UNINTENDED EXTUBATION: IMPROVING CARE FOR THE PEDIATRIC TRAUMA - PowerPoint PPT Presentation

UNINTENDED EXTUBATION: IMPROVING CARE FOR THE PEDIATRIC TRAUMA POPULATION Jennifer Fritzeen, MSN, RN, PCNS Trauma & Burn Program Manager Children’s National Medical Center

Unintended Extubations Loss or displacement of the endotracheal tube prior to decision to extubate by the primary care team

Complications of Unintended Extubation Increase ventilator days Nosocomial infections Prolonged ICU stay

Unintended Extubation Events (N=102) 25 21 Number of intervention 20 14 15 12 10 6 6 5 5 3 3 3 2 1 1 1 1 1 1 0 0 0 Q3 2011 Q4 2011 Q 1 2012 Q2 2012 Q3 2012 Q4 2012 Chest compressions Code medications Re-intubation

Event Root Cause Analysis Demographics Level of sedation Staffing Unintended extubation Patient activity ETT placement Positioning & Safety

Event Root Cause Analysis Demographics Age, Diagnosis, # ventilator days Level of sedation Staffing Unintended extubation Patient activity ETT placement Positioning & Safety

Event Root Cause Analysis Demographics Level of sedation Staffing Prn medications vs drips Unintended extubation Patient activity ETT placement Positioning & Safety

Event Root Cause Analysis Demographics Level of sedation Staffing Unintended extubation Patient activity ETT placement Restraints, procedures, interventions Positioning & Safety

Event Root Cause Analysis Demographics Level of sedation Staffing Unintended extubation Patient activity ETT placement Positioning & Safety Active repositioning, tape secure, restraint use

Event Root Cause Analysis Demographics Level of sedation Staffing Unintended extubation Patient activity ETT placement Oral vs nasal Placement on x-ray Positioning & Safety

Event Root Cause Analysis Demographics Level of sedation Staffing 1:1, paired Unintended extubation Patient activity ETT placement Positioning & Safety

Quarterly Unintended Extubation Rates 1.4 1.2 UE/100 vent days 1 0.8 0.6 0.4 0.2 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2008 2009 2010 2011 2012 2013 2014 2015

Quarterly Unintended Extubation Rates 1.4 1.2 Airway Protection Team UE/100 vent days 1 0.8 0.6 0.4 0.2 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2008 2009 2010 2011 2012 2013 2014 2015

Quarterly Unintended Extubation Rates 1.4 1.2 Standardized Taping UE/100 vent days 1 0.8 0.6 0.4 0.2 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2008 2009 2010 2011 2012 2013 2014 2015

Quarterly Unintended Extubation Rates 1.4 Airway compliance 1.2 bundle with weekly audits UE/100 vent days 1 0.8 0.6 0.4 0.2 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2008 2009 2010 2011 2012 2013 2014 2015

Airway Compliance Bundle ETT position verification – CXR, visual cue Team presence at X-ray rounds Upper extremity restraints Standardized ETT tape Sedation phase

Comparison of Annual Unintended Extubation Rates 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 2011 2012 2013 2014

Comparison of Annual Unintended Extubation Rates 0.8 0.7 0.6 0.5 PICU 0.4 Trauma/ 0.3 Burn 0.2 0.1 0 2011 2012 2013 2014

Unintended Extubations – Trauma Patients N=6 100% lacked therapeutic sedation regimen 50% risk for neurologic deficit 33% required re-intubation – inhalation injury

Population Differences PICU Trauma/Burn Average age 51 months 88 months Median age 24 months 90 months Reintubation rate 45% 33% Rate of continuous sedation 71% 0% use

Implications for the Pediatric Trauma/Burn Population Improved sedation practices Communicated sedation plan Extubation readiness criteria