Quality improvement activities in an NICU: Stop UNplanned eXtubation (SUNX)

A target unplanned extubation (UE) rate of <1/100 ventilator days has been recommended. Our hospital has 21 NICU beds (12 beds in NICU 2 and 3 for extremely low birth weight [ELBW] infants). In 2020, we experienced an abrupt UE increase, leading to the initiation of the Stop UNplanned eXtubation (SUNX) project. At that time, UE rate was 1.30/100 ventilator days. The aim of the SUNX project was to keep the low UE rate.

We collected data on UE rates from April 2019 to March 2024. The intervention was implemented through Plan-Do-Study-Act cycles. Cause analysis with the Pareto chart led to the drivers, we had to deal with: judicious use of sedations, Endotracheal tube (ETT) tape loosening, and stuff number during infant care. Additionally, we did simulation training for sudden SpO₂ decrease and UE event review. We also gathered data about ELBW infant admission and their NICU stay.

The UE rate in total NICU was kept lower than 1/100 ventilator days after the intervention. After our intervention, we found no special cause variation. It meant that our intervention was not statistically significant. However, our intervention gradually penetrated into the NICU daily practices; judicious use of sedation, ETT tape template, body position change by two nurses, UE event review, and so on. We continued a systematic approach to preventing UE.

Although abrupt UE increase in 2020 might be a special cause variation, SUNX activities brought us systematic approach for UE prevention.