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

SESSION TITLE: Education, Research, and Quality Improvement Posters 4 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2023 12:00 pm - 12:45 pm PURPOSE: 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: For phase one we focused on gathering information regarding the status of our institution by performing a retrospective analysis of all UE in the medical-surgical ICU and Neuroscience ICU at Mount Sinai West from January 1st, 2020 to December 31st, 2022. These events were identified from the institutional electronic adverse event reporting software (Datix SafetyNet©). For phase two we focused on promoting interdisciplinary communication and improving documentation by implementing of a post-event safety huddle. A huddle form was created to collect information such as: time of event, reason for intubation, comorbidities, nurse-to-patient ratio, sedation, presence of physical restraints, Richmond Agitation-Sedation Scale(RASS) score and vital signs preceding event, endotracheal tube (ETT) position at the lip line, plan for Spontaneous Breathing Trial(SBT) within 24 hours, need for reintubation within 24 hours, and completion of safety huddle. We introduced the safety huddle to the ICU staff which includes nurses, respiratory therapists and physicians, in March 2022. Goal was to achieve 80% compliance to safety huddle from time of introduction to end of the year. RESULTS: Between January 2020 and March 2022, we identified 39 UE, representing an incidence of 0.38 UE/100 ventilated days. Majority of UE events occurred in the absence of sedative titration (64%) and in presence of physical restraints (77%). From huddle implementation in March 2022 to December 31st, 2022, 22 UE were reported in the ICUs. This represents 0.57 UE/100 ventilated days. The huddle was completed in 18 cases representing 81% compliance with huddle. Approximately half of the patients had documented RASS of 0 or above, 1 hour prior to UE. Additionally, 50% of patients were considered appropriate candidates for SBT within 24 hours of event. Six (27%) patients needed re-intubation within 24 hours. Six patients had been identified as high-risk before the event, based on age, gender and medical history. These patients were discussed during the morning ICU huddle and a high-risk sign was placed in their rooms. CONCLUSIONS: We achieved our goal of 80% compliance to the safety huddle. We noticed an increase in incidence of UE after huddle implementation. However the incidence of these events in our institution is still below the proposed national benchmark. CLINICAL IMPLICATIONS: Many factors contribute to UE in the ICU and a multidisciplinary team-based approach focused on staff education and huddles can lead to early identification of patients at high risk for UE and the creation of a culture of safety around these events. DISCLOSURES: No relevant relationships by Yasmin Herrera No relevant relationships by Raymonde Jean No relevant relationships by Susannah Kurtz No relevant relationships by Joseph Mathew No relevant relationships by Adam Rothman No relevant relationships by James Salonia