A Quality Improvement Approach to Reduce Unplanned Extubation in the NICU While Avoiding Sedation and Restraints

Area of Science:

• Neonatal Intensive Care
• Patient Safety
• Quality Improvement

Background:

• Unplanned extubation (UE) is a frequent adverse event in neonatal intensive care units (NICUs).
• UE can lead to serious complications, including airway trauma and increased mortality.
• The NICU aimed to optimize neurodevelopmental outcomes by encouraging skin-to-skin care and discouraging sedation/restraints for intubated infants.

Purpose of the Study:

• To decrease the rate of unplanned extubation (UE) in intubated infants.
• To reduce UE from 1.85 to 1.5 per 100 endotracheal tube (ETT) days.
• To implement a quality improvement initiative within a neurodevelopmentally focused NICU setting.

Main Methods:

• A multidisciplinary team conducted biweekly reviews of UE events, categorizing them as preventable or nonpreventable.
• Key interventions included assigning a single process owner for UE reporting and standardizing endotracheal tube (ETT) securement procedures.
• Utilizing two clinical staff members during patient and/or ETT manipulation was implemented.

Main Results:

• Initial enhanced detection led to a temporary increase in UE rates (1.85 to 3.26 per 100 ETT days).
• Identification of preventable events and staff empowerment reduced UE frequency to 2.03 per 100 ETT days.
• Standardizing ETT taping methods initially caused a spike due to non-compliance, but improved securement methods led to favorable trending.

Conclusions:

• Reducing UE in a NICU that prioritizes neurodevelopmental care and avoids sedation/restraints presents unique challenges.
• A multidisciplinary quality improvement approach, coupled with accurate event capture, effectively reduced UE rates.
• Standardization of endotracheal tube securement proved to be the most impactful intervention for decreasing UE.