Multicenter Analysis of the Factors Associated With
Unplanned Extubation in the PICU
Robert K. Fitzgerald, MD1; Alan T. Davis, PhD2; Sheila J. Hanson, MD, MS3; National Association of
Children’s Hospitals and Related Institution PICU Focus Group Investigators
Objective: To identify factors associated with unplanned extuba-
tion in PICUs.
Design: A prospective, case-controlled multicenter study.
Setting: Eleven Pediatric Intensive Care Units collaborating
through the National Association of Children’s Hospitals and
Related Institutions PICU focus group.
Patients: Patients with unplanned extubation events and control
patients without unplanned extubation.
Interventions: Unplanned extubation events were prospectively
tracked for 1 year at 11 centers. When an unplanned extubation
occurred, up to four controls were randomly identified of other
intubated patients in the unit. For each event and control, data
associated with unplanned extubation events, reintubation, and
outcomes were collected.
Measurements and Main Results: One hundred eighty-nine
unplanned extubation events occurred out of 25,500 endotra-
cheal tube days in the study (0.74 unplanned extubations/100
endotracheal days; 95% CI, 0.64–0.85), with 654 associated
controls. Unplanned extubation rates ranged by site from 0.3
to 2.1 unplanned extubations/100 endotracheal days. Children
less than 6 years had an increased rate of unplanned extuba-
tion (0.83 for < 6 yr vs 0.45 for ≥ 6 yr; p = 0.001). After mul-
tivariate analysis, inadequate patient sedation (odds ratio, 9.1;
95% CI, 4.5–18.5), loose or slimy endotracheal tube (odds ratio,
10.4; 95% CI, 5.0–22.2), a planned extubation in the next 12
hours (odds ratio, 2.3; 95% CI, 1.3–4.1), and a nurse pulled from
another unit (odds ratio, 3.8; 95% CI, 1.4–9.9) were associated
with unplanned extubation. Sixty percent of unplanned extuba-
tions required reintubation.
1
Pediatric Critical Care, Helen De Vos Children’s Hospital, Grand Rapids, MI.
2
Grand Rapids Medical Education Partners, Milwaukee, WI.
3
Critical Care Section, Medical College of Wisconsin, Pediatrics and
Children’s Hospital of Wisconsin, Milwaukee, WI.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (http://journals.lww.com/pccmjournal).
The authors have disclosed that they do not have any potential conflicts of
interest.
For information regarding this article, E-mail: shanson@mcw.edu
Copyright © 2015 by the Society of Critical Care Medicine and the World
Federation of Pediatric Intensive and Critical Care Societies
DOI: 10.1097/PCC.0000000000000496
Pediatric Critical Care Medicine www.pccmjournal.org e217
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Unauthorized reproduction of this article is prohibited
Conclusions: The rate of unplanned extubation is higher in patients
aged less than 6 years. Patient factors, such as decreased level of
sedation, loose or slimy endotracheal tube, and staffing factors such
as floating nurse from another unit, contribute to unplanned extuba-
tion in children. (Pediatr Crit Care Med 2015; 16:e217–e223)
Key Words: adverse effect; endotracheal extubation; pediatrics;
unplanned extubation
U
nplanned extubation (UPE) is an adverse event of
mechanical ventilation in patients in the PICU and
has been of focus of many PICUs quality improve-
ment efforts over the past several years. UPE and the need
for emergent reintubation are potentially life-threatening,
associated with airway complications, hemodynamic com-
promise (1), and death (1, 2). UPE has been associated
with prolonged mechanical ventilation (3), ICU stay, and
­hospital stay (3, 4).
Multiple factors have been associated with UPEs including
patient age (5–7), type of endotracheal tube (ETT) fixation
(7–9), sedation level of patient (5, 6, 9–12), weaning of ventila-
tor with planned extubation (3, 6, 13, 14), nursing staffing ratio
(12, 14, 15), and night/day shift differences (13). Reintubation
rates for patients with UPE ranged from 22% to 52%
(5, 6, 8, 11, 12, 14, 16–18)
Because of the significant safety risk associated with UPE,
the National Association of Children’s Hospitals and Related
Institution (NACHRI) PICU Focus Group conducted a survey
in 2007 to summarize current site-specific practices related to
artificial airway management and UPE rates at different PICUs.
Because any single PICU has limited number of UPE events,
and those events are relatively rare, a multi-­institutional study
was needed to obtain a significantly large sample size given
the variation in clinical practices. This prospective, multi-
institutional study was undertaken to describe factors asso-
ciated with UPE events in PICUs. Our primary aim was to
identify and describe the factors associated with UPE in the
PICU. Our secondary aim was to identify current UPE rates
to inform the establishment of benchmarks for other centers
across the country. We hypothesized that both patient-specific
and hospital-specific factors would be associated with UPE.
 Fitzgerald et al

