A Methodical and Multidisciplinary Approach to Reducing Unplanned Extubationin a LevelIV NICU

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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). The multidisciplinary NICU UE team has been working to prevent UEs since 2017. After an increase in 2022, the team conducted an evaluation to identify potential gaps and discovered over 50% of patients were not being reintubated post-event. Identified factors that contributed to UE events were: infants with weight
Methodology: A multidisciplinary team of NICU stakeholders implemented several interventions addressing the causal buckets of our UEs in 2022. ETT x-ray annotations, candy cane taping on neobars, and auditing of ETT securement were implemented. After reviewing causal buckets for 2023, airway cards were updated to identify high-risk patients; sedation concerns were escalated; implemented taping for patients over 4 kilograms; posted clamp-down event signage to prevent premature pulling of an ETT. Created x-ray provider escalation algorithm to promote immediate adjustment of mispositioned ETT. In 2023, the team implemented a standardized post-event response apparent cause analysis (ACA) huddle. Bedside reviews were held 7-10 days post event. Key process improvements and lessons learned were discussed and disseminated.
Outcomes: 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. 2023 year end rate was 0.48 UEs/100 vent days. By April 2024, our UE rate was 0.28 UEs/100 vent days. An evidence-based, multi-disciplinary approach contributed to the reduction of UEs in the NICU. Next steps are discussed.