The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

UNPLANNED EXTUBATIONS (UE) IN NICU AND PICU AS A QUALITY MEASURE

Dave N. Crotwell, John Salyer; Respiratory Care, Seattle Children’s Hospital, Seattle, WA

Background: On-going tracking of UE is being used as a measure of clinical quality and patient safety in NICU and PICU populations. We report the methods and results of our program to measure and manage unplanned extubations. Methods: UE’s are reported by bedside personnel via an electronic incident reporting system. For the first 3 months of its use, UE’s reported in our NICU and PICU were compared to UE’s measured by manual review of every ventilator flow sheet to establish the validity of the reporting system. Following this, UE’s are tabulated for each quarter and indexed for each 100 ventilator days in each unit ([ UE รท Ventilator Days] x 100). These rates are compared to published data and commercially available clinical benchmarking data. A mean benchmarking value was calculated by taking quarterly UE’s for each reporting hospital in the benchmarking group for one year and calculating the mean UE rate for all hospitals. These findings are reported to the medical and nursing leadership of the various units. We report data for the period from 3rd quarter of 2003 to the 1st quarter 2009. Results: Results are displayed in the graph below. Conclusion/Discussion: In our NICU and PICU we utilize standard airway taping techniques (Loughead et al. Jt Comm J Qual Patient Saf 2008:34(3):164-70) as well as regularly scheduled airway security checks. We speculate that our low UE rate is a result of several factors. Our standardized taping method has been shown to result in fewer UE’s. Our clinicians are very diligent in assessing airway security during ventilator system checks. Also, beginning in 2005 we experience increased and sustained success in recruiting of new RT’s, which allowed us reduce our heavy reliance on agency staffing. Also, our PICU implemented a sedation management protocol in the beginning of 2007 and we suspect that this has also helped decrease the variability in our UE rates. Sponsored Research - None

You are here: RCJournal.com » Past OPEN FORUM Abstracts » 2009 Abstracts » UNPLANNED EXTUBATIONS (UE) IN NICU AND PICU AS A QUALITY MEASURE