Abstract
Background: Unplanned extubations (UEs) are the 4th most common adverse event in NICUs. 10% of NICU patients require CPR after UEs. UEs in neonates increase oxygen requirements, ventilator days, and chronic lung disease of prematurity rates. Neonates are at increased risk for UEs because of immature skin, morbidities associated with sedation, and a narrow zone of acceptable endotracheal tube (ETT) placement. National goals for neonatal UEs are less than 1 per 100 ventilator days.
Methods: We utilized previous PDSA cycles, fishbone diagrams, Solutions for Patient Safety QI initiative, and instituted reliability bundles to ensure we were meeting our UE standards. Actions taken included educating NICU providers, RNs, and RTs on the Kempley chart and encouraged them to discuss ETT depth in multidisciplinary rounds as the patients reached set gestational milestones.
Results: In the 6 months after implementation of the Kempley chart, the absolute number of UEs were reduced by 50%. One-third of the UEs in that period still had a prescribed depth less than that predicted by the Kempley chart, indicating challenges with compliance. We have noticed decreased variability in the frequency of UEs but have not seen a center line shift yet.
Conclusions: This suggests that compliance with the Kempley chart prediction could still be improved. In our next PDSA cycle, NICU providers will document a real-time assessment of Kempley chart compliance with any UE and nurses will audit compliance daily. Lessons learned: Precise, prescribed ETT depth is an important component of NICU UE prevention. Approximately 80% of our NICU UEs occurred in patients born at 28 weeks’ gestation or less. The UE frequency was low in the first days after birth, when skin is most immature. When these patients require chronic ventilation, timely ETT adjustments (by 0.5 cm increments based on advancing age) can prevent UEs.
Footnotes
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