Reducing Unplanned Extubations in the Neonatal Intensive Care Unit: A Retrospective and Prospective Qualitative Analysis

Abstract

Background: Unplanned extubations is a reoccurring issue in the neonatal intensive care unit. An unplanned extubation event is defined as any unplanned loss of an endotracheal tube. These events are the fourth leading causes of an adverse event in this patient population. The team set a goal to reduce these events to less than 1 per 100 ventilator days to meet benchmark criteria.

Methods: This study received IRB approval from Atrium Health, using retrospective data on unplanned extubation rates and audit tools, and a qualitative analysis of these results. The respiratory task force team at Levine Children’s Hospital developed a PDSA cycle to assist in the reduction of unplanned extubation. There were 4 bundles of changes implemented from May 2016-May 2019. These bundles included: (1) standard practice of having 2 care providers (licensed professional staff) with any procedures, documentation of the depth of the endotracheal tube position by nursing and respiratory staff during routine cares, (2) real time event analysis review with care team and, visual display of days since last unplanned extubation. A third bundle was implemented March 2018, with the use of hand mittens for patients at high risk, bedside cards for quick visual of ETT size and placement, and “Not On My Watch” campaign, and in May 2018 we developed a collaboration tool completed by RT and RN. This collaboration tool was completed twice a shift analyzing the integrity of the ETT, circuit tension and position of patient to be sure no tension was applied to ETT.

Results: The implementation of the first bundle of changes was May 2016, it was noted to reduce unplanned extubation rates by 5%. The second bundle reduced unplanned extubation events by 20%. There has been a 25% reduction of unplanned extubation events with the bundles implemented noted from January 2017 thru January 2018. After the May 2018 implementation bundle, we have a reduction of 50% in our unplanned extubations. We surpassed our goal, currently we are <0.5 events per 100 ventilator days.

Conclusions: A steady decline in events were noted with each bundle implemented. Further evaluation and establishment of hard wiring bundles will need to occur for sustainability of improvements. The “Not On My Watch” campaign was to provide ownership to the care provider, to sustain positive results and to attempt to change the culture of “it’s going to happen, no big deal”. The culture has now begun to shift from “no big deal”, to this is a safety problem.