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Original Investigation |

Association Between Overnight Extubations and Outcomes in the Intensive Care Unit ONLINE FIRST

Hayley B. Gershengorn, MD1; Damon C. Scales, MD, PhD2; Andrew Kramer, PhD3; Hannah Wunsch, MD, MSc2,4,5
[+] Author Affiliations
1Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
2Interdepartmental Division of Critical Care Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
3Prescient Healthcare Consulting, Charlottesville, Virginia
4Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York
5Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
JAMA Intern Med. Published online September 06, 2016. doi:10.1001/jamainternmed.2016.5258
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Importance  Little is known about the timing of extubations for patients in the intensive care unit (ICU) who undergo mechanical ventilation (MV) or whether overnight extubation is safe.

Objectives  To describe the frequency of overnight extubations and assess the association between overnight extubations and clinical outcomes.

Design, Setting, and Participants  This retrospective cohort study included adults (aged ≥18 years) undergoing MV performed in US ICUs as part of the Project IMPACT database from October 1, 2000, to March 29, 2009. Data were analyzed from January 1, 2015, to July 5, 2016.

Exposure  Overnight extubation defined as occurring from 7 pm to 6:59 am.

Main Outcomes and Measures  Multilevel multivariable regression analyses (clustered by individual ICU) were used to identify factors associated with overnight extubation. Propensity-matched pairs were created of patients undergoing overnight vs daytime extubation (separately for patients with MV duration <12 and ≥12 hours). Outcomes, including frequency of reintubation in the ICU, ICU and hospital mortality, and ICU and hospital length of stay (LOS), were assessed using χ2 and Mann-Whitney tests.

Results  The cohort consisted of 97 844 patients (40.8% men; 59.2% women; mean [SD] age, 58.3 [17.9] years) across 165 ICUs. Of these, 20.1% of patients underwent overnight extubation and the percentage decreased over time (23.3% in 2000-2001 vs 18.8% in 2009; P = .001). After multivariable adjustment, duration of MV of less than 12 hours had the greatest association with overnight extubation (compared with 12 hours to <1 day: adjusted odds ratio [AOR], 0.20 [95% CI, 0.19-0.21]; 1 to <2 days: AOR, 0.26 [95% CI, 0.24-0.28]; 2 to <7 days: AOR, 0.22 [95% CI, 0.21-0.24]; and ≥7 days: AOR, 0.24 [95% CI, 0.22-0.26]). In all, 4518 propensity-matched pairs had MV duration of less than 12 hours and 5761 had MV duration of at least 12 hours. For MV duration of less than 12 hours, reintubation rates were similar for overnight and daytime extubations (5.9% and 5.6%, respectively; P = .50), but mortality was increased for patients undergoing overnight extubation (ICU, 5.6% vs 4.6%, P = .03; hospital, 8.3% vs 7.0%, P = .01). The ICU LOS was shorter for overnight vs daytime extubations (median [interquartile range], 1.1 [0.8-2.3] vs 1.4 [0.9-2.5] days; P < .001), and hospital LOS was similar (median [interquartile range], 7.0 [4.0-12.0] vs 7.0 [3.0-12.0] days; P = .03). Patients with MV duration of at least 12 hours who underwent overnight extubation had more frequent reintubation in the ICU (14.6% vs 12.4%; P < .001) and higher mortality in the ICU (11.2% vs 6.1%; P < .001) and in the hospital (16.0% vs 11.1%; P < .001), with no differences in LOS.

Conclusions and Relevance  Approximately one-fifth of patients with MV in US ICUs undergo overnight extubation. These patients have higher rates of ICU and hospital mortality than patients undergoing extubation during the daytime. Further studies are needed to understand why overnight extubation results in poorer outcomes.

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Figure 1.
Distribution of Time-of-Day of Extubations

Overnight extubation was defined as occurring from 7 pm to 6:59 am. Of the primary cohort of 97 844, in total, 79.9% of extubations occurred during the daytime and 20.1% occurred overnight.

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Figure 2.
Odds of Reintubation and Mortality Associated With Overnight Extubation for Propensity-Matched Pairs Stratified by Patient Subgroup

Tests for interaction between overnight extubation and subgroups depicted for each outcome were assessed using the primary propensity-matched cohorts (all patients with mechanical ventilation [MV] duration <12 h and, separately, all patients with MV duration ≥12 h). No significant interaction (P < .05) was found between overnight extubation and any subgroup examined for any outcome. A, The full cohort included 4518 of 4522 patients undergoing overnight extubations (99.9%); 1796 of 1800 patients with medical admission undergoing overnight extubations (99.8%); 1429 of 1645 patients undergoing elective surgery and overnight extubations (86.9%); 1064 of 1077 patients undergoing emergent surgery and overnight extubations (98.8%); 256 of 263 patients in the medical ICU undergoing overnight extubations (97.3%); 1971 of 1990 patients in the surgical intensive care unit (ICU) undergoing overnight extubations (99.0%); 2189 of 2191 patients in the medical-surgical ICU undergoing overnight extubations (99.0%); 1807 of 1843 patients with an intensivist on-site undergoing overnight extubations (98.0%); and 2526 of 2532 patients without an intensivist on-site undergoing overnight extubations (99.8%). B, The full cohort included 5761 of 5763 patients undergoing overnight extubations (99.9%); 3482 of 3485 patients with medical admissions undergoing overnight extubations (99.9%); 907 of 910 patients undergoing elective surgery and overnight extubations (99.7%); 1365 of 1368 patients undergoing emergent surgery and overnight extubations (99.8%); 573 of 573 patients in the medical ICU undergoing overnight extubations (100%); 1883 of 1883 patients in the surgical ICU undergoing overnight extubations (100%); 3116 of 3118 patients in the medical-surgical ICU undergoing overnight extubations (99.9%); 2316 of 2318 patients with an intensivist on-site undergoing overnight extubations (99.9%); and 3125 of 3125 patients without an intensivist on-site undergoing overnight extubations (100%). OR indicates odds ratio.

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