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Unintended Extubation: Improving Care for the Pediatric Trauma Population
Amy Wright, MSN, RN, CCRN, CNRN, Children's National Medical Center, Washington DC

Abstract:
Background: With IRB approval, a retrospective chart review between July 2011 and December 2012 identified 119 unintended extubation (UE) events in 95 patients admitted to the pediatric, neonatal, or cardiac ICU. Cardiovascular collapse occurred in 20% of patients, and 63% required emergent reintubation. Problem: Root cause analysis (RCA) of each UE event occurring since December 2012, led to the identification of event rates in the trauma and burn (TB) population that are double that of the general PICU population (0.5 vs 0.2 UE/100 vent days). The TB patients resulting in UE events (n=6) have several unique characteristics including older median age (33 months PICU vs 90 months TB), lower reintubation rate (45% PICU vs 33% TB) and 0% use of continuous sedation (vs 71% PICU). Findings: The implementation of several interventions reduced the rate of UE in the PICU from 0.3 to 0.15 UE/100 ventilator days since January 2012. These interventions included the development of an airway compliance bundle, standardized procedures regarding morning CXRs, hospital-wide ETT taping, and BID ETT position validation on multidisciplinary rounds. Conclusions: The TB population requires additional interventions in order to achieve the success that was achieved in the general PICU population. As identified by RCA in each event, sedation practices contributed to 100% of the UE events in the TB population. These findings resulted in scrutiny of current sedation practices in this population, as well as applying neuroscience extubation criteria when appropriate in an attempt to decrease overall ventilator days.
Objective:
At the end of this activity, the learner will be able to identify the risks of unintended extubation in the pediatric population. At the end of this activity, the learner will be able to discuss interventions to improve unintended extubation rates in the pediatric trauma and burn population.
Objective Content: At the end of this activity, the learner will be able to identify the risks of unintended extubation in the pediatric population. The risks of unintended extubation in the pediatric population include cardiovascular collapse and emergent reintubation. At the end of this activity, the learner will be able to discuss interventions to improve unintended extubation rates in the pediatric trauma and burn population. Interventions resulting in improved UE rates in the pediatric trauma and burn population include development of an airway compliance bundle, standardized policies and procedures regarding ETT taping practices, routine CXRs, and ETT position validation with the multidisciplinary team. Additional evaluation of institution-specific practices regarding sedation and time to extubation in the trauma and burn population may reveal additional opportunities for improvement.


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