An Innovative Approach to Preventing Unplanned Extubations in the PICU

Purpose:
An airway safety bundle was created to address the increase in our unplanned extubation rate. The bundle had a unique feature in the form of an airway time out tool. The overall goal was to decrease the rate of events to below the national benchmark of < 1.0 per 100 ventilator days.

Relevance/Significance:
This initiative enabled us to disseminate and implement best practices in evidence-based, interprofessional, patient-centered care. Unplanned extubations are some of the most serious and potentially life threatening events in the Pediatric Intensive Care Unit (PICU). These events can be associated with cardiovascular collapse, reintubation, and increased duration of mechanical ventilation and PICU length of stay. Our PICU had experienced an increase in the number of unplanned extubations.

Strategy and Implementation:
An airway safety bundle was created to address the increase in our UE rate. The bundle shared components with those previously described in literature with a unique feature in the form of an airway time out tool. This tool is used prior to and after transfer of an intubated patient, airway related procedure such as ETT retaping, and whenever an airway safety concern was expressed. Standardization of endotracheal tube positioning, care and securement practices was implemented. Variation in sedation practices was minimized with use of a sedation assessment tool and prescription of sedation goals. Heightened situational awareness was promoted using tools from TeamSTEPPSŪ. There were also daily reminders on airway safety during shift briefs. In addition, all staff received education on the risk factors and consequences of these events.

Evaluation:
In 2013, following implementation of the bundle, the PICU experienced a 62.5% reduction in unplanned extubations (1.19 extubations/100 ventilator days to 0.45 extubations/100 ventilator days). With ongoing effort and utilizing PDSA methodology we achieved an overall reduction of 75% by the end of 2014.

Implications for Practice:
This performance improvement initiative has led to a decrease in the number of unplanned extubations in the PICU with a corresponding decrease in morbidity and mortality. This initiative was disseminated throughout the critical care specialty within the organization.