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Original Investigation
November 2016

Association Between Overnight Extubations and Outcomes in the Intensive Care Unit

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. 2016;176(11):1651-1660. doi:10.1001/jamainternmed.2016.5258
Key Points

Questions  How common are overnight extubations in the intensive care unit and are they associated with worse outcomes for critically ill patients?

Findings  In this cohort study of 97 844 patients in US intensive care units who have undergone mechanical ventilation (MV), 20.1% underwent overnight extubation. Overnight extubation was associated with significantly higher hospital mortality compared with daytime extubation.

Meaning  Overnight extubation is not common and is associated with worse outcomes for critically ill patients.


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.