MATERIALS AND METHODS Statistical Analysis

Summary statistics were used to describe the data. Quanti-
Study Design
tative data are described as the mean and the sd or as the
This prospective, multi-institutional, case-controlled study
median and the range. Nominal data are described as a per-
enrolled patients from 11 PICUs. All centers collected data
centage. The 95% CI is shown for specific variables. Differ-
for one calendar year to allow for one cycle to accommodate
ences for quantitative data were determined using the t test,
seasonal differences in patient volume and acuity. There was a
and for nominal data using the chi-square or Fisher exact
rolling start date with patient enrollment from October 2009
test, as appropriate.
to May 2011. Each individual center’s institutional review
A step-wise logistic regression analysis was performed, with
board approved the study with waiver of consent.
UPE as the dependent variable. All variables in the univariate
Subject Identification and Data Collection analysis with p value of less than 0.05 were included as indepen-
Each center identified UPE through their existing data track- dent variables, as well as additional variables felt to be of clinical
ing and improvement process mechanism. The bedside nurse significance: whether the patient was paralyzed with a neuro-
for each patient with UPE would fill out a data sheet in real- muscular blockade at the time of extubation, the product used to
time to the event. The data sheet had five sections and included secure the tube (tape/ties or a manufactured device). Significance
over 50 questions (Table E1, Supplemental Digital Content 1, was assessed at p value of less than 0.05. The statistics were run
http://links.lww.com/PCC/A185). using IBM SPSS Statistics version 21 (Armonk, NY).
With each UPE, up to four intubated control patients
were chosen randomly from the unit census at the time of RESULTS
UPE. Randomization occurred by choosing the patients Eleven PICUs of different sizes participated in the study and
with the closest birthday to the event patient, not including had a median of 25 (8–58) beds and 1225 (558–2355) annual
the birth year. If less than four additional intubated patients admissions per year. All were academic centers with residency
were in the PICU at the time of the UPE, all were selected programs. There were 189 UPE events (per center median, 14
as controls. The bedside nurses for those control patients UPE; range, 7–41) of 25,504 ETT days in the study (per center
filled out an extensive data sheet with similar information median, 2,525 d; range, 808–4079). The overall UPE rate is 0.74
(Table E2, Supplemental Digital Content 2, http://links.lww. UPE/100 ETT days, 95% CI 0.64–0.85. Six hundred fifty-four
com/PCC/A186). Prior selection as a control for one case controls were selected (per center median, 47; range, 26–163),
did not exclude a patient from being enrolled as a case if with a mean 3.5 controls per event, allowing for times when
UPE event occurred. Variables that were difficult or unre- there were less than four other intubated patients in the unit
liable to collect, such as who was present in the room for when an event occurred. UPE rates varied significantly by cen-
controls, or date of retaping for both groups, were excluded ter (p < 0.001), ranging from 0.3 to 2.1 UPE events/100 ETT
from analysis. days (Fig. 1).
UPE was defined as any displacement of an ETT from the There were no differences in the median patient age or
trachea when it was not deliberately removed by a provider. weight between UPE events and controls as shown in Table 1.
This would include UPE occurring within minutes of a planned There were differences by categorical age groupings, with a
extubation. The rate of UPE was calculated as the number of protective effect noted in the 6 months to 1 year and more
UPEs per 100 ETT days, using the device days to take into
account duration of patients at-risk and center volume differ-
ences (11). All intubated patients in the PICU were included in
the calculation of the UPE rate/100 ETT days. Tracheostomies
were not included in either the event or the control groups and
were not counted in the ETT days.
During study design, age cutoffs were determined a priori
based upon developmental progression. Patients 1 year old or
younger are unable to follow commands, patients 1–3 years
old are assumed to be unable or unwilling to follow com-
mands, patients aged 3–6 years are more able to listen but still
not going to be compliant with tube integrity instructions,
and those 6 years and older are of an age of some reason.
Post hoc univariate and multivariate analyses recategorized
the age groups into four groups (< 6 mo, 6 mo to 1 yr, 1–6 yr,
and > 6 yr) to account for the larger proportion of patients in
the youngest age groups.
For calculating UPE rates, which includes all intubated
patients not just the cases and control patients in the study, Figure 1. Rate of unplanned extubation (UPE) by site. ETT = endotracheal
three age groups were used. tube.

