2006 OPEN FORUM Abstracts
Extubation Failure rates in a PICU POPULATION
John Salyer RRT, MBA, FAARC, Ruth Barker RRT, Dave Crotwell RRT-NPS, Jerry
Zimmerman MD. Respiratory Care Department and the Pediatric Intensive Care
Unit. Children's Hospital and Regional Medical Center and the University of
Washington School of Medicine, Seattle
WA.
Introduction: We sought to measure the rate of extubation failures in our 26 bed PICU. Various
methods have been used to measure rates of extubation failure including
prospective data gathering and manual review of medical records. In our
facility, respiratory therapists generate procedural charges for all
intubations and extubations. We sought to use these data to identify episodes
of extubation failure.
Methods: We queried the hospital
transaction files, constructing a database of patients with a PICU room charge
and simultaneous charges for mechanical ventilation and included any intubation
or extubation charges. These data included service dates of each charge. Extubation failure was defined as any patient
who had an extubation charge followed by an intubation charge within 24 hours. The study period was Jan-03 through Sep 05
inclusive. Total extubation failures and
failure rates were calculated for each quarter of the calendar year. Failure rates were defined as (total
extubation failures)¸(total extubations). To
validate the accuracy of this methodology we took data from the last quarter
studied and conducted manual chart review of all patients we identified as
having and extubation failure, looking for corroboration in the medical record.
Results: There were 1150 patients
who had > 1 extubation charge for a total of 1422 extubations. There were 171 extubation failures, yielding
a failure rate = 12%. Figure 1 shows the failure rates by quarter, which ranged
from approximately 6% to 17%. Manual
chart review of the data from the last quarter revealed that all patients
identified by this method had evidence in their medical record of extubation
failure.
Discussion: This appears to
be an acceptably accurate for measuring extubation failure rates. Our own
internal validation via manual chart review convinced us that we were not
overestimating actual failure rates. A
previous study from this facility using different methodology reported an extubation
failure rate of 11% (Am J Respir Crit Care Med 1999;160:1562-1566), which
further validates our data. The most important potential source of error in our
data relate to inaccurate billing. Our
billing system includes real time and retrospective quality control mechanisms
to improve billing accuracy. Our internal data indicate billing error rates
range between 2-4%. PICU extubation failure rates are reported to range from
2.7% to 22% (Pediatr Crit Care Med 2005;6:312-318). Recent studies of larger populations
of PICU patients have revealed extubation failure rates of 4 % and 6% (Pediatr
Crit Care Med 2005; 6:312-318) & (Crit Care Med 2003; 31:2657-2664). These
findings helped lead us to develop an extubation readiness test administered by
respiratory therapists that routinely screens all ventilated patients twice
daily for extubation readiness. We plan to report the impact of this screening
in the future.