724 - A Quality Improvement Project to Reduce Unplanned Extubations In a Level III NICU

Poster Number: 724
Publication Number: 724.342

Hanine Hajj, Pediatrix, Houston, TX, United States; Kimberly D. Seelke-Hernandez, Pediatrix, Beeville, TX, United States; Cassandra Adair, Travel Nurses Across America (TNAA), Humble, TX, United States; Emily S. Sausley, HCA Houston Northwest, Houston, TX, United States; Jennifer Rawls, HCA Healthcare Houston Northwest, Spring, TX, United States; Craig Steiner, Pediatrix, College Station, TX, United States; David L. Weisoly, Pediatrix Medical Group of Houston, Spring, TX, United States

Background: Unplanned extubations (UEs) are a source of morbidity and mortality in the neonatal intensive care unit. We conducted a quality improvement project to reduce the rate of UEs at an urban level III NICU with 3500+ newborn deliveries per year.

Objective: To determine the baseline UE rate in our NICU and implement a quality initiative with a goal to reduce the rate to < 1 UE per 100 ventilator days.

Design/Methods: Baseline UE data was collected from October 2020 to March 2021. The quality improvement project was launched in April 2021 and data was analyzed quarterly. To date, the project has included 5 Plan-Do-Study-Act cycles. Intervention consisted of the implementation of an UE Prevention Bundle. The bundle included the following: standardizing endotracheal tube (ETT) taping technique, standardizing the reference to ETT depth, defining an unsecure ETT with appropriate management, and standardizing positioning of an intubated patient including mandatory involvement of 2 or 3 caregivers for specific position changes and procedures. Initial education was provided to all NICU nurses, respiratory therapists (RTs), neonatal nurse practitioners and neonatologists. Education included a power point presentation, and hands-on taping simulation on a newborn mannequin. Airway cards and audit sheets were utilized at every intubated patient’s bedside. A detailed UE debriefing sheet was filled for each UE event. Subsequent steps included re-education of newer staff members, improving communication between nurses and RTs with more specific role assignments, as well as focus on optimal handling of intubated patients during skin-to-skin care.

Results: Average ventilator days for the duration of the quality initiative was 43 ventilator days per quarter. Review of the audit sheets showed an overall compliance rate of 96.7% (9 missed audits sheets out of 275 ventilator days). Baseline UE rate was 9.6 UE per 100 ventilator days as of March 2021. UE rates for the subsequent 7 quarters since launching the project were as followed: 5.0, 3.2, 4.2, 0, 0, 2, and 0 UE per 100 ventilator days. Rate was decreased to 1 UE for the last 100 ventilator days as of November 2022. Circumstances of the 1 unplanned extubation in the last 100 ventilator days happened while infant was receiving skin-to-skin care with mother.

Conclusion(s): Our quality improvement project was successful in reducing UEs in a single center level III NICU. Key steps in achieving our goal were implementation of an UE Prevention Bundle, as well as extensive staff education and involvement.