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 Online Clinical Investigations

Table 1. Comparison of Unplanned Extubations to Controls

Unplanned Extubations Control

n = 189* n = 654* p

Age (mo), median (IQR) 7.0 (2.8–37.0) 7.0 (2.0–39.3) 0.55

Age, as categories, n (%) 0.024
  0 to < 6 mo 84 (44.9) 273 (42.1)
 > 6 mo to < 1 yr 22 (11.8) 123 (19.0)
  1 to < 6 yr 51 (27.3) 127 (19.6)
 > 6 yr 30 (16.0) 125 (19.3)
Weight (kg), mean (sd) 15.6 (20.5) 15.8 (21.7) 0.90
Planned extubation In <12 hr, n (%) 71 (38) 74 (10) < 0.001
Nasal ETT, n (%) 13 (7) 102 (16) 0.002
ETT size, mean (sd) 4.23 (1.3) 4.24 (1.2) 0.90
Cuffed ETT, n (%) 121 (64) 491 (75) 0.003
Commercial device, n (%) 9 (5) 45 (7) 0.40
 Taped to unit standard 154 (83) 590 (92) 0.001
 Tape loose or slimy 48 (26) 18 (3) < 0.001
 End-tidal CO2 device in place 141 (77) 512 (80) 0.35
Required suctioning > 1×/hr, n (%) 22 (12) 35 (5) 0.001
Patient activity, n (%)
 Continuous sedation 103 (55) 469 (72) < 0.001
 Neuromuscular blockade use 14 (8) 68 (11) 0.26
 Restraints applied 91 (49) 204 (32) < 0.001
 Sedation holiday 11(6) 26 (4) 0.29
Staffing
 Nurse years of experience (sd) 7.1 (7.8) 7.5 (8.5) 0.52
  Nurse is critical care registered nursing certification, n (%) 21 (13) 101 (18) 0.07
  Nursing assignment ratio 1:1, n (%) 96 (52) 455 (72) < 0.001
  Nurse pulled from another unit, n (%) 15 (8) 26 (4) 0.03
 Respiratory therapist years of experience (sd) 11.6 (9.6) 10.8 (9.5) 0.35
IQR = interquartile range; ETT = endotracheal tube.
*Missing data results in individual factor sum being less than total.

