2003 OPEN FORUM Abstracts
A MULTI DISIPLINARY APPROACH TO IMPROVING ACCIDENTAL EXTUBATION RATES IN A PEDIATRIC INTENSIVE CARE UNIT .
Dan Wells BS,RRT,RN, Scott Pettinichi MEd,RRT-NPS,
Richard Brilli MD Cincinnati Children's Hospital Medical Center. Cincinnati,OH
Background: Quarterly, our PICU (pediatric intensive care unit) tracks as part of a performance improvement program rates of unplanned extubations. The PICU, which recently increased from 15 to 25 beds in January of 2003, has an average daily census of almost 13 with an average length of stay of 3.7 days. We have on average a 50/50 split when it comes to medical and surgical patients, with 3170 mechanical ventilator days in 2002.
In the first quarter of 2002, our unplanned extubation rate rose to over 2.5 per 100 mechanical ventilator days. It was also noted that over half of these patients were post-operative otolaryngology patients, some of which were intubated for seven to ten days. It was decided that ETT (endotrachael tube) security of intubated patients would become a major priority in our PICU.
Methods: Through multi disciplinary discussion of the issue, three factors were identified to be related to our unacceptable high rate of accidental extubations in the PICU. They were:
1. The integrity of the ETT tape job
2. Adequate sedation of intubated patients, and
3. The appropriate use of restraints.
A plan was developed to address these three factors among the three groups of clinicians responsible for these factors; physicians, nurses, and respiratory therapists. The attending physicians, respiratory therapy and nursing leadership would stress to all PICU team members the importance of these three factors.
This emphasis was communicated through e-mail, word of mouth, and a poster in the PICU conference room. The poster, which had 3 big calendars for the months of October, November, and December, was labeled "Days without an accidental extubation in the PICU". As each day went by without an unplanned extubation, that day got a big X over it. After 30 days of no unplanned extubations, the PICU staff was treated to lunch by the otolaryngology and critical care medicine divisions. In such a way, we sought to make the endeavor challenging, fun, and rewarding.
RESULTS: For the months of October and November, we had no unplanned extubations, a feat we had never accomplished before. Six months later our unplanned extubation rate is back to about 1.3 per 100 mechanical ventilation days, which we feel is very acceptable.
CONCLUSION: A multidisciplinary approach is an excellent way to identify, brainstorm and solve performance improvement issues that are present, resulting in a positive affect on patient care outcomes.