operational definitions were developed to capture contributing factors and adverse events associated with UEs. Data were extracted through electronic medical records by 3 respiratory therapists and local Virtual Pediatric Systems (VPS) database. Consistency of data extraction and classification were evaluated.
Results:
From January 2016-December 2021, 408 UEs in 339 subjects were reported: PICU 52 (13%), CICU 31 (7%), and NICU 325 (80%). The median (interquartile range) of age and weight was 2.0 (0-4.0) months and 5.3 (3.0-8.0) kg. Many UE events were not witnessed (54%). Common contributing factors were routine nursing care (no. = 70, 18%), ETT retaping (no. = 62, 16%), and being held (no. = 15, 3.9%). The most common adverse events with UE were desaturation < 80% (33%) and bradycardia (22.8%). Cardiac arrest occurred in 12%. Sixty-seven percent of UEs resulted in re-intubation within 72 h. The proportion of re-intubation across 3 units was significantly different: PICU 62%, CICU 35%, NICU 71%, P < .001.
Conclusions:
UEs occurred commonly in a large academic children's hospital. Whereas UE was associated with adverse events, re-intubation rates within 72 h were < 70% and variable across the units.
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