Nurse staffing and unplanned extubation in the pediatric intensive care unit*

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Abstract
Objective: To determine the association between unplanned extubations and years of nurse experience and nurse-to-patient ratio in the pediatric intensive care unit (PICU). Design: Case-control study. Setting: University-affiliated children’s hospital PICU. Patients: Unplanned extubations were identified from January 1999 through December 2002. Three control patients for each of the patients experiencing an unplanned extubation were selected on three matching factors: age, intubation duration, and severity of illness as defined by the Pediatric Risk of Mortality (PRISM) III. Interventions: None. Measurements and Main Results: Fifty-five of 1,004 intubated patients (5.5%) experienced an unplanned extubation during the 4-yr period. A conditional logistic regression analysis was used to evaluate the association between a patient’s risk of an unplanned extubation and the nurse’s years of PICU experience and nurse-to-patient ratio. Factors associated with unplanned extubations included the documentation of patient agitation (odds ratio, 2.99; 95% confidence interval, 1.14, 7.86) and a nurse-to-patient ratio of 1:2 (one nurse caring for two patients) relative to a nurse-to-patient ratio of 1:1 (odds ratio, 4.24; 95% confidence interval, 1.00, 19.10). Years of PICU nursing experience, patient restraints, and the method of sedation delivery (continuous infusion vs. intermittent bolus) were not associated with unplanned extubations. Conclusions: Pediatric patients are more likely to experience an unplanned extubation when being cared for by a nurse assigned to two patients compared with a nurse caring for one patient. To provide safe patient care, health care policymakers and hospital administrators should consider the nurse-to-patient ratio and its potential association with adverse events in hospitalized children.