Improving Unplanned Extubation Rates in Critically Ill Neonates and Children: Pathway to Sucess

Abstract

Background:

Unplanned extubation (UE), defined as unexpected dislodgement, accidental or patient-induced, of an ETT, is a significant patient safety concern, including risk of aspiration, O₂ desaturation, and cardiopulmonary decompensation. In 2016, UE rates exceeded the Solutions for Patient Safety (SPS) national benchmark of 0.68 and 1.48 events per 100-patient-ventilator-days (PVD), respectively, in our PICU and NICU.

Methods:

Preventative strategy bundles were developed through PDSA cycles to decrease UE including standardized anatomical reference points; ETT securement methods; airway care practices; extubation readiness; and analysis of each UE. Staff received education on key interventions through electronic learning modules, skills labs, and education at the bedside. New product trials led to adopting a standardized taping method and securement devices for all ETTs ≥ 5.0 mm ID. Protective airway practices include visualization of ETT placement and securement at each hand-off. Two licensed practitioners are required during patient movement; one dedicated to hold the ETT. Ventilated patients are assessed each shift for extubation readiness. If criteria met, a spontaneous breathing trial is conducted. Results are discussed and documented during hand-off and daily rounds. A multidisciplinary apparent cause analysis form was developed and utilized for every UE, followed by a bedside huddle, where the team identifies contributing factors, morbidities, and processes and interventions to promote patient safety.

Results:

Both ICUs continue to demonstrate improvements over time compared to our baseline UE rate and the SPS benchmark. In the NICU, UE rates were significantly better than the 2016 baseline every year after 2018 (P < .001), to a low of 0.52 (95% confidence interval 0.31-0.87) in 2021. In PICU, progressive improvement occurred over time with UE rates dropping to 0.10 (95% confidence interval 0.03-0.38) by 2020, statistically significantly better than our 2016 baseline (P = .02) and the 2020 SPS benchmark (P = .03). No UE serious harm events have occurred in the last 29 consecutive months.

Conclusions:

Interdisciplinary collaboration significantly reduced our UE rates and serious patient harm by developing a culture of safety around artificial airway protection using an evidence-based airway protection bundle, standardized ETT securement practices and extubation readiness evaluation aided in UE reduction rates. Intervention compliance monitored through data collection monthly.