than 6-year age categories in the univariate analysis, and per-
sisting for the 6-month to 1-year age group in the multivariate
analysis (Tables 1 and 2). However, the calculated rate of UPE,
number of UPE/100 ETT days, was almost double in children
6 years old or younger compared with older children (Table 2).
There was no difference in UPE rates between the youngest
(< 1 yr) and the 1–6-year-old age groups (0.81 and 0.89,
respectively, p = 0.541).
There was no association between time of day and UPE.
When broken down by the typical time for a 12-hour shift, 101
of 187 (54%) of the UPE’s occurred between 7 am and 7 pm,
whereas 86 of 187 (46%) occurred on the night shift between
7 pm and 7 am. In the 8-hour nursing shift model, the distribu-
tion was 67 of 187 (36%) between 7 am and 3 pm, 58 of 187
(31%) between 3 pm and 11 pm, and 62 of 187 (33%) between
11 pm and 7 am.
The univariate analysis of the factors associated with UPE
is shown in Table 1. Cases of UPE were more likely to have
extubation planned within the next 12 hours, require frequent
suctioning, have loose or slimy tape securing the tube, have
restraints in place, and have the bedside nurse pulled from
another unit. Nasal ETTs, taping the ETT per unit standard,

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 Fitzgerald et al
Table 2.Rate of Unplanned Extubation in
Children by Age
Unplanned Endotracheal Rate/100 d
Age, yr Extubation Intubation Days (95% CI)
<1 106 13138.22 0.81 (0.65–0.96)
1 to < 6 51 5701.2 0.89 (0.65–1.14)
>6 30 6674.17 0.45 (0.29–0.61)
(< 1 yr) vs (1 to < 6 yr), p = 0.55; (< 1 yr) vs (> 6 yr), p = 0.004; and
(1 to < 6 yr) vs (> 6 yr), p < 0.001.
continuous infusion of sedation, and a nurse-patient assign-
ment ratio of 1:1 were protective against UPE. The use of para-
lytic agents and the use of commercial products to secure the
ETT were the same in cases of UPE and the control group.
Inadequate sedation level as assessed by the bedside nurse
was associated with a higher UPE percentage, as shown in
Figure 2, where 46% of the UPE patients were said to have
an adequate level of sedation compared with 93% of the con-
trols (p < 0.001).
Using logistic regression, we analyzed the relationship
between specific independent variables and UPE (Table 3).
Inadequate sedation and having a tube that was loose or slimy
carried the odds ratio of UPE at 9.1 and 10.4, respectively. A
planned extubation in the next 12 hours also carried a two
times greater risk of UPE compared with no planned extuba-
tion. When a nurse was pulled from another unit, there was a
almost a four-fold risk of UPE.
Outcomes and Adverse Events of UPEs
Of the 189 UPEs, 21 events were missing data on need for rein-
tubation. One hundred and four of the 168 (62%) remaining
UPE patients required reintubation. As shown in Table 4, most
were reintubated for a respiratory issue including oxygen desat-
uration or increased work of breathing. There were two cardiac
arrests associated with UPE. Reintubation was more common
in the younger age group with 68% of children aged 12 months
old or younger requiring reintubation, whereas 50% of those
aged 12 months old or older were reintubated (p < 0.016). The
median age of children requiring reintubation was 5 months
compared with 13 months for those not reintubated.
Figure 2. Sedation level at the time of unplanned extubation (UPE).
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Five of the 104 patients (4.8%) who required reintuba-
tion had problems associated with reintubation. Of those, one
required a much smaller ETT secondary to airway edema, one
had airway bleeding, two had symptomatic bradycardia, and
one developed hypotension.
DISCUSSION
This is the largest, prospective, multicenter study of the
common quality and safety issue of UPE in pediatrics. UPE
occurred in this study at a rate of 0.74 events per 100 ventila-
tor days. This rate is 25% less than the multicenter trial look-
ing specifically at extubation failure (17), as well as the target
upper rate suggested by the recent concise data review pub-
lished regarding UPE in children (19). This rate is within the
range for pediatric UPE found in the published literature,
mostly single-center trials, with ranges of UPE rates from 0.2
to 2.7 (5–9, 11, 12, 14, 16). This rate is consistent with, but
at the upper range of, rates found in recent pediatric studies
looking at quality improvement programs aimed specifically at
reducing UPE (5, 6, 16).
There was wide intersite variation in the UPE rate, with a
seven-fold difference ranging from 0.3 to 2.1 UPE events/100
ETT days. These differences in rate may be explained by dif-
ferences in institutional practice that were found to be signifi-
cantly associated with UPE such as nurse staffing or degree of
sedation in intubated patients. It is not felt that this rate dif-
ference is from a difference in UPE reporting, as all sites had
active vigilance for UPE according to the study definition.
There have been conflicting study results about the association
of age with UPE, with several finding that younger age groups
are at higher risk for UPE (5–7) and others finding no associa-
tion (11, 12). Our study found no difference in the median age
between the cases of UPE and controls; however, when compared
by rate of UPE/100 ETT days, children 6 years old or younger
were at increased risk of UPE. Todres postulated that the risk is
higher in younger age groups given their short tracheal length
(20). In addition, developmental immaturity and inability to
understand and comply with care activities may contribute to
increased risk of UPE. This study supports the higher risk for
UPE in younger patients, with no difference between the rates of
UPE in the youngest (< 1 yr) and the 1–6-year-old age groups.
Also, it is important to note that although the rate is higher in the
younger age group, there is still a significant risk in older patients,
0.45/100 ETT days. Strategies aimed at identifying risks for and
decreasing UPE in the future should not just focus on younger
patients but should include all pediatric patients.
Interestingly, when the less than 1-year age group was bro-
ken down in post hoc analysis, the 6-month to 1-year age group
had lower odds of UPE than both the less than 6-month and
the 1–6-year age groups in both the univariate and the multi-
variate analyses. This may be due to case sampling, as it can-
not be confirmed with the UPE rate as this age breakdown was
post hoc and not requested for the overall UPE of all intubated
patients. We could speculate that this is due to more consis-
tent sedation outside of the neonatal period before reaching
the unruly toddler age; however, this would need further study.
 Online Clinical Investigations

