Impact of adding an airway safety prompt to the A-F bundle on unplanned extubation in the intensive care unit

Endotracheal intubation is a life-saving intervention for adults with acute respiratory failure (ARF) but may result in unplanned extubation (UE). The success of UE prevention efforts has varied. We describe the development, implementation and impact of an airway safety quality improvement programme (ASQIP) embedded in an existing ABCDEF (A-F) bundle on UE occurrence.

Before-and-after evaluation of an ASQIP.

42-bed mixed intensive care unit (ICU) at a university-affiliated teaching hospital.

Consecutive adult patients, endotracheally intubated for ARF.

The ASQIP, developed from a literature review, the results of a national clinician survey, local clinician focus group input and root cause analyses of prior UE events, included interprofessional rounding scripts and was embedded into an existing A-F bundle. Multiple implementation strategies were employed, including didactic education to all ICU nurses (registered nurse, RN) and respiratory care therapists (RTs), the daily posting of signs of the ASQIP on the doors of rooms with a patient deemed to be at high risk for UE, and daily reminders from managers to bedside RTs and RNs.

ASQIP implementation was effective and was associated with a significantly lower incidence of UE per 100 MV days (before 0.43 vs after 0.29; p=0.04).

A multidisciplinary quality improvement initiative that incorporates airway safety within the A-F bundle may help reduce UE rates in critically ill adults. Future research is needed to validate standardised communication and assess the long-term sustainability of such interventions.