RT Journal Article
SR Electronic
T1 A Multidisciplinary Approach to Pediatric UE Documentation and Notification Using a Hospital Wide Unplanned Extubation Leadership Group
JF Respiratory Care
FD American Association for Respiratory Care
SP 3951226
VO 68
IS Suppl 10
A1 Massa, Kelly
A1 Stump, Angela
A1 McMahon, Kimberly
A1 Keith, James
A1 Zamora, Arlene
A1 Hoffmann, Alana
A1 Burr, Katlyn
YR 2023
UL http://rc.rcjournal.com/content/68/Suppl_10/3951226.abstract
AB Background: Unplanned extubations (UE) are defined as an uncontrolled and accidental removal of a breathing tube and is an essential quality indicator in pediatric critical care that contributes to patient health outcomes. In many studies, quality improvement (QI) projects have been shown to make positive impacts to hospital inadvertent events such as UE. In previous QI projects utilizing the Solution for Patient Safety (SPS) guidelines, our institution (244 bed pediatric hospital, Level 1 Trauma Center, Level IV NICU) has created post UE swarms, UE prevention education, and standardized the handling and securement of endotracheal tubes hospital wide however we still experienced gaps in the documentation and notification process of UE occurrence. We aimed to review the effect on reporting and recording UE events in real time after initiation of a UE leadership workgroup. Methods: A multi-disciplinary UE leadership QI workgroup was created in January 2023 and included Physicians (NICU and PICU), Patient Safety, and Respiratory therapists (RT). This workgroup standardized the post UE swarm form and included check offs for documentation and notification post UE. The workgroup also updated their documentation of UE rate by recording unit based and hospital rate of UEs to further find common causes. Our institution’s Quality and Safety Dashboard was linked to our electronic medical record (EMR) system to pull patient data (Figure 1). More precise reasons for extubation were added as documentation options. An IRB-except review of UE reporting, documentation and rate were analyzed pre and post implementation of the UE leadership's group focused efforts. Results: In 2022, our institution saw 12 UE events and 9 were recorded appropriately in the EMR resulting in a 75% reporting rate. Since implementation of the UE leadership workgroup in 2023, we have seen 6 total UE events with 100% reporting rate. Comparing quarter 1 of both years, we have increased our recording rate from 50% in 2022 to 100% in 2023. UE rates remained below SPS benchmark pre/post implementation (Figure 2). Conclusions: Focused efforts of a hospital wide UE leadership group resulted in increased documentation of notification of UE events in our pediatric hospital. The UE leadership group has raised awareness and decreased siloed unit-based work so efferently it is being expanded to the enterprise. Further research on UE documentation and notification in other populations must be completed. Figure 1 details the UE dashboard/report driven from EMR documentation.Figure 2 displays the UE rate per unit and hospital for 2022 and 2023.