Preventing Unplanned Extubation in Neonatal Intensive Care

Laura A. Stokowski, RN, MS


June 19, 2014

Reducing Unplanned Extubations in the NICU

Merkel L, Beers K, Lewis MM, Stauffer J, Mujsce DJ, Kresch MJ
Pediatrics. 2014 Apr 28. [Epub ahead of print]

A Quality Improvement Project

This quality improvement project was conducted to try to reduce the rate of unplanned extubations (UEs) in mechanically ventilated infants. The first objective was to determine the baseline rate of UEs (unintended dislodgement or removal of an endotracheal [ET] tube) in this neonatal intensive care unit (NICU). A multidisciplinary team then developed bundles of potentially better practices to be implemented sequentially in a series of 5 plan-do-study-act (PDSA) process improvement cycles. These cycles, which ranged in length from 5 to 10 months, included the following:

Cycle 1: Staff education about UEs with an emphasis on security of the ET tube; and a new requirement for at least 2 professional staff to be involved in ET taping and procedures involving moving the infant, such as weighing or transferring the infant out of bed.

Cycle 2: Placement of alert cards at the bedside showing the infant's risk level for a UE and details about the ET tube position. Documentation of ET tube position and security in the medical record was also implemented in this cycle.

Cycle 3: Implementation of a commercially available ET tube securing product rather than conventional taping.

Cycle 4: Development of a tool for real-time UE root cause analysis.

Cycle 5: Improving the safety culture by displaying a large sign showing the number of days since the NICU's last UE. The use of mittens or socks on the hands of larger infants was also implemented during this cycle.

The rate of UE was calculated as the number of UEs per 100 patient-intubated days. The baseline rate of UEs in this NICU was 2.4 per 100 patient-intubated days. The UE rate following each PDSA cycle is shown in the Table.

Table. UE Rates Following PDSA Cycles

PDSA Cycle Practices Implemented Mean UE Rate
1 Staff education; 2-person procedures 0.8
2 Airway alert cards; ET tube documentation 1.4
3 Commercial ET tube-securing product 1.8
4 Real-time UE root cause analysis 1.1
5 Display "days since last UE"; mittens 0.6

ET = endotracheal; PDSA = plan, do, study, act; UE = unplanned extubation

The team found that heightened staff awareness of the problem of UE, adopting standardized methods of ET tube security, and having 2 staff members involved in procedures with intubated patients were most effective in reducing UEs. In cycle 3, the implementation of a commercially available ET tube-securing device (NeoBar®; Neotech; Valencia, California), the UE rate climbed significantly.

This temporary increase in the UE rate associated with this change was attributed to the learning curve necessary for staff to become comfortable and proficient with the use of this device. On the other hand, the PDSA cycle that led to the most significant reduction in the UE rate was the last cycle, involving the implementation of 2 new process changes: a publicly visible progress display and the use of mittens or socks on the hands of infants older than 34 weeks postmenstrual age. The project authors suggest that these changes were effective because they provided constant visual reminders of the risk for UE and the need to follow recommended preventive measures, further strengthening the culture of safety in the NICU.

Identifying the risk for UE and displaying this on a card posted at the bedside served as another visual reminder. Risk for UE in this project took into consideration the likelihood that a UE would occur in a particular infant as well as the chances that the infant might suffer harm should reintubation be necessitated by a UE.

Continuing education of staff was provided incrementally throughout the project by staff experts ("champions"). Real-time analysis of each UE, using a form designed by the researchers, was performed by the staff (registered nurses, respiratory therapists, and physicians) who were caring for the infant at the time of the UE. This enabled the researchers to determine the root causes of UEs and to identify gaps in compliance with the process improvements that had already been implemented.

Generally, UE rates were not affected by unit census or acuity levels of the patients. Staffing levels were not reported. Most UEs occurred in infants weighing 750-1500 g and occurred more frequently on the day shift. Two UEs occurred during transfer of a baby to the mother's chest for skin-to-skin (kangaroo) care.


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