Table 3. Multivariate Analysis of Factors Associated with Unplanned Extubationa

Independent Variables OR (95% CI) p

Elective extubation planned in < 12 hr 2.4 (1.3–4.5) 0.003

Tape loose or slimy 11.4 (5.2–25.0) < 0.001
Sedation levelb < 0.001
 Sedation level suddenly awake 19.7 (9.7–39.9) < 0.001
 Sedation level inadequate 9.5 (4.5–19.8) < 0.001
Nurse pulled from another unit 2.7 (1.0–7.0) 0.042
Status of endotracheal tubec 0.027
 Cuffed: inflated 0.72 (0.40–1.29) 0.27
 Cuffed: deflated 1.9 (0.9–4.0) 0.10
Age d
0.048
 6 mo to < 1 yr 0.40 (0.18–0.89) 0.03
 1 yr to < 6 yr 1.3 (0.7–2.4) 0.48
 > 6 yr 0.67 (0.32–1.43) 0.30
Oral endotracheal tube – e
0.13
Tube taped according to the standard for the unit – 0.24
Restraints applied – 0.71
Neuromuscular blockade use – 0.50
Total no. of patients assigned to nurse – 0.25
Continuous sedation infusing – 0.58
Required suctioning > 1×/hr – 0.38
Product used to secure the tube – 0.75
OR = odds ratio.
a
Logistic regression analysis, with unplanned extubation as the dependent variable; variables were entered into the model if p < 0.05, and only removed
if p > 0.10.
b
The reference value was “sedation level adequate.”
c
The reference value was “uncuffed.”
d
The reference value was “6 months old or older.”
e
Variable was not entered into the model, so no odds ratio was calculated.

