Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit Utilizing Quality Improvement Methodology

Unplanned extubations (UEs) are a common adverse event among neonatal patients and can be associated with significant morbidity. Our level IV neonatal intensive care unit (NICU) UE rate was 1.33 events/100 ventilator days, which exceeded published rates. In response, our interdisciplinary quality improvement (QI) team developed targeted interventions aiming to reduce the institutional UE rate to be in alignment with the published Solutions for Patient Safety centerline (0.6 events/100 ventilator days).

Baseline UE events in the pre-intervention period (2020 and 2021) were compared with events after implementation of interventions (2022 and 2023). Targeted interventions were implemented via Plan-Do-Study-Act cycles and included a formalized UE huddle process, leadership rounding, Kamishibai cards to measure UE bundle adherence, standardized endotracheal tube (ETT) securement process, and annotated ETT depth on chest radiographs. The primary outcome measure was UE rate (events/100 ventilator days). Additional process measures included tracking UE bundle adherence and contributing cause event analysis.

In the preintervention period, 2020 and 2021, 100 and 87 UE events were recorded, respectively. One year after implementation of the first interventions (2022), events decreased to 48 with an additional decrease to 35 in 2023. When comparing 2023 with 2020, a 65% reduction in annual UE events was noted with a centerline shift from 1.33 to 0.77/100 ventilator days.

Utilizing QI methodology to drive interventions significantly reduced annual UE events and rate in a level IV NICU. Standardized practices, interdisciplinary collaboration, and thorough discussion highlighting the preventability of UE events were critical to this project's success.