Incidence, Outcome and Determinants of Unplanned Extubation Among Pediatric Intensive Care Unit Addis Ababa, Ethiopia, 2023: Nested, Unmatched Case-Control Study Design

Abstract

Background

Unplanned extubating is the most common adverse event occurring in intensive care units (ICUs) and significantly increases morbidity and mortality in children, but there is limited current evidence on unplanned extubating in Ethiopia. Therefore, this study aimed to determine the incidence, outcome, and determinants of unplanned extubating among children in the pediatric intensive care unit in Addis Ababa, Ethiopia, in 2023.

Methods

A nested unmatched case–control design study was conducted at selected government hospitals in Addis Ababa from September 1, 2022, to April 30, 2023. A total of 198 intubated child patients (66 cases of unplanned extubating were nested with 132 controls of planned extubating) were followed up until they completed the full weaning process or based on hospital protocols. Data was collected through standardized data extraction, and the data was cleaned, entered into Epidata version 4.6, and exported to SPSS version 25.0 for further analysis. Binary and multiple logistic regression analyses were used to identify determinants of unplanned extubating, with an adjusted odds ratio (AOR) of 99% confidence interval (CI) at p value <0.01.

Results

The study revealed a high mortality rate of 15.65% among intubated children in pediatric intensive care units, and the incidence of unplanned extubating was 7.2 per 100 days. This study identified determinants of unplanned extubating among patients admitted to the pediatric intensive care unit: agitated patients (AOR = 3.708; 99% CI: 1.401–9.81), working in night shift hours (AOR: 8.789; 99% CI: 2.37–32.58), use of plaster or roll bandages separately (AOR = 4.12; 99% CI: 1.215–13.96), A nurse-to-patient ration 1:2 (AOR: 6.65, 99% CI: 1.87–23.69), intermittent sedation (AOR, 3.717; 99% CI, 1.017–10.816), physically restrained (AOR = 3.717; 99% CI: 1.02–13.54), and death outcome (AOR = 14.86, 99% CI: 3. 24–68.097), respectively.

Conclusion and Recommendations

This study found that the incidence and mortality rate of unplanned extubating were high, with identified determinants increasing the risk of unplanned extubating among patients admitted to pediatric intensive care unit. Therefore, policymakers and health planners should design further protocols and algorithms for the management of pediatric endotracheal intubation (ETT) quality of patient outcomes and to prevent unplanned extubating in a resource limited set up.

Plain Language Summary

Unplanned extubating is a common adverse event in intensive care units that affects critically ill patients and increases morbidity and mortality rates. This study aimed to identify the determinants of unplanned extubating among children in Addis Ababa, Ethiopia, in 2023. This follow-up, unmatched case–control study included 198 intubated children, with 66 cases and 132 controls. The study used binary and multiple logistic regression analyses to identify determinants of unplanned extubating, and the Kaplan–Meier curve to determine survival outcomes. This study determined that the incidence of unplanned extubating was high, with identified determinants increasing the risk of unplanned extubating among patients admitted to pediatric intensive care units, such as agitation, night shift, intermittent sedation, endotracheal tube (ETT) taping by plaster or roll bandage separately, physical restraint, and the type of endotracheal tube (uncuffed). Therefore, policymakers and healthcare planners should consider these determinants during pediatric care unit training and guideline development for pediatric endotracheal intubation (ETT) mechanical ventilation outcomes.

Keywords:

• unplanned extubation
• incidence
• outcome
• pediatric intensive care unit and determinant

Abbreviations

AACHB, Addis Ababa city health bureau; CCU, Critical care unit; EFMOH, Ethiopian federal ministry of health; ETT, Endotracheal tube; ICU, Intensive care unit; MV, Mechanical ventilation; OI, Oxygen index; PE, Planned extubation; PICU, Pediatrics intensive care unit; SE, Self extubation; SPHMMC, St. paul’s hospital millennium medical college; TT, Tracheostomy tube; UPE, Unplanned extubation; Y12HMC, Yekatit 12 hospital medical college.

Ethics Approval

Ethical approval was obtained from St. Paul Hospital Millennium Medical College Ethical Review Board (Ref. No. Pm 23/417), this requirement was not waived by the Institutional Review Board and confirmed that all experimental protocols were approved by St. Paul’s Hospital Millennium Medical College Institutional Ethical Review Board.

Informed Consent

The authors confirmed that written informed consent was obtained from all subjects aged greater than 18 years, and for minor subjects less than 18 years old prior to study initiation and written inform consent was obtained from their parent or legal guardian(s) or legally authorized representatives before the study. Authors had confirmed that all methods were carried out in accordance with relevant guidelines and regulations of Helsinki Declaration. Authors had confirmed that all experimental protocols were approved by St. Paul Hospital Millennium Medical College Institutional Review Board/Ethics Committee (Ref. No. Pm 23/417).

Acknowledgment

First, thank the Almighty God for his grace and blessings. Our deepest gratitude goes to Saint Paul’s Hospital, Millennium Medical College, for the financial support and pursuit of this opportunity. The authors would also like to express their gratitude to the pediatrics intensive care unit (PICU) facilities in Addis Ababa, data collectors, supervisors, and study participants.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors(s) declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.

Additional information

Funding

This study was funded by the Saint Paul’s Hospital, Millennium Medical College. However, the funder had no role in the study design, data collection, analysis, preparation of the manuscript, or the decision to publish.