Reasons for Reintubation After

Table 4. (13). Our study supports the finding of two previous single-
Unplanned Extubation center pediatric studies, showing no difference in the rate of
UPE by time of day (5, 6) when split by a 12-hour shift model
Factors n (%) and an 8-hour shift model. The difference with the adult stud-
ies may be related to differences in PICU staffing models.
Secretions 12 (14)
In previous studies, inadequate ETT fixation was one of
Stridor/wheezing 11 (13) the leading causes of UPE (7–9). However, no single method
Increased work of breathing 37 (43) of ETT stabilization in the clinical setting could be identi-
Apnea 10 (12)
fied as superior for minimizing UPE events (21). Loughead
et al (22) and Richmond et al (23) found that UPE rates
Cardiac arrest 2 (2) decreased after implementing and educating staff on a new
Cardiovascular failure 1 (1) taping method. ETT fixation method and the materials used
Hypoxia 60 (69)
were not controlled for in this study. Ninety-three percent of
ETT were secured using tape in both case and control groups.
Hypercapnia 8 (9) Importantly, we found that there was a significantly higher rate
of UPE when the ETT was not taped to the individual unit’s
Previous studies in adults report that UPE occur at different standard. Certainly, further study looking at the association of
rates according to the time of day, due to staffing issues at night UPE with differences in securement methods would be helpful,

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 Fitzgerald et al
but our data suggest that simply being consistent with taping
method within a unit leads to less UPE.
Cuffed ETT were associated with a decreased rate of UPE
compared with uncuffed ETT; however, this significance was
not retained with the multivariate analysis. The decreased UPE
in the univariate analysis was associated with cuffed ETT with
cuff inflated (p < 0.001 vs uncuffed). There was no difference
in UPE rate, with a cuffed ETT with the cuff deflated (p = 0.88
vs uncuffed). This may be due to cuffed ETT and inflated cuffs
being used more commonly in older children.
The amount of secretions and how loose or slimy the tape
was at the time of UPE were significantly higher in the UPE
group. The percentage of patients requiring suctioning greater
than one time per hour was used a surrogate for amount of
patient secretions. Admittedly quantifying these factors is diffi-
cult, with a significant subjective component to them, but their
association with UPE does make clinical sense. Focusing fur-
ther efforts on secretion control and securing tubes in patients
with significant secretions would be useful.
Inadequate sedation is clearly a risk factor for UPE in both
prior (5, 6, 9–12) and the current study. Our study also sup-
ports prior work reporting increased UPEs occurring, whereas
the patient was being weaned or within 1 day of planned
extubation (3, 6, 13), which may also be related to weaning
of sedation. Our study is limited by the fact that sedation was
assessed subjectively by the nurse after the UPE event and at
a single time point in the control group. Most of the institu-
tions involved in the study used a sedation scale although these
scales were different enough that categorizing patients across
institutions was impossible. The use of sedation scales has been
shown to impact UPE rates and allow for objective measure-
ment of sedation level and in some nurse-driven protocols for
sedation dosing (16). We did find a significantly lower rate of
UPE in patients on continuous sedation infusions, but finding
a specific sedation infusion regimen that was better was not
possible. There were over 50 different infusion combinations
of the patients on continuous sedation medications. Although
most were a combination of a narcotic, benzodiazepine, and/
or dexmedetomidine, there were many that included ketamine,
propofol, or pentobarbital.
In our study, the control patients had more than double
the rate of nasal intubation compared with the cases of UPE,
with a trend toward significance in regression analysis. Nasal
intubation is potentially protective for a few different reasons
including increased stabilization in the nasopharynx and pos-
sibly being more comfortable in babies to allow for non-nutri-
tive sucking on a pacifier.
Nurse staffing patterns have also been associated with UPEs.
UPEs occurred more frequently within 1 hour before or after
a shift change, possibly related to the absence of the nurse at
the bedside (24). UPE rates also increased when there was a 2:1
nurse-to-patient ratio as compared with a 1:1 nurse-to-patient
ratio (12, 14). This finding was also borne out in the NACHRI
PICU Focus Group Survey, where centers with the lowest UPE
rates had better nurse: patient staffing ratios. In addition, the
likelihood of UPEs increased when a nursing assignment had
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a higher acuity load (14). In our study, a 1:1 nursing-to-patient
ratio was protective against UPE in the univariate analysis, but
did not remain significant in the multivariate analysis. An inter-
esting finding in the multivariate analysis was the four times rel-
ative risk of having a UPE when a nurse was pulled from another
unit. Staffing flexibility is required in PICUs to deal with surges
in patient volume, and at times this requires pulling nursing staff
from the Neonatal ICU and acute care floors. Enhanced educa-
tion programs or attempting to have pulled nurses care for non-
intubated patients may lead to lower UPE rates.
There are multiple limitations to this case-control study. The
study design of selecting controls during the same shift as the
case of UPE although appropriate in identifying patient-spe-
cific factors may limit the identification of unit factors that are
affected by unit acuity and staffing or for center-specific prac-
tices. In addition, because the majority of patients intubated in
PICUs are 1 year old or younger, random sampling of patients to
select the control group will result in a greater selection of these
younger patients, potentially diluting age-related effects con-
tributing to UPE. Self-reported variables, such as tube integrity,
amount of secretions, and sedation level, are clearly subjective
as they were recorded by the unblinded bedside nurse caring
for the patient who just had an UPE. Record of such events is
unlikely to be completely free of bias, including subconscious
attempts to justify the UPE. However, bias may lead to overes-
timation, but it is unlikely to account for all of the association
with UPE given the very large odds ratios for these variables.
Some variables planned in the initial study design, such as the
activity of the patient at the time of UPE or persons in the room
at the time of the event, were not able to be analyzed. Multiple
selections of too many activities with limited data definitions
resulted in a loss of reliability. In addition, we were unable to
compare the cases of UPE with the unextubated control patient
for these variables. It was difficult for the bedside nurse of the
control patient to remember specific activities corresponding
to an uneventful window of time versus for the nurse of the
patient who just underwent an eventful UPE. Further study
should be designed to account for these limitations.
As pediatric hospitals across the country look at quality
improvement and high reliability processes, UPE is an impor-
tant safety event that deserves attention. The rate of 0.74
UPE/100 ventilator days means that these events occur at a rate
more than double CA-BSI rate of 3.1 events/1000 catheter days
found in the NACHRI CA-BSI study (25). Because complica-
tions and the need for reintubation are not uncommon with
UPE, further efforts to decrease this adverse event in PICUs are
needed. These data can be used to create and study bundles of
care in a collaborative fashion to improve the safety of intu-
bated children in the ICU.
CONCLUSIONS
Multiple factors contribute to UPE in children. Patient age less
than 6 years is associated with an increased rate of UPE. Patient
factors, such as decreased level of sedation and increased amount
of secretions, are associated with UPE. Staffing factors such as
floating nurse from another unit are also associated with UPE.

