Background:
Throughout 2016 and 2017, Hassenfeld Children’s Hospital (HCH) at NYU Langone implemented the first four solutions for patient safety (SPS) factors for unplanned extubation (UE) prevention, including (1) standardized anatomic reference points and securement methods; (2) protocol for high-risk situations; (3) multidisciplinary apparent cause analyses; and (4) active discussion of extubation readiness. Despite an initial decrease in our UE rate (number of events per 100 ventilator days) from 1.22 in 2017 to 0.53 in 2018, we continued to have multiple events, particularly in the neonatal intensive care unit (NICU). From 2019 to 2020, we saw an increase in our UE rate from 0.52 to 0.60.
Objectives:
We aimed to reduce our UE rate further by implementing strategies beyond the SPS bundle elements, specifically in the NICU where the majority of our events occurred.
Methods:
We implemented the following additional strategies: (1) modified the NICU-specific protocol for UE prevention based on event reviews and staff feedback; (2) required respiratory therapist presence at rounds for all intubated patients; (3) standardized respiratory therapist progress notes for documentation of endotracheal tube securement and discussion of extubation readiness; (4) implemented UE Kamishibai (“K”) Card audits for high-risk situations; (5) mandated high-risk signage at the head of the bed for all intubated NICU patients specifying the reason the patient is high risk; and (6) held a UE prevention boot camp for the frontline NICU staff and UE champions.
Results/Figures/Tables:
Following the institution of additional targeted strategies in 2020, we saw a steady decline in our UE rate, particularly in the NICU. In 2021, HCH achieved an annual UE rate of 0.49 UEs per 100 ventilator days. In 2022, we reduced our annual UE rate even further to 0.35 and as of June 2023, the current UE rate for the year is 0.05 UEs per 100 ventilator days.
Conclusions/Implications:
Compliance with prevention bundles and established protocols declined over time. Existing prevention bundles must be audited and modified based on the review of events and user feedback. Creating a culture where all staff feel accountable for preventing a UE requires consistent re-education and reinforcement.
Footnotes
Supplemental digital content is available for this article. Clickable URL citations appear in the text.
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
To cite: Dapul H, Basile C, Verma S, Alessi S, Malizia R, Haines E. Beyond the Bundle: Reducing Unplanned Extubation Rates after Implementation of SPS Factors. Pediatr Qual Saf 2024;9:e694.