A prospective observational quality improvement study of the sustained effects of a program to reduce unplanned extubations in a pediatric intensive care unit

Background: The use of endotracheal intubation is routine in the care of critically ill children. Unplanned extubation exposes the patient to morbidity and mortality over and above that associated with the patient's underlying disease. All unplanned extubations are unacceptable because of their potential for causing unnecessary harm to the patient.

Objective: To prospectively determine whether a quality improvement program adopted 9 years ago has continued to be successful in maintaining a low rate of unplanned extubation in our pediatric intensive care unit (PICU).

Design: Prospective, observational study.

Setting: 10-bed PICU in an urban, county, teaching hospital.

Patients: All intubated pediatric patients in the PICU from February 15, 2009 to February 14, 2010.

Intervention: None.

Measurements and results: Prior to the implementation of the program in 2000, our PICU had an unplanned extubation rate of 6.4 unplanned extubations per 100 ventilated days. After implementation of the quality improvement program, the rate of unplanned extubation decreased to 1.0 unplanned extubation per 100 ventilated days. In this study, we reevaluated the unplanned extubation rate 9 years after the implementation of the quality improvement program. We found that the rate had remained unchanged (P > 0.05): 1.5 unplanned extubations per 100 ventilated days as compared to 1.0 unplanned extubation per 100 ventilated days. There were no significant differences (P > 0.05) in age, weight, endotracheal tube size, duration of intubation or rate of unplanned extubation.

Limitations: In this study, no randomization took place, in which one group was not subject to the quality improvement program. We did not account for potential changes in severity of illness or staffing issues.

Conclusions: In the 9 years since implementation, our program has remained successful in decreasing unplanned extubations. It is important to periodically reevaluate quality improvement programs to determine whether they have continued to achieve their intended goals. The initiative is reported here using the Standards for Quality Improvement Reporting Excellence (SQUIRE).