Table 3 Rate of unplanned extubations/100 ventilated days by study month. 4. Discussion The ultimate goal of every intervention is to improve the health and quality small molecule of life in all patients. The objective of this study was to improve the quality of care in our PICU by reducing unplanned extubations. In order to accomplish this, we used the plan (P) do (D) study (S) act (A) model [12]. PDSA is a dynamic, continuous quality improvement plan. In this process, effective interventions should be aimed at specific features of a target group, and the healthcare problem must be quantifiable. In our case, the target group included all those responsible for the care of the intubated patient in the PICU. The objective was to reduce the rate of unplanned extubations to a level within national benchmark standards.

By using this approach, we were able to significantly reduce the unplanned extubation rate in our PICU. The first stage of PDSA is the planning (P) stage in which there is analysis of the intended area of improvement. In this case, it was determined that the rate of unplanned extubations in the PICU was well above national benchmark standards. At the same time that we determined the rate of unplanned extubations in, we also examined possible causes. Several factors that contribute to an unplanned extubation have been previously identified [1, 10, 13]. These include inadequate sedation, the use of neuromuscular blockade, improper use of restraints, improper tube position, inattentive support staff who dislodges the tube during routine care (e.g.

, obtaining a radiograph), inadequate taping of the endotracheal tube, patient-to-nurse ratios of greater than 1 : 1, occurrence of a procedure or transport at the time of the unplanned extubation, and a lax attitude towards an unplanned extubation [1, 10, 13]. As we investigated the causes of unplanned extubation in the PICU during the planning (P) stage, we found that three of the aforementioned factors contributed significantly to the high rate of unplanned extubations. Therefore, the intervention program used in the do (D) phase focused on addressing these issues, and time and effort were not wasted on ��correcting�� factors that were not contributing to the problem in our unit. In other institutions, different factors may be operative and would need to be addressed in a program specific to that setting.

In the study (S) phase, we recollected data to determine whether the changes achieved the desired results. Using the targeted intervention program, we were able to reduce the unplanned extubation rate from 6.4 to 1.0 unplanned extubations, per 100 ventilated days. When examining the time of day in which the unplanned extubations occurred, the intervention Brefeldin_A reduced unplanned extubations in all time periods. Nonetheless, even after education about sedation of the intubated pediatric patient, inadequate sedation continued to be a contributing factor in unplanned extubations.