ABSTRACT #51

FACTORS ASSOCIATED WITH UNPLANNED EXTUBATION IN THE INTENSIVE CARE UNIT - A QI PROJECT

Yasmin Herrera, Venus Sharma, Sara Luby, Susannah Kurtz, Adam Rothman, Raymond E. Jean, James Salonia, Joseph Mathew

PURPOSE AND GOALS: Unplanned Extubation (UE) in the Intensive Care Unit (ICU) is an indicator of quality of care and is associated with increased length of hospital stay. The proposed national benchmark is less than one UE per 100 ventilator days. With this quality improvement (QI) project we aim to analyze factors leading to UE and implement strategies to reduce the rate of unplanned extubations while promoting a culture of safety.

METHODS: We performed a retrospective analysis of all UE in the combined medical-surgical ICU and the Neuroscience ICU at Mount Sinai West from January 1st, 2020 to September 30th, 2022. These events were identified from the institutional electronic adverse event reporting software (Datix SafetyNet©)

EVALUATION PLAN: Our first intervention was to implement a post-event multidisciplinary safety huddle to improve documentation around UE. A huddle form was created to collect information such as: time of the event, reason for intubation, comorbidities, nurse-to-patient ratio, sedation, presence of physical restraints, Richmond Agitation- Sedation Scale (RASS) score and vital signs preceding the event, endotracheal tube (ETT) position at the lip line, plan for Spontaneous Breathing Trial (SBT) within the next 24 hours, need for reintubation within 24 hours, and completion of the safety huddle. We introduced the post-event huddle to the ICU staff, including residents, nurses, respiratory therapists, critical care fellows, and attending physicians.

SUMMARY OF RESULTS: Between January 2020 and September 2022, we identified 55 UE, representing an incidence of 0.43 UE per 100 ventilated days. Based on chart review, the majority of UE events occurred in the absence of sedative titration (67%) and in presence of physical restraints (76%). After huddle implementation in March 2022 and up until September 30th, 2022, 14 UE were reported in the ICUs. This represents 0.59 UE per 100 ventilated days. The huddle was completed in 13 cases representing 81% compliance with huddle. Approximately half of the patients had a documented RASS of 0 or above, 1 hour prior to UE. Additionally, 50% of patients were considered appropriate candidates for SBT within 12 hours of the event. Five (31%) of the patients needed re-intubation within 24 hours. Four patients had been identified as high-risk before the event, based on age, gender and past medical history.

REFLECTIVE

CRITIQUE:

A multidisciplinary team-based approach focused on staff education and huddles can lead to early identification of patients at high risk for UE and create a culture of safety around UE. Many factors contribute to UE in the ICU including risk factors such as a history of polysubstance abuse, male sex, planned SBT and a positive RASS score. Despite a slight increase in rate of UE during the intervention period, the reintubation rates were low and the majority of the UEs were planned for SBT. Further research and resources are needed to identify modifiable risk factors and interventions to decrease the rate of UE.