Reducing Unplanned Extubations in the NICU

Abstract

Background:

Unplanned extubation and re-intubations are not benign events and have been well noted to increase the risk of adverse events. To reduce unplanned extubation we adopted strict care standards to be followed in order to reach our set goal in reducing unplanned extubations per patient ventilator days. Many look to the securing device for blame on unplanned extubation, however we hypothesis adopting a strict care standard would be the key in our success and not the altering of the securing the device.

Methods:

Every unplanned extubation (UE) between Jan 2013 and August 2016 was reviewed to establish the average rate of UE per patient ventilator day and to identify when and how each event occurred in order to determine root cause. Mandatory NICU RCP staff meetings were held to share analysis and to determine the root causes. Staff was tasked to identify practice variations and create standardized process improvements. A "Save My Airway" questionnaire form was created in order for every UE to be examined in real time explaining how the UE occurred and how it could have been prevented. This was then shared with all the NICU RCP's to evaluate and assess for potential solutions as a group. NICU Staff presented and evaluated each UE as a group for Performance Improvement. New Standards of Care were implemented, monitored, and modified after each UE. Each UE was analyzed by using the Pareto chart and each month was analyzed using control charts.

Results:

Baseline data showed a 3.5-year average of 56 ventilator days per unplanned extubation (UE) and the goal was set to achieve 70. During the year of the P. I. Project we were able to improve by 168% to 150 ventilator days per UE. By continuous monitoring post P. I. project, we continued to improve and make further gains and are currently at 259 ventilation days per UE, which is a 363% improvement.

Conclusions:

The key to reducing unplanned extubations in the NICU was the implementation of the "New Standards of Care" changing the staff's awareness and bedside practice along with the reporting of each individual UE with the 'Save My Airway' questionnaire. As per our hypothesis we were able to exceed our goal and continue to maintain and improve without any change to the securing device. The change in culture has solidified our practice and sustainability. When indexed to 1 UE per 100 patient ventilator days our current rate is 0.38 which exceeds the suggested benchmark rate of <1 UE per 100 patient ventilator days.