2016 Articles

Cumulative Probability and Time to Reintubation in United States Intensive Care Units

Miltiades, Andrea; Gershengorn, Hayley; Hua, May; Kramer, Andrew; Li, Guohua; Wunsch, Hannah

OBJECTIVE: Reintubation after liberation from mechanical ventilation is viewed as an adverse event in intensive care units (ICUs). We sought to describe the frequency of reintubations across U.S. ICUs and to propose a standard, appropriate time cut-off for reporting of reintubation events.
DESIGN & SETTING: We conducted a cohort study using data from the Project IMPACT database of 185 diverse ICUs in the U.S.
PATIENTS: We included patients who received mechanical ventilation and excluded patients who received a tracheostomy, had a do-not-resuscitate order placed, or died prior to first extubation.
MEASUREMENTS: We assessed the percentage of patients extubated who were reintubated; the cumulative probability of reintubation, with death and do-not-resuscitate orders after extubation modeled as competing risks, and time to reintubation.
MAIN RESULTS: Among 98,367 patients who received mechanical ventilation without death or tracheostomy prior to extubation, 9,907 (10.1%) were reintubated, with a cumulative probability of 10.0%. Median time to reintubation was 15 hours (interquartile range 2-45 hours). Of patients who required reintubation in the ICU, 90% did so within the first 96 hours after initial extubation; this was consistent across various patient subtypes (89.3% for electives surgical patients up to 94.8% for trauma patients and ICU subtypes (88.6% for cardiothoracic ICUs to 93.5% for medical ICUs).
CONCLUSIONS: The reintubation rate for ICU patients in US ICUs is approximately 10%. We propose a time cut-off of 96 hours for reintubation definitions and benchmarking efforts, as it captures 90% of ICU reintubation events. Reintubation rates can be reported as simple percentages, without regard for deaths or changes in goals of care that might occur.