003 - Equitable reduction of unplanned extubation, a QI project: Overcoming racial, language and socioeconomic disparity

Publication Number: 3.4749

Gayathri Sreenivasan, Maria Fareri Children's Hospital at Westchester Medical Center, Astoria, NY, United States; Parvathy Krishnan, Floating Hospital for Children at Tufts Medical Center, MA, MA, United States; Lance Parton, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, United States; Meenakshi Singh, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, United States

Background: Unplanned extubation (UE) is an avoidable adverse event in the NICU associated with serious complications. Quality improvement (QI) projects have reported effective UE reduction, but the aspect of equity is often not addressed. QI projects enhance health outcomes, yet the impact on health disparities remains underexplored. Without a focus on equity, QI can exacerbate existing disparities and may unintentionally disadvantage vulnerable populations.

Objective: QI project was initiated in 2021 in Maria Fareri Children’s Hospital NICU, aimed at reducing the occurrence of UE. It targeted the key components of best practice bundle, resulting in 50% reduction of UE rates by the end of 2023 with new centerline of about 1.1 compared to the previous 2.2 per 100 ventilator days, that sustained into 2024. The primary goal of the QI was achieved, and the secondary aim was to ensure equitable reduction in UE, assessing through the lens of self-reported parental race, language and socioeconomic status (SES).

Design/Methods: Each best practice bundle intervention was introduced in sequential manner while ensuring adherence and successful implementation. UE data was gathered and stratified by race, primary language and SES, with type of insurance as a marker of SES. Control chart was created for every variable to appreciate pre-intervention disparity and post-intervention benefit.

Results: Preintervention data showed racial, language and socioeconomic disparity. Caucasian, primary English speakers and Medicaid population were major contributors. Main factors weighing in on UE was addressed in a stepwise manner using model of improvement and comprehensive best practice bundle was implemented by December 2022. Caucasians saw a significant reduction in UE control chart qualifying a shift change, African Americans saw an initial rise followed by subsequent low UE, Hispanic and unspecified race UE remained low. Primary English speakers had a significant reduction in UE control chart qualifying a shift change, while primary non-English UE remained low. There was significant reduction in UE control chart qualifying a shift change in Medicaid population, while Private insurance population remained low. The major contributors of UE saw significant reduction in rates, qualifying a special cause variation starting December 2022, with successful implementation of the best practice bundle.

Conclusion(s): Before the QI initiative, UE rate was higher among Caucasian, primary English speakers and Medicaid-insured patients. Our QI project revealed that standardization effectively reduced UE rates and also aided in reduction of disparity.

Caucasian Population – Control (U) chart
Pre-intervention- Caucasian were contributing 47.2% to total UE and were biggest racial contributor. Post intervention- Caucasian were contributing 25.7% to total UE.

Primary English language – Control (U) Chart


Medicaid insurance – Control (U) chart
Pre-intervention- Medicaid population were contributing 73.6% to total UE and were biggest SES contributor. Post intervention- Medicaid were contributing 58.4% to total UE.