The Impact of Unintended Extubation Rate Tracking in Adults: An Approach to Baseline Outcomes for Improving Patient Safety

Background:

Unintended extubations (UEs) are considered an indicator of healthcare quality in intensive care units (ICUs). We define endotracheal tube (ETT) and tracheostomy decannulations as UEs. UE is a complication of artificial airways in patients with and without mechanical ventilation. UEs involving ETTs have been reported in 3-16% of mechanically ventilated patients (1), and several studies identify UEs as a marker of quality of weaning care. Intermountain Healthcare is an integrated healthcare system in the intermountain west with 23 acute care hospitals of which 20 provide respiratory care services. We sought to identify the incidence and root causes of UEs & trends in artificial airway practices associated with adult patients in our ICUs.

Methods:

During Q4 2018, outcomes regarding UEs were tracked via electronic medical record documentation, event reports and daily safety huddles. Charts were reviewed to identify root causes such as activity level, securing device, caregiver/family presence, ventilator settings and reintubation. We acknowledge UEs may have been previously under-reported and true prevalence was unknown. While some element of normalization of UEs may have been prevalent, an increased culture of safety is occurring. With data tracking, we have appreciated improved reporting behaviors.

Results:

Documented UEs were noted in 30 pts (Table 1). Trends included: 1) time of day (11 UEs occurred before 10 AM with only 1 occurring after 10 PM), 2) no difference in UE occurrence appeared associated with the airway securing method, 3) 15 pts were in a spontaneous ventilator mode, and 4) the majority of UEs did not occur during early mobility. The ICU with the most aggressive mobility practice (TID) had zero UEs. We found 3.3% of mechanically ventilated pts had a UE with 7 (23%) of them requiring reintubation.

Conclusions:

Additional methods of baseline data inquiries found that the most consistent contributors were sudden wakefulness and variation in restraint application. During 2019, all UEs are being reviewed for further trend analysis as well as standardized response interventions to assess efficacy of UE mitigation. We emphasize the importance of baseline analysis to identify root causes and care plan gap solutions. Reference: 1. Boulain T. Unplanned extubations in the adult intensive care unit: a prospective multicenter study: association des Reanimateurs du Centre-Ouest. Am J Respir Crit Care Med 1998;157:1131-1137.

Table 1: Oct 1, 2018- Dec 30, 2018 Adult Unintended Extubation/Decannulation Outcomes Across an Integrated Healthcare System