Implementation Strategies Used to Reduce Unplanned Extubations in the Neonatal ICU

Background: Unplanned extubation (UE) is the premature or unintended removal of an artificial airway and can cause worse patient outcomes. Study objectives were to describe implementation strategies used to reduce UE in the Hospital for Sick Children neonatal ICU (NICU) and their influence on UE rates, and contributing factors and patient characteristics of infants who had an UE, and compare them between the biological sexes. We hypothesized that the boys would experience more UEs and worse outcomes compared to the girls. Methods: The single-center retrospective cohort study included all infants who experienced UE (2007-2019). Outcomes consisted of implementation reduction strategies developed by using the plan-do-study-act quality-improvement methodology and UE characteristics, including patient (eg, sex, length of stay) and unplanned extubation situation characteristics (eg, events and/or procedures, repeats). Five plan-do-study-act cycles were implemented. Analyses included text summaries of all strategies, and quantitative descriptive and comparative statistics. Results: UE per 100 ventilator days decreased from 3.46 to 0.14. Key success factors included setting achievable goals; ensuring that strategies were evaluated and amended; maintaining consistency over the long-term; incorporating strategies in the NICU; having institutional support and validation; and having good communication. There were 302 UE in 257 infants, 141 boys (55%), average ± SD gestational age of 31 ± 6 weeks, and 31 (12%) had 45 repeated UEs. The only significant difference between the biological sexes was that more boys (129 [92%]) versus girls (94 [83%]) received the Hospital for Sick Children NICU endotracheal tube taping protocol (P = .030). The incidence of UE occurred in a 2-peaked pattern, highest for those < 32 weeks and ≥ 32 weeks of gestational age. Infants < 32 weeks of gestational age and with repeated UE had longer durations of invasive mechanical ventilation and length of stay. For infants <32 versus => 32 weeks gestational age, the median (interquartile range) duration of mechanical ventilation was 38 (16-77) d versus 6 (3-13) d and hospital length of stay 61 (30-100) d versus 16 (10-41) d. For infants with repeated versus no repeated unplanned extubations, duration of mechanical ventilation was 69 (26-125) d versus 13 (4-52) d and hospital length of stay 90 (39-137) d versus 32 (12-75) d. Conclusions: Detailed well-planned UE reduction strategies significantly reduced the rate of UEs with key factors of success identified. UE characteristics and infant morbidity did not differ between the biological sexes. Infants < 32 weeks of gestational age and with repeated UE had a longer duration of mechanical ventilation and length of stay.