Abstract
Background: Unplanned extubation (UE) is a preventable adverse event and may lead to additional complications such as cardiovascular resuscitation or respiratory compromise in a critically ill neonate during an emergent reintubation. A quality improvement project to reduce unplanned endotracheal tube dislodgement would reduce these morbidities. Aim: To reduce unplanned extubations in the NICU to 1 UE/100 ventilator days by October 2018. Setting: A level 4 NICU with 950 annual admissions and a baseline rate of 9.9 unplanned extubations/100 ventilator days Culturally, our NICU clinical team accepted unplanned extubation as a normal risk factor in the patient population and did little to challenge this status –quo. We felt we could decrease our UE rate through the use of standardized securement equipment, standardized care delivery models and a re-education program for all NICU staff. Methods: We formed an inter-professional task force consisting of a Neonatologist, two Respiratory Therapists and the NICU Nurse Educator. We tracked all of our unplanned extubations as well as required the staff involved to file an electronic safety report. PDSA cycles consisted of: staff attitude survey, development of data collection tool, protocol of 2 staff members for all transfers of intubated patient, staff education around securement device and daily retaping of ETT to securement device. UE and ventilator days were extracted from a respiratory database and electronic medical record. Control charts (u-chart) were created using QI Macrosã and IHI-Healthcare control chart rules used to determine special cause variations. The Maine Medical Center Institutional Review Board determined that this was quality improvement and did not qualify as research. Results: A special cause variation was noted via control chart rules for the mean UE rate from baseline of 9.9 UE/100 ventilator days (8/2017-11/2017) compared to post-intervention mean of 1.6 UE/100 ventilator days (8/2018-3/2019). In addition, during the intervention phase of the project (12/2018-7-2018), a special cause variation was noted with an UE rate of 5 UE/100 ventilator days (Figure 1). Conclusions: Development of a QI project by a multidisciplinary taskforce, along with several PDSA cycles including education and staff awareness, reduced UE rate by 84% in a level 4 NICU. Ongoing surveillance, education and review of UE cases will be key to maintaining UE at a goal of 1 UE/100 ventilator days.
Footnotes
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