unintended extubation: improving care for the pediatric trauma population · 2015-11-29 ·...
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![Page 1: Unintended Extubation: Improving Care for the Pediatric Trauma Population · 2015-11-29 · IMPROVING CARE FOR THE PEDIATRIC TRAUMA POPULATION Jennifer Fritzeen, MSN, RN, PCNS Trauma](https://reader033.vdocument.in/reader033/viewer/2022050519/5fa2899842ff362bc066a04c/html5/thumbnails/1.jpg)
UNINTENDED EXTUBATION: IMPROVING CARE FOR THE PEDIATRIC TRAUMA POPULATION
Jennifer Fritzeen, MSN, RN, PCNS
Trauma & Burn Program Manager
Children’s National Medical Center
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Unintended Extubations
Loss or displacement of the endotracheal tube prior to decision to extubate by the primary care team
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Complications of Unintended Extubation
Increase ventilator days
Nosocomial infections
Prolonged ICU stay
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Unintended Extubation Events (N=102)
5
1 12
3
110
1 1
3
0
21
14
6 6
12
3
0
5
10
15
20
25
Q3 2011 Q4 2011 Q 1 2012 Q2 2012 Q3 2012 Q4 2012
Chest compressions Code medications Re-intubation
Nu
mb
er o
f in
terv
enti
on
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Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placement
Positioning & Safety
Staffing
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Event Root Cause Analysis
Unintended extubation
DemographicsAge, Diagnosis, # ventilator days
Level of sedation
Patient activityETT placement
Positioning & Safety
Staffing
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Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedationPrn medications vs drips
Patient activityETT placement
Positioning & Safety
Staffing
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Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityRestraints, procedures, interventions
ETT placement
Positioning & Safety
Staffing
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Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placement
Positioning & SafetyActive repositioning, tape secure, restraint use
Staffing
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Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placementOral vs nasalPlacement on x-ray
Positioning & Safety
Staffing
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Event Root Cause Analysis
Unintended extubation
Demographics
Level of sedation
Patient activityETT placement
Positioning & Safety
Staffing1:1, paired
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
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
UE
/10
0 v
en
t d
ay
sQuarterly Unintended Extubation Rates
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
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
UE
/10
0 v
en
t d
ay
s
Airway Protection Team
Quarterly Unintended Extubation Rates
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
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
UE
/10
0 v
en
t d
ay
s
Standardized Taping
Quarterly Unintended Extubation Rates
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
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
UE
/10
0 v
en
t d
ay
s
Airway compliance bundle with
weekly audits
Quarterly Unintended Extubation Rates
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Airway Compliance Bundle
ETT position verification – CXR, visual cue
Team presence at X-ray rounds
Upper extremity restraints
Standardized ETT tape
Sedation phase
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Comparison of Annual Unintended Extubation Rates
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
2011 2012 2013 2014
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Comparison of Annual Unintended Extubation Rates
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
2011 2012 2013 2014
PICU
Trauma/Burn
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Unintended Extubations – Trauma Patients
N=6
100% lacked therapeutic sedation regimen
50% risk for neurologic deficit
33% required re-intubation – inhalation injury
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Average age 51 months 88 months
Median age 24 months 90 months
Reintubation rate 45% 33%
Rate of continuous sedation use
71% 0%
Population Differences
PICU Trauma/Burn
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Implications for the Pediatric Trauma/Burn Population
Improved sedation practices
Communicated sedation plan
Extubation readiness criteria