066 - A Methodical and Multidisciplinary Approach to Reducing Unplanned Extubations in a Level IV NICU

Publication Number: 66.3612

Ashley Reed, Children's Health, Dallas, TX, United States; Rebecca Palmer, Children's Health, Dallas, TX, United States; Jeanne R R. Gaines, Children's Health, Waxahachie, TX, United States; Jerithea Tidwell, Children's Health Dallas, Dallas, TX, United States; Veronica G. Contreras, Childrens Health, DALLAS, TX, United States; Nimrod Otieno, Children's Health, Dallas, TX, United States; Reed E.. Graham, Childrens medical center, FORT WORTH, TX, United States; Travis Reynolds, Children's Health, Rockwall, TX, United States; Aprilyn Hilton, Childrens Health System of Texas - - Dallas, TX, dallas, TX, United States; Alice Figueroa, Childrens Medical Center Dallas, North Richland Hills, TX, United States; Prabhjot Kaur, Children's Medical Center Dallas, Wylie, TX, United States; courtney J. Campbell, UTSW, Frisco, TX, United States; Renea Powell, Children's Health, Campbell, TX, United States; Syed T. Ahmed, University of Texas Southwestern Medical School, Dallas, TX, United States; Sushmita Yallapragada, University of Texas Southwestern Medical School, Dallas, TX, United States

Background: Unplanned extubations (UE) in neonates can result in severe consequences such as airway obstruction, hypoxia, respiratory distress, and even death. It is crucial to prevent UEs to maintain stable breathing, minimize the need for reintubation, and improve outcomes for neonates in the neonatal intensive care unit (NICU).

Our multidisciplinary team in the Level IV NICU at Children’s Health has been working to prevent UEs since 2017. In 2022, our UE rate spiked to 0.50 UEs/100 vent days which prompted our team to reinvigorate our work. The team conducted an evaluation to identify factors that contributed to UE events and found that over 50% of patients were not being reintubated post-event (Figure 1).

Objective: Reduce UEs to 0.40 UEs/100 vent days by December 31, 2024.

Design/Methods: Several interventions addressing the causal buckets (Figure 2) were implemented in 2022-2023 (FIgure 3): (1) x-ray annotations of ETT tube depth (June 2022) (2) candy cane taping on neobars (July 2022) (3) auditing of ETT securement (December 2022) (4) updated high-risk airway cards (February 2023) (5) sedation escalation (March 2023) (6) taping for patients over 4 kilograms (April 2023) (7) clamp-down event signage to ensure an ETT tube would not be pulled without proper intervention (October 2023) (8) x-ray provider escalation algorithm (December 2023).

In 2023, the team implemented a standardized post-event response apparent cause analysis (ACA) huddle within one-hour post-event. A bedside review would take place, within 7-10 days, to discuss and identify key process improvements and lessons learned that was disseminated to the rest of the unit.

Implementation involved timely planning over months of creating guidelines, flowcharts and extending education in various formats (in person, virtual and email correspondence) to all disciplines in the NICU.

Results: From January to June 2023, our UE rate was 0.62 UEs/100 vent days which was reduced to 0.25 UEs/100 vent days from July to December. We ended 2023 with an overall rate of 0.48 UEs/100 vent days. The current rate for 2024 is 0.38 UE/100 vent days.

Conclusion(s): An evidence-based, multi-disciplinary approach is essential to the success of reducing UEs. Multiple interventions targeted contributing factors within specific causal buckets that proved effective in decreasing the rate of UEs.

Next steps include a sedation guideline for intubated patients awaiting tracheostomy placement, participating in the SPS NICU cohort initiative focusing on proactive safety huddles, a standardized extubation readiness test (ERT), and securement options for patients < 1500 grams.

Reintubated vs Not Reintubated
Figure 1: Reintubated vs Not Reintubated within 1 hour of Unplanned Extubation from 2021 to 2024.

Causal Buckets for Unplanned Extubations
Figure 2: 2022 and 2023 Causal Buckets for Unplanned Extubations

Unplanned Extubation Rate and Interventions
Figure 3: Unplanned Extubation Rate and Interventions from January 2022 through September 2024.

Reintubated vs Not Reintubated
Figure 1: Reintubated vs Not Reintubated within 1 hour of Unplanned Extubation from 2021 to 2024.

Causal Buckets for Unplanned Extubations
Figure 2: 2022 and 2023 Causal Buckets for Unplanned Extubations

Unplanned Extubation Rate and Interventions
Figure 3: Unplanned Extubation Rate and Interventions from January 2022 through September 2024.