| Summary: | Background: Unplanned extubation (UE) in intensive care units (ICUs) is a significant patient safety concern, associated with increased morbidity and healthcare utilization; the reported rates of UE vary from 1% to 15%. There is sparse data on the effects of multiple performance improvement (PI) strategies to decrease the rate of UE, particularly in inner-city ICU populations. This study evaluates the impact of PI strategies on UE rates and associated patient outcomes in an adult ICU. Objectives: To determine the impact of performance improvement (PI) strategies on rates of unplanned extubation (UE), reintubation, tracheostomy, mortality, and length of hospital stay in ICU patients. Design: Retrospective cohort study Methods: This retrospective observational study included 6,397 mechanically ventilated patients admitted to a single tertiary ICU between 2015 and 2023. Three distinct time periods were compared: Period 1 (2015–2017, pre-PI), Period 2 (2018–2020, early-PI), and Period 3 (2021–2023, sustained-PI). Demographics, sedation practices, UE characteristics, and outcomes were analyzed using logistic regression. Results: UE incidence declined significantly from 3.79% in Period 1 to 2.17% in Period 3 ( p = 0.002). Reintubation rates dropped from 45.2% to 26.7% ( p = 0.011), and tracheostomy rates from 19.0% to 2.2% ( p < 0.001). Multivariate analysis showed reduced odds of reintubation in Periods 2 (OR = 0.219, p = 0.001) and 3 (OR = 0.345, p = 0.021) and reduced odds of tracheostomy in Period 3 (OR = 0.011, p = 0.016). Risk factors for reintubation included the absence of prior intubation history and not undergoing spontaneous breathing trials. Older age (⩾71 years) and positive urine toxicology for opiates were strongly associated with tracheostomy. Conclusion: Implementation of PI strategies significantly reduced rates of unplanned extubation, reintubation, and tracheostomy. These findings support continued quality improvement initiatives in ICU airway management.
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