ACKNOWLEDGMENTS
We thank and give great credit to Lynn Lostocco and the Chil-
dren’s Hospital Association (formerly National Association of
Children’s Hospitals and Related Institutions) PICU Patient
Care Focus group. We acknowledge the following individuals
and institutions for collection of data and support in develop-
ment of the study: Rachel Blanton, Helen DeVos Children's
Hospital; Megan Boone, RN, MSN, Kosair Children's Hospital;
Melissa Christensen, BS, CCRC, Children’s Hospital of Wis-
consin; Mary Jo Giaccone, RN, MSN, Cincinnati Children's
Hospital Medical Center; Shonda Grappe, RN, BSN, Arkan-
sas Children's Hospital; Jerril Green, MD, Arkansas Children's
Hospital; Paula Lafond, RN, Children's Hospital of Illinois at
OSF; Alicia Layman, RN, BSN, Cook Children's Medical Cen-
ter; Lynne Lostocco, RN, MSN, Children’s Hospital Association;
Vicki Montgomery, MD, Kosair Children's Hospital; David R.
Schmidt, MSN, CNS, CPNP, CCRN, Children’s Hospital of Los
Angeles; Karen Shambaugh, University of Michigan C.S. Mott
Children's and Von Voigtlander Women's Hospital; Meg Sour-
beer, RN, MSN, Inova Fairfax Hospital for Children; and Tangela
Welch, RN, CCRN, Children's Mercy Hospitals and Clinics.
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