The Science Journal of the American Association for Respiratory Care

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.

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