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UNINTENDED EXTUBATION: IMPROVING CARE FOR THE PEDIATRIC TRAUMA POPULATION
Jennifer Fritzeen, MSN, RN, PCNS
Trauma & Burn Program Manager
Children’s National Medical Center
Unintended Extubations
Loss or displacement of the endotracheal tube prior to decision to extubate by the primary care team
Complications of Unintended Extubation
Increase ventilator days
Nosocomial infections
Prolonged ICU stay
Unintended Extubation Events (N=102)
5
1 12
3
110
1 1
3
0
21
14
6 6
12
3
0
5
10
15
20
25
Q3 2011 Q4 2011 Q 1 2012 Q2 2012 Q3 2012 Q4 2012
Chest compressions Code medications Re-intubation
Nu
mb
er o
f in
terv
enti
on
Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placement
Positioning & Safety
Staffing
Event Root Cause Analysis
Unintended extubation
DemographicsAge, Diagnosis, # ventilator days
Level of sedation
Patient activityETT placement
Positioning & Safety
Staffing
Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedationPrn medications vs drips
Patient activityETT placement
Positioning & Safety
Staffing
Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityRestraints, procedures, interventions
ETT placement
Positioning & Safety
Staffing
Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placement
Positioning & SafetyActive repositioning, tape secure, restraint use
Staffing
Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placementOral vs nasalPlacement on x-ray
Positioning & Safety
Staffing
Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placement
Positioning & Safety
Staffing1:1, paired
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2008 2009 2010 2011 2012 2013 2014 2015
UE
/10
0 v
en
t d
ay
sQuarterly Unintended Extubation Rates
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2008 2009 2010 2011 2012 2013 2014 2015
UE
/10
0 v
en
t d
ay
s
Airway Protection Team
Quarterly Unintended Extubation Rates
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2008 2009 2010 2011 2012 2013 2014 2015
UE
/10
0 v
en
t d
ay
s
Standardized Taping
Quarterly Unintended Extubation Rates
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2008 2009 2010 2011 2012 2013 2014 2015
UE
/10
0 v
en
t d
ay
s
Airway compliance bundle with
weekly audits
Quarterly Unintended Extubation Rates
Airway Compliance Bundle
ETT position verification – CXR, visual cue
Team presence at X-ray rounds
Upper extremity restraints
Standardized ETT tape
Sedation phase
Comparison of Annual Unintended Extubation Rates
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
2011 2012 2013 2014
Comparison of Annual Unintended Extubation Rates
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
2011 2012 2013 2014
PICU
Trauma/Burn
Unintended Extubations – Trauma Patients
N=6
100% lacked therapeutic sedation regimen
50% risk for neurologic deficit
33% required re-intubation – inhalation injury
Average age 51 months 88 months
Median age 24 months 90 months
Reintubation rate 45% 33%
Rate of continuous sedation use
71% 0%
Population Differences
PICU Trauma/Burn
Implications for the Pediatric Trauma/Burn Population
Improved sedation practices
Communicated sedation plan
Extubation readiness criteria
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