Just Don’t: Unplanned Extubation

Project Topic:

Unplanned extubation in adult patients

Hospital Unit(s):

Medical Intensive Care Unit (MICU)
Surgical Intensive Care Unit (SICU)

CSI Participants:

• Taylor Baker, BSN, RN
• Melanie Furr, BSN, RN
• Kayla Johansson, BSN, RN, CCRN
• Vanessa Migliori, BSN, RN
• Stephanie Riveros, BSN, RN

Project Goals/Objectives:

1. Educate 95% of critical care nurses on a new “unplanned extubation prevention” bundle
2. Educate 100% of charge nurses and clinical nurse coordinators on a new unplanned extubation risk assessment wheel
3. Decrease both the number of unplanned extubations and the incidence density 40%
4. Increase the percentage of patients extubated within two hours of passing spontaneous breathing trials to 70%
5. Improve compliance with implementation of elements in the prevention bundle 80%

Project Outcomes:

1. Educated 95.3% of critical care nurses on the prevention bundle
2. Educated 100% of charge nurses and clinical nurse coordinators on the risk assessment wheel
3. Increased unplanned extubations 7%
4. Increased the percentage of patients extubated within two hours of passing spontaneous breathing trials to 72.4%
5. Increased compliance with prevention bundle elements to 83%
6. These outcomes resulted in an estimated annual fiscal impact of $83,860 with a 433% return on investment.

Project Overview:

According to 2020 Airway Safety Network data, unplanned extubations contribute to extended ventilator days and critical care length of stay, increased incidence of ventilator-associated pneumonia, and significant mortality. Data estimates the average cost of every unplanned extubation event to be nearly $41,000.

In 2022, 27 unplanned extubations were reported in our hospital’s adult MICU and SICU. Our CSI team decided to tackle this challenge and collaborated with a respiratory therapist to analyze the problem, identify contributing factors and develop improvement strategies.

After a thorough literature review and analysis, we developed two new tools: an unplanned extubation prevention bundle and a risk assessment wheel. The bundle provides the latest evidence-based practices for preventing unplanned extubation. The wheel identifies patients at risk of self-extubation, allowing clinicians to ensure proper allocation of the people resources and equipment necessary to maintain airway safety and prevent further complications.

Following development of these tools, our CSI team educated 95% of critical care nurses and 100% of charge nurses and clinical nurse coordinators on the prevention bundle and risk assessment wheel, respectively. Our improvement strategy using the bundle emphasized extubation of patients within two hours of passing breathing trials and achieving a high rate of bundle implementation compliance among our units’ nurses.

We collected pre-intervention data to establish a baseline through bedside audits using the Kamishibai card (or K-card) lean process. Post-intervention data showed that:

• The percentage of patients extubated within two hours of passing breathing trials increased from 60.3% to 72.4%
• Compliance with bundle implementation increased from 33% to 83%
• The number of re-intubations and ventilator days post re-intubation both decreased
• The average number of patients placed on phenobarbital for treatment of alcohol withdrawal increased from an average of 1 to 6.2 patients per month.

These outcomes saved our hospital a projected $83,860 annually with a 433% return on investment.

While our CSI team is pleased with these significant improvements and fiscal savings, our interventions ultimately were not enough to reduce the incidence of unplanned extubations or the calculated incidence density. However, we learned some valuable lessons and have recommended a handful of additional improvement projects.