title: Plan to Have No Unplanned: A Collaborative, Hospital-Based Quality-Improvement Project to Reduce the Rate of Unplanned Extubations in the Pediatric ICU.
abstract: BACKGROUND
  Although under-reported and understudied, unplanned extubations carry a significant risk of patient harm and even death. They are an important yardstick of quality control of care of intubated patients in the ICU. A unit-based risk assessment and multidisciplinary approach is required to decrease the incidence of unplanned extubations.
  
  
  METHODS
  As part of a quality-improvement initiative of Children's Hospital at Montefiore, all planned and unplanned extubations in a multidisciplinary 20-bed pediatric ICU were evaluated over a 12-month period (January to December 2010). At the end of 6 months, an interim analysis was performed, and high-risk patient groups and patient care factors were identified. These factors were targeted in the second phase of the project.
  
  
  RESULTS
  Over this period, there were a total of 267 extubations, of which 231 (87%) were planned extubations and 36 (13%) were unplanned. A patient care policy targeting the risk factors was instituted, along with extensive nursing and other personnel education in the second phase. As a result of this intervention, the unplanned extubation rate in the pediatric ICU decreased from 3.55 to 2.59/100 intubation days. All subjects who had an unplanned extubation during nursing procedures or transport required re-intubation, whereas none of the unplanned extubations during ventilator weaning required re-intubation.
  
  
  CONCLUSIONS
  A targeted approach based on unit-specific risk factors is most effective in quality-improvement projects. A specific policy for sedation and weaning can be very helpful in managing intubated patients and preventing unintended harm.
authors.affiliation: Pediatric Intensive Care, Mayo Clinic, Rochester, Minnesota. sandeeptripathi2000@yahoo.com.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Tripathi
authors.affiliation: Pediatric Intensive Care, Children's Hospital at Montefiore, Bronx, New York.
authors.forename: Denise J
authors.initials: DJ
authors.lastname: Nunez
authors.affiliation: Pediatric Intensive Care, Children's Hospital at Montefiore, Bronx, New York.
authors.forename: Chaavi
authors.initials: C
authors.lastname: Katyal
authors.affiliation: Pediatric Intensive Care, Children's Hospital at Montefiore, Bronx, New York.
authors.forename: H Michael
authors.initials: HM
authors.lastname: Ushay
mesh_terms: D000293:Adolescent; D060666:Airway Extubation / Q000592:standards / Q000706:statistics & numerical data*; D002648:Child; D003299:Cooperative Behavior; D005260:Female; D006284:Health Plan Implementation / Q000379:methods*; D006801:Humans; D015278:Intensive Care Units, Pediatric / Q000592:standards / Q000706:statistics & numerical data*; D008297:Male; D009518:New York; D018802:Patient-Centered Care / Q000592:standards*; D058996:Quality Improvement / Q000706:statistics & numerical data*; D012307:Risk Factors; D015300:Ventilator Weaning / Q000592:standards / Q000706:statistics & numerical data
keywords: endotracheal extubation; intensive care unit; mechanical ventilation; medical errors; patient safety; pediatric; quality improvement