Skip to main content
 

Main menu

  • Home
  • Content
    • Current Issue
    • Editor's Commentary
    • Coming Next Month
    • Archives
    • Top 10 Papers in 2020
  • Authors
    • Author Guidelines
    • Submit a Manuscript
  • Reviewers
    • Reviewer Information
    • Create Reviewer Account
    • Appreciation of Reviewers
  • CRCE
    • Through the Journal
    • JournalCasts
    • AARC University
    • PowerPoint Template
  • Open Forum
    • Call for Abstracts 2021
    • 2020 Abstracts
    • Previous Open Forums
  • Podcast
    • English
    • Portugûes
    • 国语

User menu

  • Subscribe
  • My alerts
  • Log in

Search

  • Advanced search
American Association for Respiratory Care
  • Subscribe
  • My alerts
  • Log in
American Association for Respiratory Care

Advanced Search

  • Home
  • Content
    • Current Issue
    • Editor's Commentary
    • Coming Next Month
    • Archives
    • Top 10 Papers in 2020
  • Authors
    • Author Guidelines
    • Submit a Manuscript
  • Reviewers
    • Reviewer Information
    • Create Reviewer Account
    • Appreciation of Reviewers
  • CRCE
    • Through the Journal
    • JournalCasts
    • AARC University
    • PowerPoint Template
  • Open Forum
    • Call for Abstracts 2021
    • 2020 Abstracts
    • Previous Open Forums
  • Podcast
    • English
    • Portugûes
    • 国语
  • Follow aarc on Twitter
  • Visit aarc on Facebook
Meeting ReportAerosols, Oxygen Therapy, Airways Care

Setting the Stage: A Culture Change in Prevention of Un-Planned Extubation and Decreasing Serious Harm in Pediatric Patients

Angela Saunders, Michael Jaeger, Mary Noonan, Shanon Brannen, Caitlin Ryan, Julie Zix and Kristen Melton
Respiratory Care October 2020, 65 (Suppl 10) 3446075;
Angela Saunders
Respiratory Care, Cincinnati Childrens Hospital Medical Center, Williamsburg, Ohio, United States
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Michael Jaeger
Respiratory Care, Cincinnati Childrens Hospital Medical Center, Williamsburg, Ohio, United States
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Mary Noonan
Respiratory Care, Cincinnati Childrens Hospital Medical Center, Williamsburg, Ohio, United States
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Shanon Brannen
Respiratory Care, Cincinnati Childrens Hospital Medical Center, Williamsburg, Ohio, United States
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Caitlin Ryan
Anderson Center, Cincinnati Childrens, Cincinnati, Ohio, United States
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Julie Zix
NICU, Cincinnati Childrens, Cincinnati, Ohio, United States
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Kristen Melton
NICU, Cincinnati Childrens, Cincinnati, Ohio, United States
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
Loading

Abstract

Background: Unplanned extubations are serious harm. Serious harm is directly related to increased length of stay, increased time on the ventilator, increased ICU time and increased risk of cardiovascular collapse and death. Over the past few years we worked to change the culture, create buy in, and engage all disciplines to decrease the amount of serious harm. This past year we have focused on specific pieces of an UE bundle, the key drivers, and interventions. Each ICU determined and development a protocol for a standardized approach for securement and placement of the ETT. The bedside providing team works collaboratively to hold each other accountable. We use a high-risk protocol, ensuring that we have a plan in place for any movement of the patient or manipulation of the ETT. The development of a "knowing note" to share with the caregivers explaining safe kangaroo care, providers at bedside during this time, and kangaroo hold simulations. The care provided is a team driven approach with real time bedside huddles, plans of care and consistent messaging. Everyone has a chance and is supported to speak up around safety. The Leadership team and the members are multi-disciplinary, and they meet monthly to review the cases and data. This has created engagement of everyone and aids in proving the safest care for our patients. Each unit has developed an extubation readiness tool that is utilized for planning and rounding on the patient. Many of the approaches we implemented are evaluated with our K-Card rounding tool.

Methods: We used the Solutions for Patient Safety Unplanned Extubation Bundle. The inclusion of a multidisciplinary team and culture change was needed to create buy in for participation, and to decrease serious harm. We evaluated some key metrics to strategize how to overcome barriers, and measure accomplishments. These were used to determine outcomes. Our goal was to decrease the UE rate from 0.66 to 0.63 per 100 vent days (w/o trach) by June 30th, 2020. Every event had a real time huddle, information was gathered and entered into a Red Cap data base. The data was evaluated on a month to month bases and entered into run charts.

Results: All the initiative have shown a 60% decrease in our overall numbers of UE and have saved over 1.2 million potential dollars that would have been used to care for patients.

Conclusions: Our measured success related to decreasing unplanned extubations and working towards elimination of serious harm was attributed to the engagement of a multi-disciplinary team.

Figure1
  • Download figure
  • Open in new tab
  • Download powerpoint

Footnotes

  • Commercial Relationships: None

  • Copyright © 2020 by Daedalus Enterprises
Previous
Back to top

In this issue

Respiratory Care
Vol. 65, Issue Suppl 10
1 Oct 2020
  • Table of Contents
  • Index by author
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on American Association for Respiratory Care.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Setting the Stage: A Culture Change in Prevention of Un-Planned Extubation and Decreasing Serious Harm in Pediatric Patients
(Your Name) has sent you a message from American Association for Respiratory Care
(Your Name) thought you would like to see the American Association for Respiratory Care web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Setting the Stage: A Culture Change in Prevention of Un-Planned Extubation and Decreasing Serious Harm in Pediatric Patients
Angela Saunders, Michael Jaeger, Mary Noonan, Shanon Brannen, Caitlin Ryan, Julie Zix, Kristen Melton
Respiratory Care Oct 2020, 65 (Suppl 10) 3446075;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Setting the Stage: A Culture Change in Prevention of Un-Planned Extubation and Decreasing Serious Harm in Pediatric Patients
Angela Saunders, Michael Jaeger, Mary Noonan, Shanon Brannen, Caitlin Ryan, Julie Zix, Kristen Melton
Respiratory Care Oct 2020, 65 (Suppl 10) 3446075;
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
  • Figures & Data
  • Info & Metrics
  • References

Related Articles

Cited By...

Info For

  • Subscribers
  • Institutions
  • Advertisers

About Us

  • About Us
  • Editorial Board
  • Reprints/Permissions

AARC

  • Membership
  • Meetings
  • Clinical Practice Guidelines

More

  • Contact Us
  • RSS
American Association for Respiratory Care

Print ISSN: 0020-1324        Online ISSN: 1943-3654

© Daedalus Enterprises, Inc.

Powered by HighWire