Reducing Unplanned Extubations in the NICU Using Lean Methodology

Discussion

This project was initiated with a voice of the customer survey to assess cultural readiness for change. During the define phase of this process improvement, the NICU moved from an open bay design to private rooms. The walking distance between patients and the size of the new single-patient room NICU (4 times the square footage of the open unit) required the staff to adjust to new workflows. This transition presented some initial difficulty, especially with the simultaneous implementation of some of the improvements. We anticipated that the 2 caregivers to turn model would be the most difficult to implement, but staff were able to adapt. Survey results demonstrated to our process improvement team that the culture did not support the perception that unplanned extubations were always an unpreventable event. The majority of respiratory and nursing staff reported that at least some of the unplanned extubations were preventable. The free text portion of the survey provided a number of comments from staff stating how the events affected them on a personal and professional level. Overall, the results displayed a desire by staff to improve the safety of the care provided to their patients.

During this define and measure portion of our project, staff voiced concerns that they perceived unplanned extubations occurred more frequently with larger infants and when staffing levels were not appropriate. Data from the analysis phase showed no statistical difference in patient weight, a surrogate for size, which did not support their perceptions. Additionally, staffing was at the planned level when unplanned extubations occurred. When this information was relayed to staff, the educators reviewed the physiological and environmental factors contributing to unplanned extubations that the improvements targeted. These factors were similar to those identified in the literature and were aligned with countermeasures implemented during our improve phase of the PDSA project. In a comprehensive review, Silva et al² reported that risk factors for unplanned extubations included restlessness/agitation (13–89%), poorly fixated ETT (8.5–31%), ETT manipulation (17–30%), and performance of bedside procedures (27.5–51%). Veldman et al¹⁰ reported unplanned extubations occurred most frequently when fixation of the ETT was difficult, handling of the infant by nursing staff or during care or with active infants in whom dislocation of the ETT occurred without external manipulations.

Lean and Six Sigma principles were used in this process improvement initiative to engage those who perform beside care to identify and correct defects. An ease impact chart allowed staff to identify the quick wins or opportunities that would make an impact without significant investment in resources and time. Similar to reports in the literature,¹¹ the use of this lean tool further engaged participants in the change.

The data collection period was significantly longer for the pre-improvement group. The acuity of the NICU influenced the number of intubated days. There were periods where admissions of premature infants requiring intubation and mechanical ventilation were low. Rather than using raw numbers, we controlled for this variance by comparing the rate of unplanned extubations using the formula: number of unplanned extubations/100 intubated days. Therefore, the proportion of intubated days was identical for both the pre- and the post-improvement groups. The difference in the data collection periods was attributed to the variance in volume and patient acuity in our NICU.

Two improvements evidenced the most change: ETT assessment for growth and addressing ETT migration. Routine chest radiographs to assess ETT placement are no longer a practice in our NICU. The literature reports risks associated with radiation exposure in the neonatal period,^12–14 which influenced our practice in the NICU. Rather than obtain a chest radiograph daily to assess ETT position, chest radiographs are only obtained when a clinical indication, such as verification of central line placement or clinical deterioration, exists. Since chest radiography was conducted only when needed, the improvement team recognized the value of standardizing practice and positioning the infant to also facilitate ETT evaluation. Changes in practice, specifically RTs holding the head of the intubated infant midline for any portable radiologic study, were implemented. This improvement enabled the team to evaluate ETT position in addition to using the image to evaluate the condition for which it was ordered.

During the analysis phase, we found that the relationship between patient growth and the need to reposition the ETT was not being routinely addressed by the clinical team. Knowledge gaps may have contributed to the inability of the nursing and respiratory staff to appreciate the importance of assessing growth and its relationship to ETT malposition. Our focus on discussing ETT position in relation to growth weekly during patient family-centered rounds resulted in improved awareness of this concept and a structured process to identify and correct ETT malposition.

The timing of patient assessments, specifically simultaneous RT and RN assessments, allowed ETT securement and position to be evaluated. This bedside team investigated and addressed small changes, often only one quarter cm, in the movement of the ETT and problems with the adhesiveness of the tape. Collaboration between RTs and RNs not only identified potential causes for an unplanned extubation but provided sufficient staff at the bedside to correct the defect. Through a process of coordinating care, we were able to avoid unintentional movement of the ETT.

Data collected in the pre-improvement phase showed that a significant number of subjects with unplanned extubations were not re-intubated. During this phase of the study, there were also a higher number of intubated days and a lower number of noninvasive days. When subject demographics were analyzed, no appreciable differences in the pre- and post-improvement groups were detected. However, the number of orders, in the electronic health record, to wean from invasive support increased in the post-improvement group. We suspect that in the post-improvement phase, there was an increased use of noninvasive ventilation, which was influenced by earlier extubation.

In our current practice, we investigate all of our unplanned extubations and provide closed-loop feedback to staff. Each time an unplanned extubation occurs, a thorough chart review is conducted, and information obtained is reviewed with staff. Staff identifies the defects as well as improvements to help us to prevent further unplanned extubations. The review is done in a non-punitive manner. A cumulative report of unplanned extubations are reviewed at the interdisciplinary performance improvement meetings monthly. Continuous review and closed-loop feedback to staff identify deviations from standard practice and increase staff awareness of the importance of adhering to the aforementioned practice changes. Reviewing our progress toward our goal of 1 unplanned extubation/100 intubated days also helps to change the culture in the NICU to a high-reliability learning culture and one that embraces opportunities to enhance patient safety.

The use of a PDSA process allowed our NICU care team to implement better practices or process changes. Similar to published reports in the literature,^3,4,15 we were able to reduce unplanned extubations in our NICU through staff education and the implementation of standard practices of care.

There were a number of limitations to this study. The data were retrospectively collected in the pre-improvement phase, and the cause(s) leading to unplanned extubation could not always be identified. There may have been more than one contributing factor to the unplanned extubation, which, due to data collection limitations, could not be identified. For example, a note in the patient medical record might identify that formula was seen in the ETT, which prompted extubation and evaluation for the need to re-intubate or support the infant on either noninvasive ventilation or oxygen therapy. However, this patient may have been turned by a single caregiver, without assistance before the event, but never documented. Rather than reviewing all unplanned extubations, a random sample of unplanned extubation events were selected for this study. This presents a potential limitation in that all possible opportunities and evaluation of process improvements could not be identified.

As a result, our data collection tool and process for reviewing unplanned extubation events have changed. Our tool is very prescriptive and is completed by all members of the direct care team involved in the care of the child at the time of the unplanned extubation. Multidisciplinary review of the event and completion of our unplanned extubation tool must now occur within 12 h of the event.

Reliance on staff self-reporting unplanned extubation occurrences in our safety reporting system was also a limitation. To gather reliable data, redundant processes are needed to minimize the propensity of not accurately capturing all events. In addition to our data collection tool, described above, we are currently in the process of revising our electronic health record to capture unplanned extubation events.