P2D131: Experiences of a Multidisciplinary QI Team in Reducing Unplanned Extubation with a Phased Approach in a Large Level IV NICU

Purpose/Objectives: Unplanned extubation (UE) in the Neonatal Intensive Care Unit (NICU) is a matter of substantial safety hazard and is increasingly recognized as an important quality indicator of patient safety in the NICU. UE increases the risk of short-term and long-term complications. The NICU at Maria Fareri Children's Hospital is a 54-bed level IV NICU. Prior to the initiation of this Quality Improvement(QI) project in the first quarter of 2021, there was no formal system in place to audit or minimize the occurrences of UE in the unit. Our SMART aim was to decrease the rate of UE by 10% from the baseline within 12 months from January to December 2022.

Design/Methods: An interdisciplinary QI team was formed. The definition of UE was standardized. All UE were identified using an Apparent Cause Analysis (ACA) form. ACA form was used to identify the causes related to UE and key areas for improvement. Interventions were implemented in a step-by-step fashion and reviewed monthly using the model for improvement. (Figure 1)The causes of UE were at least biannually analyzed using Pareto charts. A run chart was used to share the monthly data with the entire division and to identify the special cause variation

Results: During the period spanning from March 2021 to December 2021, the total number of UE was 103, with a monthly frequency ranging from 0 to 14 events. Concurrently, the total number of ventilator days was 5,338, with a monthly range of 61 to 437 days. Thus, our baseline UE rate was calculated to be 2.3 per 100 ventilator days. Retaping, bedside cares, and position change was identified as the primary contributors to over 50% of the UE events. Other potential contributing factors included increased secretions, suctioning, and agitation, among others. 86% of the recorded events necessitated reintubation.

By the end of 2022, we observed a significant reduction in the rate of UE. From August 2022, the rates have remained below the median of 2.3 per 100 ventilator days for 7 consecutive months, indicating a special cause variation ‘shift’ in the system. (Figure 2)Over the 6 months period, our rate of UE was 1 per 100 ventilator days. This was a significant improvement from the pre-intervention period. The aggregate rate of UE was reduced by 39 % by the end of December 2022 (from 2.3 in 2021 to 1.5/100 ventilator days).

Conclusion/Discussion: A significant UE rate reduction was achieved by continuously evaluating high-risk factors and ensuring the implementation of best practices in a sequential manner. This QI initiative provides a roadmap to tackle a serious safety event in the NICU with a well-organized and phased quality improvement tool. It underlines the importance of shared decision-making to tackle long-standing system problems and improve outcomes.