Organizational factors increase risk of unplanned extubation in neonatal intensive care unit

1. In a retrospective study, higher nursing overtime hours and rate, and increased number of patients supported by mechanical ventilation were associated with higher rates of unplanned extubation in a neonatal intensive care unit (NICU).

2. Unplanned extubation followed by reintubation was associated with increased mechanical ventilation time and risk of bronchopulmonary dysplasia.

Evidence Rating Level: 2 (Good)

Study Rundown: A significant proportion of infants admitted to the NICU require endotracheal tube placement and mechanical ventilation for respiratory support. A feared complication of mechanical ventilation is unplanned extubation, which may lead to clinical instability and impact the risk of future morbidity such as time requiring ventilatory support and the development of bronchopulmonary dysplasia (BPD). In this retrospective cohort study, researchers assessed if staffing-related organizational factors affected the rates of unplanned extubation at a NICU in Canada as well as the clinical consequences of unplanned extubation. Some organizational factors that were significantly associated with unplanned extubation were higher nursing overtime hours and rate, and increased total number of patients on mechanical ventilation in the NICU. In a subpopulation of infants at risk for BPD (<29 weeks of age), those with unplanned extubation who were reintubated had longer duration of mechanical ventilation, and higher risk of developing BPD. One major limitation of the study is that organizational factors assessed were collected via a nursing administrative database, which does not provide information on non-nursing related risk factors for unplanned extubation. Overall, this study provides evidence that organizational factors related to overtime work, nursing ratios, and unit occupancy may contribute to unplanned extubation and has significant clinical consequences.

Click here to read the article in the Journal of Pediatrics

Relevant Reading: Unplanned Extubation in Neonatal Intensive Care Unit: A Systematic Review, Critical Appraisal and Evidence-Based Recommendations

In Depth [retrospective cohort]: This retrospective cohort study included all infants admitted to Montreal Children’s Hospital–McGill University Hospital Centre NICU between April 2016 to Dec 2019. Unplanned extubation has been recorded in the NICU unplanned extubation event database since 2016 at the study institution and was used to retrieve data related to unplanned extubation. Organizational factors retrieved from the clinical administrative database included nursing provision ratio, nursing overtime rate, unit occupancy rate, and number of patients supported by mechanical ventilation. Clinical outcomes were assessed in infants <29 weeks of age at risk for BPD and included development of BPD (primary outcome), mortality, duration of mechanical ventilation, and length of stay. In this cohort, there were 2.1 unplanned extubation events per 100 mechanical ventilation days. Organizational factors that were significantly associated with unplanned extubation were nursing overtime hours (p=0.01), nursing overtime rate (aOR 1.09, 95% CI 1.01-1.18, p=0.01), and number of patients on mechanical ventilation (aOR 1.17, 95% CI 1.06-1.29, p<0.01). In a subpopulation of infants at risk for BPD (<29 weeks of age), those with unplanned extubation who were reintubated had longer duration of mechanical ventilation (aOR 13.06, 95% CI, 4.88-37.69, p<0.05) and odds of developing BPD (aOR 2.86, 95% CI 1.01-8.58, p<0.05). Unplanned extubation followed by reintubation did not affect mortality or length of stay.

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