091 - PRUDENT- A quality improvement project on Prevention of Unplanned Extubation in Neonates
Friday, April 25, 2025
5:30pm – 7:45pm HST
Publication Number: 91.6205
Mohan B Krishnamurthy, Joan Kirner Women's & Children's Sunshine hospital, Victoria, Australia, Clyde North, Victoria, Australia; Gillian W. Foo, Western Health, Melbourne, Victoria, Australia; Mei Wan Lee, Western health, Sunshine West, Victoria, Australia; Amy Goodwin, Western Health, Melbourne, Victoria, Australia; Sopania Khun, Western Health, Melbourne, Victoria, Australia
Neonatologist Joan Kirner Women's & Children's Sunshine hospital, Victoria, Australia Clyde North, Victoria, Australia
Background: Unplanned extubation (UE) is an important preventable adverse event in the neonatal intensive care unit. UE places an already vulnerable patient at risk of hypoxia and may result in short and long-term morbidities. The universal UE rate is targeted at < 1 per 100 intubation days. There are several modifiable risk factors contributing to UE. Objective: This quality improvement project aims to improve practices to prevent UE in neonates. Design/Methods: We identified current gaps in practice through a questionnaire-based survey conducted in Newborn Services (NBS) along with review of data from 2023. The key components of change were identified and measures were taken to improve practice. These include consistent reporting and review of events around UE, endotracheal tube (ETT) securement technique, review of the related guidelines with inclusion of additional resources (photos), development of an ETT cot card and an airway awareness poster (Image 1) to reinforce our practices. Results: Questionnaire based survey showed that 90% of staff felt (Image 3) that the UE occurred in a NICU setting and were due to inadequate ETT securement (54%), a very active baby (32%), suboptimal ETT position (10%), blocked ETT (2%). Most of the UE were said to occur during cares or changing position of the neonate (56%), kangaroo care (20%) or ETT retaping (17%) Analysis of available data for 2023, showed 6 UE events in total of 327 intubation days (UE rate 1.83 per 100 intubation days). Loose ETT tapes and occurrence during ETT retaping or kangaroo care were leading causative factors (Image 2). Following staged implementation of the practice changes with ongoing education, review of 2024 data (Image 3) at the time of abstract submission has shown a reducing trend in the UE rate from 5.08 to 1.39 per 100 intubation days (January to September 2024).
Conclusion(s): The PRUDENT project has helped to identify key components contributing for UE and implementation of practice changes has demonstrated a reduction in the unit’s UE rate. Future endeavours would focus on assessment of compliance and consideration of alternative ETT securement devices (e.g. neobar) for extreme preterm neonates along with ongoing education and data review.
ETT Cot card and PRUDENT education poster Image 1.pdfImage 1
