Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit: The Elusive Benchmark

Unplanned extubation (UE) is a common adverse event in the neonatal intensive care unit (NICU). At our level IV NICU, we initiated a quality improvement project in 2012 to reduce UE rates from 7.47 to below 100 intubated days. We describe the strategies used.

Multiple plan-do-study-act cycles were performed to address key drivers. Important interventions focused on staff education, consistent use of a new endotracheal (ET) tube securing device, 2 providers during bedside activities, documentation of ET tube position, and targeted sedation. Process measures included immediate root cause analyses for UE events and the use of the endotracheal tube securing device. The primary outcome was the UE rate per 100 intubated days.

Over a nearly 6-year study period, quarterly UE rates decreased from 7.19 to 0.66 per 100 intubated days. The proportion of neonates requiring reintubation remained stable (64%-76%). Rates of root cause analysis completion and use of the ET securing device were more than 90% in the last 3 years of the study. The majority (61%) of UE events occurred in infants with birth weights greater than 2 kg, and 46% of infants had a prior UE. UE was associated with desaturation (50%), bradycardia (22%), and the need for resuscitation (7%).

This quality improvement effort in a level IV NICU achieved a reduction in UE rates to below 1 per 100 intubated days after more than 5 years. Consistency in practices and widespread communication with the staff was critical to the effort.