Long-term impact of a quality improvement program on unplanned extubation and clinical outcomes in adult intensive care units: a 24-year single-center observational study.

Introduction: Unplanned extubation (UE) remains an important patient safety issue in intensive care units (ICUs) and is associated with morbidity, prolonged mechanical ventilation, and mortality, particularly when reintubation is required. Long-term evidence on sustained quality improvement (QI) programs in adult ICUs remains limited. This study evaluated the association between a continuous QI program and UE incidence and identified factors associated with reintubation and mortality after UE. Methods: We conducted a single-center observational study at a tertiary medical center. UE events were prospectively registered from January 1, 2001, to December 31, 2024, and clinical data were retrospectively analyzed. The QI program implemented from 2001 onward included standardized procedures, sedation and weaning protocol revision, adjustment of physical restraint practices, high-risk patient management, team-based QI frameworks, improved endotracheal tube fixation, and an artificial intelligence-based weaning prediction system. UE incidence was assessed among mechanically ventilated patients. First-episode UE patients from 2009 to 2024 were analyzed to compare outcomes between patients with and without reintubation within 48 h. Multivariable logistic regression was used to identify factors associated with reintubation and in-hospital mortality. Results: Over 24 years, 1,574 UE episodes occurred among 64,346 ventilated patients, with an overall rate of 2.51 per 100 ventilated patients. The rate declined from 6.82 in 2001 to 0.65 per 100 ventilated patients in 2024 ( Conclusion: A sustained, bundled, multidisciplinary QI program was associated with a durable decline in UE over 24 years. Early risk stratification and targeted post-UE monitoring may help identify high-risk patients and guide post-event management in adult ICUs.