title: Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit.
abstract: OBJECTIVE
  Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs.
  
  
  METHODS
  Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program.
  
  
  RESULTS
  From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation.
  
  
  CONCLUSIONS
  We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.
authors.affiliation: Department of Critical Care Support Services, University of Michigan Health System, 200 East Hospital Dr, F5815 Box 0208, Ann Arbor, MI 48109, USA. rsadowsk@umich.edu
authors.forename: Roxanne
authors.initials: R
authors.lastname: Sadowski
authors.forename: Ronald E
authors.initials: RE
authors.lastname: Dechert
authors.forename: Kenneth P
authors.initials: KP
authors.lastname: Bandy
authors.forename: Julie
authors.initials: J
authors.lastname: Juno
authors.forename: Varsha
authors.initials: V
authors.lastname: Bhatt-Mehta
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Custer
authors.forename: Frank W
authors.initials: FW
authors.lastname: Moler
authors.forename: Susan L
authors.initials: SL
authors.lastname: Bratton
mesh_terms: D002648:Child; D002675:Child, Preschool; D006801:Humans; D015278:Intensive Care Units, Pediatric / Q000592:standards*; D007902:Length of Stay; D008824:Michigan; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000009:adverse effects / Q000592:standards* / Q000706:statistics & numerical data; D017749:Total Quality Management; D015300:Ventilator Weaning