Reducing Unplanned Extubations in the Neonatal ICU Through Plan-Do-Study-Act Cycles and Quality Improvement Methods

Background: Unplanned extubation (UE) is the unintended dislodgement or removal of an ET tube not ordered by the medical team. UE is the fourth most common adverse event in NICUs and has become a quality indicator for patient safety. UE is associated with hypoxia, ventilator associated pneumonia, intraventricular hemorrhage, cardiopulmonary arrest, risk of multiple intubations and increased number of ventilator days. The aim of this quality improvement (QI) project is to reduce the UE rate in NICU patients from 1.5 UE events/100 ventilator days in the year 2015 to Methods: A key driver diagram was created with the following primary drivers: 1. Standardized security of the ET tube by trialing various taping methods, review of chest radiograph and ET tube placement and established RT competency training and review; 2. Standardized care of the intubated infant requiring two clinicians to reposition, standardized infant position for chest radiograph and review sedation with the medical team; 3. Reviewed UE events by completed safety report, completed audit tool, debriefed in real time and reviewed events at multidisciplinary unit council and division meetings; 4. Extubation readiness assessment through an RT driven ventilator protocol and reviewed ventilator parameters prior to UE if infant did not require re-intubation. The process measures are compliance with the completion of an audit sheet for every UE. The outcome measure is the rate of UE/100 ventilator days. Our team reports the date of the last UE at the NICU9s daily safety huddle. Plan-Do-Study- Act (PDSA) cycles were performed during this effort. Results: The outlier data point January 2015 is a special cause variation, which required re-education on how to evaluate if an infant is intubated during a hypoxic event prior to removal of the ET tube. The U chart shows an unstable process in the UE rate during 2016. Standardization and trials of different taping methods led to a lower UE rate until February 2017 when an alternative tape was erroneously stocked in the NICU and removed. The UE has improved to Conclusions: PDSA cycles enable rapid test of change and troubleshooting on the frontline. Due to our short interval data review process, we were able to detect special cause variations and act quickly with interventions. Using QI methods enabled the improvement of UE.