Setting the Stage: A Culture Change in Prevention of Un-Planned Extubation and Decreasing Serious Harm in Pediatric Patients

Abstract

Background:

Unplanned extubations are serious harm. Serious harm is directly related to increased length of stay, increased time on the ventilator, increased ICU time and increased risk of cardiovascular collapse and death. Over the past few years we worked to change the culture, create buy in, and engage all disciplines to decrease the amount of serious harm. This past year we have focused on specific pieces of an UE bundle, the key drivers, and interventions. Each ICU determined and development a protocol for a standardized approach for securement and placement of the ETT. The bedside providing team works collaboratively to hold each other accountable. We use a high-risk protocol, ensuring that we have a plan in place for any movement of the patient or manipulation of the ETT. The development of a "knowing note" to share with the caregivers explaining safe kangaroo care, providers at bedside during this time, and kangaroo hold simulations. The care provided is a team driven approach with real time bedside huddles, plans of care and consistent messaging. Everyone has a chance and is supported to speak up around safety. The Leadership team and the members are multi-disciplinary, and they meet monthly to review the cases and data. This has created engagement of everyone and aids in proving the safest care for our patients. Each unit has developed an extubation readiness tool that is utilized for planning and rounding on the patient. Many of the approaches we implemented are evaluated with our K-Card rounding tool.

Methods:

We used the Solutions for Patient Safety Unplanned Extubation Bundle. The inclusion of a multidisciplinary team and culture change was needed to create buy in for participation, and to decrease serious harm. We evaluated some key metrics to strategize how to overcome barriers, and measure accomplishments. These were used to determine outcomes. Our goal was to decrease the UE rate from 0.66 to 0.63 per 100 vent days (w/o trach) by June 30th, 2020. Every event had a real time huddle, information was gathered and entered into a Red Cap data base. The data was evaluated on a month to month bases and entered into run charts.

Results:

All the initiative have shown a 60% decrease in our overall numbers of UE and have saved over 1.2 million potential dollars that would have been used to care for patients.

Conclusions:

Our measured success related to decreasing unplanned extubations and working towards elimination of serious harm was attributed to the engagement of a multi-disciplinary team.