Unplanned extubation (UE) is one of the most significant patient safety issues in the neonatal intensive care unit (NICU), with consequences including airway trauma, cardiopulmonary resuscitation, and in rare cases, death. Importantly, there are evidence-based practices that can prevent UEs from occurring.
Observing an increase of UEs in the NICU at NewYork-Presbyterian and Weill Cornell Medicine prompted NICU staff to pursue a quality improvement initiative (QI) to uncover the extent and root causes of the problem and implement solutions needed to produce and sustain change.
Led by NewYork-Presbyterian and Weill Cornell Medicine neonatologist Emily Ahn, M.D., neonatologist Sean Cullen, M.D., Ph.D., and overseen by principal investigator neonatologist Priyanka Tiwari, M.D., the project involved a multidisciplinary collaboration to reduce UEs through a standardized care bundle emphasizing consistency in reporting, documentation, and communication among all NICU staff.
Below, Dr. Ahn and Dr. Cullen discuss the rationale for their QI project and the process they followed that resulted in a dramatic reduction in unplanned extubations.
The number of UE events declined from 80 in 2019 to 10 in 2022, and we achieved a sustained reduction of UEs to <1 per 100 ventilator days.
— Dr. Emily Ahn
Identifying the Scope of the Unplanned Extubation Events
Dr. Ahn: During my first month in fellowship in the NICU, I vividly remember an event with a very critically ill newborn whose endotracheal tube dislodged. A colleague reinserted the tube, but the baby required increased support. This very serious event became the impetus for me to look at how often this occurred with our NICU infants. I partnered with Dr. Tiwari, who had already begun gathering information on the issue of unplanned extubations. After reviewing background data, we found it was a large problem that could use a dedicated team to focus on it.
Dr. Cullen: If you speak to anybody who has worked in a NICU, they will definitely have a lasting memory of the code bell sounding and what that means to anyone actively working on the unit. You are instantly thrust into an adrenaline-fueled response because a baby is in need of immediate coordinated care from many different team members to bring them back to a stable position.
In the first phase of our QI project, we dove deep into our policies and found that there were no standard guidelines on how to document UE events and how to communicate its details throughout the NICU. We realized that different members or teams in the unit had varying policies of how they recorded and documented UE events, so we were not capturing the full extent of the problem. To establish the actual number of occurrences, we had to first consider each documentation method used by those in the NICU.
Dr. Ahn: Approximately 700 infants are admitted annually to our NICU of which an average of 71 infants are at <32 weeks gestation — an extremely preterm population. In our level IV regional NICU, we determined UEs secondary to tube dislodgement were a target for improvement given that our rate was more than twice the benchmark goal of <1 per 100 ventilator days. Our goal was to reduce the rate of UEs from a baseline of 2.3 per 100 ventilator days to <1.
Developing a Quality Improvement Plan
Dr. Ahn: Our QI initiative focused on implementing a systematic approach that would include formalizing documentation and data collection on these events, standardizing endotracheal tube taping procedures, and developing a debrief guide to analyze each unplanned extubation event.
The strength of our QI project is that it spanned more than four years, with interventions tested during a time of numerous transitions for the unit. We are proud that this initiative adds to the growing body of literature on UE reduction.
— Dr. Sean Cullen
Dr. Cullen: Our multidisciplinary QI team included attending physicians, nurses, nursing management, respiratory therapists, QI specialists, radiology technicians, and family advisory council members. We enlisted our medical trainees for data collection and analysis, education of staff on interventions, and ensuring proper implementation. Our QI team met monthly to discuss interventions and review UE events. QI team members also participated in working groups, including the regional and national Children’s Hospitals’ Solutions for Patient Safety (SPS) Network to share resources and consider recurrent issues. The QI process we established consisted of:
- Standardizing the UE protocols, which included adherence to a modified, site-specific UE care bundle derived from the SPS network
- Manual recording of the UE events by a fellow
- Nursing input of details of each UE into the hospital-wide reporting system
- Respiratory therapist completion of the Apparent Cause Analysis (ACA) form
- Dissemination of information at unit-wide staff meetings
- Just-in-time feedback and education workshops regarding adherence to the UE prevention bundle elements
- Implementing standardized method for taping endotracheal tubes utilizing simulation training for front-line staff
- Creation of a post-event debrief guide to maintain UE classification, discuss patient specific prevention measures, promote shared common language, and facilitate onboarding of new staff
- Improvement of inter-shift communication through implementation of a bedside airway card and x-ray annotation with ETT securement distance
Achieving a Marked Reduction in UE Events
Dr. Ahn: Through the QI initiative, we saw significant improvements. The number of UE events declined from 80 in 2019 to 10 in 2022, and we achieved a sustained reduction of UEs to <1 per 100 ventilator days. The most impactful interventions were attributed to multidisciplinary engagement and active involvement of our medical trainees, the development of a standardized care bundle, and the creation of the debrief guide.
In addition, involving attendings, fellows, nursing, and respiratory therapists in the QI process raised their awareness of UE risks. We also found that it was very important to have a designated person on each shift who could be called upon as an expert in these events — study champions — which then allowed for continuity and consistency in reporting and documenting UE occurrences. Study champions provided a constant clinical presence to ensure fidelity of the implemented changes and also obtain real-time feedback on adjustments to improve outcomes. Key factors in our success were maintaining consistency in practices across day and night shifts, empowering the study champions to provide leadership and ensure compliance with standards, and the team’s relentless commitment to continuous improvement and patient safety.
Unplanned extubations are a major concern for every NICU. With the success of our initiative, we hope that other units are inspired to explore how a multidisciplinary quality improvement project can accomplish a reduction of a major patient safety event such as an unplanned extubation.
— Dr. Emily Ahn
Dr. Cullen: Not only did this multifaceted QI initiative lead to a significant reduction in UE rates, it also prompted us to change the unit’s overall goal to achieve less than 0.5 events per 100 ventilator days — down from our previous goal of 1 per 100 days. The strength of our QI project is that it spanned more than four years, with interventions tested during a time of numerous transitions for the unit. We are proud that this initiative adds to the growing body of literature on UE reduction using the SPS bundle, while also adding new interventions developed by our QI NICU team.
The team has since collaborated extensively with other NICU teams within the NewYork-Presbyterian enterprise, and we have all presented our findings in national forums, including the Pediatric Academic Societies and the Academic Pediatric Association’s Quality Improvement meetings.
Dr. Ahn: Unplanned extubations are a major concern for every NICU. With the success of our initiative, we hope that other units are inspired to explore how a multidisciplinary quality improvement project can accomplish a reduction of a major patient safety event such as an unplanned extubation.
