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Published on: January 17, 2011
Improving Unplanned Extubation Rates in a Single Pediatric Intensive Care Unit Led by a Respiratory Therapist
Christy L Thomas1, Jordan M Unlap1, Caleb R Watson1
1Ms. Thomas, Unlap, Watson, Jones, and Park are affiliated with the Department of Respiratory Care Services, Children's of Alabama, Birmingham, Alabama, USA.
Insights
Unplanned extubations in critically-ill children decreased by 72.5% through quality improvement interventions. This sustained reduction in pediatric intensive care units highlights the importance of a dedicated champion and established prevention bundles.
Area of Science:
- Pediatric Critical Care Medicine
- Quality Improvement Science
- Patient Safety
Background:
- Unplanned extubations (UE) in critically-ill children lead to significant morbidity, mortality, and increased healthcare costs.
- Despite successful multi-center implementation of prevention bundles, UE rates persist as a common source of preventable harm.
- Existing prevention strategies require further enhancement for sustainable reduction.
Purpose of the Study:
- To achieve a 50% sustainable decrease in UE per 100 invasive ventilation days within a pediatric intensive care unit (PICU).
- To implement and evaluate multiple quality improvement interventions over a five-year period (2020-2025).
- To assess the impact of interventions on patient outcomes and balancing measures.
Main Methods:
- A longitudinal, multi-intervention quality improvement project in a single quaternary care PICU.
- Utilized Plan-Study-Do-Act (PDSA) cycles to drive iterative improvements.
- Built upon the initial implementation of the Solutions for Patient Safety Network UE prevention bundle, with a dedicated QI respiratory therapist.
Main Results:
- Achieved a 72.5% decrease in UE/100 invasive ventilation days, meeting criteria for a center line shift from 0.58 to 0.16.
- Sustained the reduced UE rate from Q1 2023 through Q2 2025 without adverse impact on balancing measures like invasive ventilation duration.
- Observed a decrease in the percentage of PICU patients requiring invasive ventilation (42% to 33%).
Conclusions:
- Multiple interventions, driven by a dedicated champion, significantly reduced and sustained UE rates in the PICU.
- The study validates the importance of building upon established prevention bundles for pediatric patient safety.
- Quality improvement initiatives can effectively decrease preventable harm without negatively affecting other critical care metrics.
Background:
Unplanned extubations (UE) are directly associated with morbidity, mortality, and increased health care costs among critically-ill children. Multi-center implementation of the Solutions for Patient Safety Network prevention bundle has been successful, but UE rates remain a common cause of preventable health care harm.
Methods:
This was a longitudinal (2020-2025), multi-intervention quality improvement (QI) project in a single quaternary care pediatric intensive care unit (PICU) driven largely by a new QI respiratory therapist. Interventions built upon the initial implementation of the UE prevention bundle. The smart aim of this project was to sustainably decrease UE/100 invasive ventilation days in the PICU at Children's of Alabama by 50% through multiple Plan-Do-Study-Act (PDSA) cycles.
Results:
The baseline event rate was 0.58 UE/100 invasive ventilation days. Criteria for a center line shift to 0.16 UE/100 invasive mechanical ventilation days (72.5% decrease) were met in the first quarter of 2023 following four PDSA cycles and sustained through the end of the project. There was no change in invasive ventilation days/patient/quarter, but the percentage of PICU patients exposed to invasive ventilation by quarter starting dropped from 42% to 33% beginning in the first quarter of 2021. There were no center line shifts in post-UE outcomes over the project period including re-intubation within 1 h, re-intubation with cardiopulmonary resuscitation, or no re-intubation.
Conclusions:
Through multiple interventions, UE/100 invasive ventilation days decreased by 72.5% and has been sustained from the first quarter of 2023 through the second quarter of 2025 without impacting balancing measures such as invasive ventilation duration. These results support the importance of building upon the Solutions for Patient Safety Network UE prevention bundle and having a dedicated champion to drive improvement and sustainability.
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