Assessing the level of sedation in the intubated pediatric patient is difficult. Sedation assessment scales such as the Ramsay scale, modified Ramsay sedation protocol, and the COMFORT scale have been used in the assessment of sedation in intubated children as well as for guiding medication Enzalutamide side effects administration [10, 14�C17]. Only the COMFORT scale has been validated in children [15]. Given that inadequate sedation continued to be a factor, further examination and adoption of a sedation protocol may be helpful. Since care in our PICU does not include the routine use of physical restraints, these data were not examined. Because our interventions were successful, we acted (A) on them by adopting them on a permanent basis. Nonetheless, we must be careful in attributing our success to our interventions.

Some would argue that with the small sample size, the improvement in rate of unplanned extubation was due to the Hawthorne effect [18] where performance improvement is attributed to the fact that performance is being studied and not actual quality improvement. Because PDSA is a dynamic process, the rate of unplanned extubation will be reexamined at a later date to determine whether the level of improvement has been maintained. Ideally, the statistical process control method would have been used to investigate trends in the rate of unplanned extubation prior to the implementation of the program. However, since there were only ten unplanned extubations in the first time period and two in the second period, this method could not be utilized.

Nonetheless, there was no indication that the rate of unplanned extubations had begun to decrease prior to the implementation of the program (Table 3). The time periods chosen for the study were similar in both groups. They were carefully selected due to the seasonality of pediatric diseases such as respiratory syncytial virus. The six-month period when there were no data collection was to allow for this seasonality. The age, weight, size of endotracheal tube, and duration of intubation were not different in the groups. Although there were differences in the reasons for intubation in the two groups, the differences likely would have biased the results towards a higher rate of unplanned extubation in the postintervention group since the patients intubated for respiratory failure would likely have more secretions and be more ill than those intubated for apnea. The similarity in the two groups leads us to believe that the decrease in the rate of unplanned extubation was due to our interventions and not due to differences in patient groups. In conclusion, we demonstrated that the rate of unplanned extubation in a PICU can be decreased with a targeted intervention AV-951 program tailored for the specific problems.