title: Reducing failed extubations in the intensive care unit.
abstract: BACKGROUND
  Failed extubation is associated with substantially increased morbidity, mortality, and costs for patients receiving mechanical ventilation. A study was designed in 1998 to identify risk factors for failed extubation and use a quality improvement model to reduce failed extubation rates in a surgical intensive care unit (SICU) in an academic hospital.
  
  
  METHODS
  Study design involved a prospective cohort SICU with a concurrent control SICU. The primary outcome was rate of failed extubations per 1,000 ventilator days. Information on risk factors for failed extubations was also collected. Performance improvement staff identified failed extubation patients, and respiratory therapy provided information on ventilator days. The quality improvement model implemented three phases between October 1998 and June 2000: (1) identifying factors associated with failed extubation, (2) developing a guideline to reduce failed extubation, and (3) implementing the guideline.
  
  
  RESULTS
  Significant factors associated with failed extubation included suctioning more frequently than every 4 hours versus the current model of "every 4 hours or greater" (odds ratio [OR] 11.3; 95% confidence interval [CI] 1.5-88.3), being agitated or sedated versus being alert (OR 4.5, CI: 1.2-14.7), and oxygen saturation < or = 95% versus > or = 95% (OR 4.0; CI: 1.2-13). Failed extubation rate in the SICU decreased from 8/1,000 in October 1998 to 1.5/1,000 in June 2000, and control SICU rates remained unchanged (8/1,000).
  
  
  CONCLUSIONS
  The intervention significantly reduced the rate of failed extubation in the SICU. By employing a quality improvement model and identifying risk factors for failed extubation, providers should be able to decrease risk of failed extubation for SICU patients.
authors.affiliation: Departments of Anesthesiology/Critical Care Medicine and Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 295, Baltimore, MD 21287-7294, USA. ppronovo@jhmi.edu
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.forename: Mollie
authors.initials: M
authors.lastname: Jenckes
authors.forename: May
authors.initials: M
authors.lastname: To
authors.forename: Todd
authors.initials: T
authors.lastname: Dorman
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Lipsett
authors.forename: Sean
authors.initials: S
authors.lastname: Berenholtz
authors.forename: Eric B
authors.initials: EB
authors.lastname: Bass
mesh_terms: D000046:Academic Medical Centers / Q000592:standards*; D000328:Adult; D015142:Baltimore; D016022:Case-Control Studies; D003211:Concurrent Review; D003625:Data Collection; D003657:Decision Making; D005568:Forms and Records Control; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000592:standards* / Q000706:statistics & numerical data; D017146:Models, Organizational; D019982:Organizational Case Studies; D010043:Outcome and Process Assessment, Health Care; D011182:Postoperative Care / Q000592:standards*; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000592:standards* / Q000706:statistics & numerical data; D013597:Systems Analysis; D017749:Total Quality Management / Q000379:methods / Q000458:organization & administration*; D017211:Treatment Failure