(1293) Decreasing Unplanned Extubations Through Respiratory Therapist-Driven Quality Improvement

Introduction: Unplanned extubations (UPE), the accidental removal of an endotracheal tube (ETT), are associated with morbidity and increased costs in the pediatric intensive care unit. National UPE rates range from 0.11 to 6.4 events/100 ventilator days. We aimed to decrease our local UPE rate by 50% within 12 months through respiratory therapist-driven quality improvement interventions.

Methods: The setting was a 24-bed medical/surgical pediatric intensive care unit within a free-standing quaternary care children’s hospital. In April 2022, ETT Rounds were launched. These consisted of an independent respiratory therapist evaluating the securement of each ETT during weekday afternoons. Interventions to improve securement were performed and documented. Just-in-time education was provided to bedside staff at the time of the intervention. In April 2023, these rounds were expanded to include night shift. In March 2023, mandatory hands-on ETT securement classes were launched for all bedside staff. The primary outcome was UPE events/100 ventilator days. Three consecutive months trending up or down as well as six consecutive months below the centerline were considered special cause variation resulting in a centerline shift. Data was collected through the end of May 2023.

Results: Starting in January 2021, the pre-intervention centerline was 0.83 UPE events/100 ventilator days. Following the initial ETT Rounds intervention, the centerline shifted in the desired direction to 0.35 UPE events/100 ventilator days (58% decrease). Interventions during ETT Rounds peaked in October 2022 at 27.5% of daily audits. Starting in January 2023, the intervention rate decreased for five consecutive months to 0% in May 2023. No UPEs occurred from January through May 2023.

Conclusions: Respiratory therapist-driven quality improvement is an effective strategy to decrease UPE rates in the pediatric intensive care unit. ETT Rounds and securement classes are simple and low cost interventions with likely excellent external validity for similar units.