Abstract
Background: Unplanned extubation (UE) poses a substantial risk, potentially resulting in clinical instability, cardiac arrest, and need for immediate re-intubation. As a part of a UE reduction effort, our objective was to develop a UE risk assessment score (UERAS) tool to identify risk factors, provide clinicians timely alerts, facilitate bedside mitigation strategies, and decrease UE. We hypothesize that our UERAS tool demonstrates high reliability and UERAS implementation is associated with UE reduction.
Methods: In a 75-bed non-cardiac pediatric ICU, we developed the UERAS by modifying Vats’ (PCCM 2017) UE risk assessment tool adding additional factors identified through local UE reviews. Initial UERAS had 14 elements, which was reduced to 12 items in January 2024 by removing two items (significant movement and agitation) due to subjectivity (Table 1). The range of total score remains 0-18 after the change by adding more weight in two existing items (rescue medication administration >3 over 6 h, sedation score > the goal). A pilot of the UERAS was conducted in a 24-bed section of the Pediatric ICU to assess inter-rater reliability (IRR). Pediatric ICU RTs underwent standardized training. For IRR assessment, two RTs independently evaluated ICU patients. IRR was assessed using Pearson’s correlation coefficient. Upon demonstrating high IRR, UERAS was expanded across the entire 75-bed PICU. Mitigation actions were developed for high-risk UE patients including immediate bedside clinicians alert via EHR chat and interdisciplinary bedside huddles (tier 0).
Results: During the pilot phase, 50 paired observations were conducted by 16 RTs with an IRR of 0.997 (P < .001). From March 2023 through April 2024, 3,206 assessments were conducted in 476 patients, median age of 86 months with 57% male. 302 (92%) were positive for sedation levels (rescue medication administration, sedation score > the goal), 126 of those patients (41.7%) high-risk cases saw increased sedation to counter high UERAS scores. Comparing to pre- implementation phase (July 2022-March 2023), UERAS implementation phase (July 2023-March 2024) had significantly lower UE events: 0.44/100 ventilator days (13 UEs) vs. 0.16/100 ventilator days (5 UEs), absolute difference 0.28/100 UE event, 95% CI 0.003-0.563, P = .049.
Conclusions: The UERAS scores showed high inter-rater reliability. Implementation of the UERAS with mitigation practice was associated with significant reduction in UEs in the Pediatric ICU.
Footnotes
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