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

Bertoni, C Briana; Bartman, Thomas; Ryshen, Gregory; Kuehne, Brandon; Larouere, Marissa; Thomas, Leslie; Wishloff, Erin; Shepherd, Edward G.; Dillard, Julie; Pavlek, Leeann R.; Moallem, Mohannad

doi:10.1097/pq9.0000000000000346

Cited by 8 publications

(11 citation statements)

References 17 publications

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“…Given the potential short- and long-term consequences of UEs and the associated increased healthcare costs, UE prevention has become an important focus of quality improvement (QI) efforts for NICU patients. Because single-center QI initiatives have been successful in reducing UEs in the NICU [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ] and one NICU among our regional perinatal centers (RPC) had been working to improve UE locally without much success, we proposed a multi-center QI collaborative as a model to drive improvement.…”

Section: Introductionmentioning

confidence: 99%

Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

et al. 2022

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Background: Unplanned extubations (UEs) occur frequently in the neonatal intensive care unit (NICU). These events can be associated with serious short-term and long-term morbidities and increased healthcare costs. Most quality improvement (QI) initiatives focused on UE prevention have concentrated efforts within individual NICUs. Methods: We formed a regional QI collaborative involving the four regional perinatal center (RPC) NICUs in upstate New York to reduce UEs. The collaborative promoted shared learning and targeted interventions specific to UE classification at each center. Results: There were 1167 UEs overall during the four-year project. Following implementation of one or more PDSA cycles, the combined UE rate decreased by 32% from 3.7 to 2.5 per 100 ventilator days across the collaborative. A special cause variation was observed for the subtype of UEs involving removed endotracheal tubes (rETTs), but not for dislodged endotracheal tubes (dETTs). The center-specific UE rates varied; only two centers observed significant improvement. Conclusions: A collaborative approach promoted knowledge sharing and fostered an overall improvement, although the individual centers’ successes varied. Frequent communication and shared learning experiences benefited all the participants, but local care practices and varying degrees of QI experience affected each center’s ability to successfully implement potentially better practices to prevent UEs.

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Section: Introductionmentioning

confidence: 99%

Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

et al. 2022

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“…The containment of patients with band restraint was already prohibited in our institution and strongly criticised in the literature about its use. 26 28 29 The project team was in search of a model that would provide a less restrictive alternative, and the challenge was to find a national company that would manufacture a model similar to those used internationally, which was a great differential in the way of providing adequate restriction and comfortable in the paediatric population, that is, effective according to best practices. These new models provide limitations in movements with restriction of elbow flexion and pinch of the fingers with comfort and prevention of accidental exit of the traction devices.…”

Section: Discussionmentioning

confidence: 99%

“…25 Adequacy of sedation is a subject that presents many challenges because sedation for the prevention of agitation and consequently the prevention of UE can lead to excessive levels of sedation, increasing the duration of mechanical ventilation and length of hospital stay. 26 According to Society of Critical Care Medicine Clinical Practice Guidelines Finding a balance between oversedation and undersedation is paramount. That guideline suggests the use of COMFORT-B scale to evaluate the ideal depth of sedation, the same scale used for our study.…”

Section: Discussionmentioning

confidence: 99%

Quality improvement project to reduce unplanned extubations in a paediatric intensive care unit

et al. 2023

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BackgroundUnplanned extubations are recurrent adverse events in mechanically ventilated children and have been the focus of quality and safety improvement in paediatric intensive care units (ICUs).Local problemTo reduce the rate of unplanned extubation in the paediatric ICU by 66% (from 2.02 to 0.7).MethodsThis is a quality improvement project that was conducted in a paediatric ICU of a private hospital at the quaternary level. All hospitalised patients who used invasive mechanical ventilation between October 2018 and August 2019 were included.InterventionsThe project was based on the Improvement Model methodology of the Institute for Healthcare Improvement to implement change strategies. The main ideas of change were innovation in the endotracheal tube fixation model, evaluation of the endotracheal tube positioning, good practices of physical restraint, sedation monitoring, family education and engagement and checklist for prevention of unplanned extubation, with Plan–Do–Study–Act, the tool chosen to test and implement ideas for change.ResultsThe actions reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 2 years, totalling 743 days without any event. An estimate was made comparing cases with unplanned extubation and controls without the occurrence of this adverse event, which resulted in savings of R$955 096.65 (US$179 540.41) during the 2 years after the implementation of the improvement actions.ConclusionThe improvement project conducted in the 11-month period reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 743 days. Adherence to the new fixation model and the creation of a new restrictor model, which enabled the implementation of good practices of physical restraint were the ideas of change that had the greatest impact in achieving this result.

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“…Previous studies have mainly focused on strategies to reduce the incidence of unplanned extubation (UE) of the endotracheal tube (ETT). Unplanned extubation (UE) or accidental displacement of the ETT can cause common adverse effects in patients, including lung collapse, cardiovascular instability, trauma to the upper respiratory tract, ventilator-associated pneumonia, and so on [17]. A study including 182 neonates requiring mechanical ventilation in Australia showed that the UE rate in the neonatal population was 4.75 per 100 days of ventilation [18].…”

Section: Discussionmentioning

confidence: 99%

“…Subsequently, the team implemented various interventions in the NICU to prevent unplanned removal, such as changing the ETT taping method, increasing the contact surface area of the adhesion, and avoiding loose securement. After implementation of quality improvement approaches, the incidence of UEs decreased dramatically while avoiding the need for sedation and restraints [23].…”

Section: Discussionmentioning

confidence: 99%

Risk factors associated with the initial unplanned removal of orogastric tubes in NICU: A Single Center Study in China

Fang

Dai

Liu

et al. 2023

Preprint

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Background: Newborns, in particular, are at higher risk for unplanned removal of orogastric tubes (UROGTs). Because there is a lack of studies identifying the incidence and risk factors for UROGTs in China, we designed this case‒control study to investigate them. Method: This study was conducted in China. A total of 111 neonates who received orogastric tubes between October 2022 and February 2023 were analyzed. Univariate and multivariate logistic models were used for risk factor analyses. Results: The rate of UROGTs was 56.8%, and the incidence was 7.2 per 100 tube days. An increased risk of UROGTs was associated with higher agitation scores (OR=17.82, P=0.001), no oral feeding (OR=0.02, P=0.007), fixation tape loosening (OR=22.75, P=0.027) and tape wetting (OR=12.6, P=0.021). Conclusions: The incidence of UROGTs was found to be significantly higher than that of endotracheal tube extubation. The risk factors were higher agitation scores, no oral feeding, fixation tape loosening and tape wetting.

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

Abstract: Supplemental Digital Content is available in the text.

Cited by 8 publications

References 17 publications

Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

Quality improvement project to reduce unplanned extubations in a paediatric intensive care unit

Risk factors associated with the initial unplanned removal of orogastric tubes in NICU: A Single Center Study in China

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