Impact of a Multidisciplinary Quality Improvement Project in Reducing Adverse Events Associated With Unplanned Extubations

Background: The Newborn and Infant Critical Care Unit (NICCU) at Children9s Hospital Los Angeles is a high acuity, Level 4, neonatal intensive care unit with diverse and complex critical airway pathologies. Unplanned extubations (UE) are the 4th most common adverse events in neonatal intensive care settings in the United States. UE rates ranging from 0.14 UEs/100 ventilation days to 5. 3 UEs/100 ventilation days have been recently reported at this institution. However, through a rigorous quality improvement project, we improved the UE rates from 0.77 to 0.5 UE/100ventilator days (VD) and have sustained positive outcomes. Methods: Prospective data collection (with root cause analysis of each UE) was collected from the beginning of 2014 until February 2017 (Phase 1). In November/December 2016, a multidisciplinary UE team was created and discussed goals and interventions to address the data collected. Over the course of 2017 multiple interventions, each completed with Plan-Do-Study-Act (PDSA) methodology, were implemented (Phase 2). Interventions such as education and standardization of endotracheal tube securement, developmental tools, and infant positioning practices were developed. The leadership team comprised of physicians, a nursing manager, and respiratory mangers conducted weekly bedside audits. A rigorous automated tool was created for real time data capture and weekly audits. UE rates and the yearly mean were evaluated monthly alongside important adverse events associated with UE. Comparison of adverse events and their risk factors were done using Chi-square and t-tests as appropriate. Results: Over this 4-year period, there were 144 UEs with UE rates varying between 0 to 1.1 UE/100 VD (Figure 1). During Phase 2, there was approximately a 50% reduction (0.60 in Phase 1 vs 0.32 in Phase 2, p value= 0.02). The number of cardiopulmonary resuscitation events was also reduced by more than 50% (0.09/100VD in Phase 1 vs 0.04/100VD in Phase 2, P=0.12). Causes of UE changed over time with a reduction in unwitnessed UE and UE due to agitation (Figure 2). Conclusions: UE is associated with significant morbidity. Using a multidisciplinary QI project team approach, we have reduced the rates of UE and the associated adverse events.