The Science Journal of the American Association for Respiratory Care

2011 OPEN FORUM Abstracts


Russell E. Graham1, Roberta Melton1, Michael Bernstein1, Stanley Rhone1, Khalid Almoosa2, Bela Patel2; 1Respiratory Care, Memorial Hermann - Texas Medical Center, Houston, TX; 2Pulmonary/Critical Care, University of Texas - Houston, Houston, TX

Background: Unplanned Extubation (UE) has been identified as a "threat to patient safety", with "risk factors and prevention strategies that have not been fully explored" (1). UE is routinely reported as part of each facility's adverse event reporting system and/or quality improvement program. One journal article placed UE as a focus for Morbidity/Mortality Conferences (MMC)(2). Memorial Hermann - Texas Medical Center (MH-TMC) routinely provides mechanical ventilation (MV) in 7 adult ICU's, comprising over 120 ICU beds. UE surveillance is part of the Respiratory Care Department's Quality Improvement Program. Method: Retrospective review of ongoing UE surveillance, maintained as part of the RC department's MV database. Literature and best practices are reviewed, with UE data for each month analyzed for developing patterns and/or causal relationships. Results: Eight months of data have been collected. UE has been reported as events per 1000 ventilator days, as well as by number of UE to total number of ventilator days by individual ICU (Table 1). There have been 98 UE events, with 3723 intubations during the same time period. The ratio of UE/Intubation is 0.026; the significance of this value has not yet been determined. Additional data including staffing rations, reintubation, sedation, time of day, and restraint use is collected and analyzed for significance. To date, less than 30% of the UE require reintubation. Restraints have been in place in over 80% of the UE events. No clear UE event pattern can be identified with staffing ratios. No correlation with degree of risk has been identified. Conclusion: Continued collection of data, with further isolation of associated factors regarding UE events is necessary to better identify and prevent UE. The development of a database has assisted in more uniform data collection and analysis, and will remain part of the Department's Quality Improvement Plan. 1 Tanios M et al "Can We Identify Patients at High Risk for Unplanned Extubation? A Large-Scale Multidisciplinary Survey" Respir Care 2010;55(5):561-568 2 Ksouri H et al "Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice" Am J Crit Care 2010;19:135-145 Sponsored Research - None