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Melton K, Lee A, Macartney J, Montgomery V, Nock M, Sisson P, Cooper I, Lyren A, Wood L. Reducing Pediatric Unplanned Extubation: A National Quality Improvement Collaborative. Pediatrics 2025; 155:e2024068304. [PMID: 40288779 DOI: 10.1542/peds.2024-068304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 02/11/2025] [Indexed: 04/29/2025] Open
Abstract
OBJECTIVE Unplanned extubation (UE) is a significant cause of harm for pediatric patients. Hospitals working with a quality improvement collaborative, Solutions for Patient Safety, tested and developed a UE bundle that demonstrated significant UE reduction after implementation. The objective of this study was to spread the UE bundle to a large number of children's hospitals using workgroups to facilitate bundle implementation for UE reduction. METHODS Pediatric hospitals implemented the UE bundle in their neonatal, pediatric, and cardiac intensive care units and submitted data on their UE rate (UE number per ventilator days) and reliability to the bundle. Participating hospitals were divided into smaller workgroups that were used to identify barriers to bundle implementation, measurement, and maintenance. Workgroups were used to facilitate peer-to-peer discussion and sharing of resources, tools, and ideas. RESULTS Eighty-three hospitals participated in workgroups between January 2020 and July 2023. During that time, the overall network rate of UE was reduced from 0.662 UE events per 100 ventilator days to 0.53 UE events per 100 ventilator days, representing a 19.9% reduction in UE events. After participating in workgroups, 53 hospitals (74%) experienced significant UE rate reductions or a significant increase in reliability to the bundle. Most hospitals maintained stable UE rates and reliability. Barriers to bundle implementation and auditing were identified and addressed in the workgroups. CONCLUSIONS The use of workgroups was an effective method to facilitate bundle spread, support group learning, and provide resources to promote improvement efforts in a large improvement collaborative. Through structured improvement methods, children's hospitals have continued to decrease the rate of UE.
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Affiliation(s)
- Kristin Melton
- Cincinnati Children's Hospital and the University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anthony Lee
- Nationwide Children's Hospital, Columbus, Ohio
| | | | | | - Mary Nock
- UH Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Patsy Sisson
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ingrid Cooper
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anne Lyren
- UH Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Children's Hospitals' Solutions for Patient Safety (SPS)
| | - Lara Wood
- Children's Hospitals' Solutions for Patient Safety (SPS)
- Seattle Children's Hospital, Seattle, Washington
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Golden A, Neel ML, Goode R, Alrifai MW, Hatch LD. Association of unplanned extubations and neurodevelopmental outcomes in very low birthweight infants. J Perinatol 2024:10.1038/s41372-024-02203-y. [PMID: 39733197 DOI: 10.1038/s41372-024-02203-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 12/04/2024] [Accepted: 12/16/2024] [Indexed: 12/30/2024]
Affiliation(s)
- Alexandra Golden
- Vanderbilt University School of Medicine, Nashville, TN, USA.
- Department of Pediatrics, Weill Cornell Medical Center, New York, NY, USA.
| | - Mary Lauren Neel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Rachel Goode
- Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Wael Alrifai
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Clinical Informatics Center (VCLIC), Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Research and Innovation in Systems Safety (CRISS), Vanderbilt University Medical Center, Nashville, TN, USA
| | - L Dupree Hatch
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Ibrahim L, Deghidy J, Kanth B, Fazlullah H, Layug A, Abid I, Gad AI. Unplanned Extubation in Extremely Preterm Neonates: Incidence, Risk Factors, and Impact on Clinical Outcomes. Cureus 2024; 16:e73688. [PMID: 39677257 PMCID: PMC11646050 DOI: 10.7759/cureus.73688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2024] [Indexed: 12/17/2024] Open
Abstract
Background Unplanned extubation (UE) poses a significant safety risk to mechanically ventilated, preterm, and critically ill neonates in the neonatal intensive care unit (NICU). Objective The aim of this study was to evaluate the incidence of UE from January 2018 to December 2021, identify contributing risk factors, and compare the outcomes with a cohort of extremely preterm (EP) infants. Methods A retrospective study was conducted in the NICU at the Women's Wellness and Research Center, Hamad Medical Corporation in Qatar. The study included 25 EP neonates who experienced UE events. The characteristics and outcomes of these infants were compared with a matched cohort of 75 EP infants without UE, selected using propensity score matching at a ratio of 1:3 to balance key baseline characteristics. This study was initiated in early 2018 following the introduction of a care improvement bundle that integrated various care practices and involved multiple healthcare staff. Results We recorded 25 UE events in our cohort of 507 EP neonates, totaling 5,668 invasive ventilation days. The incidence of UE events was 0.44 per 100 ventilation days over the four-year period, ranging from 0.60 in 2018 to 0.27 in 2020. UE occurred mainly during routine care activities (24%), due to agitation (20%), or during endotracheal tube manipulation (20%). Following a UE event, 64% of the neonates required positive pressure ventilation, and 88% were reintubated. Comparisons between the UE and non-UE groups revealed that UE was associated with significantly higher rates of bronchopulmonary dysplasia (BPD) (91.3% vs. 59.6%, p = 0.006), severe BPD (34.8% vs. 8.8%, p = 0.008), and increased postnatal steroid use (72.0% vs. 18.7%, p < 0.001). Neonates in the UE group had significantly longer hospital stays (127.0 days (IQR: 112.0-183.2) vs. 101.0 days (IQR: 90.0-139.5), p = 0.010), a higher median discharge postmenstrual age (42.8 weeks (IQR: 41.1-50.4) vs. 40.1 weeks (IQR: 37.3-46.6), p = 0.006), and a higher rate of receptive neurodevelopmental delays (50.0% vs. 19.5%, p = 0.009). Conclusion Neonates who experienced UE faced an increased risk of adverse respiratory and neurodevelopmental outcomes, including higher rates of BPD, increased postnatal steroid use, and longer NICU stays. This highlights the critical role of nursing care and continuous quality improvement efforts in the NICU to prevent UE.
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Affiliation(s)
- Linda Ibrahim
- Women's Wellness and Research Center, Hamad Medical Corporation, Doha, QAT
| | - Jihan Deghidy
- Women's Wellness and Research Center, Hamad Medical Corporation, Doha, QAT
| | - Bilal Kanth
- Women's Wellness and Research Center, Hamad Medical Corporation, Doha, QAT
| | - Habeebah Fazlullah
- Women's Wellness and Research Center, Hamad Medical Corporation, doha, QAT
| | - Apple Layug
- Women's Wellness and Research Center, Hamad Medical Corporation, Doha, QAT
| | - Iqra Abid
- Department of Respiratory Medicine, Sidra Medicine, Doha, QAT
| | - Ashraf I Gad
- Women's Wellness and Research Center, Hamad Medical Corporation, Doha, QAT
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Yager H, Tauzin M, Durrmeyer X, Todorova D, Storme L, Debillon T, Casagrande F, Jung C, Audureau E, Layese R, Caeymaex L. Respiratory outcomes and survival after unplanned extubation in the NICU: a prospective cohort study from the SEPREVEN trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:586-593. [PMID: 38636983 PMCID: PMC11503181 DOI: 10.1136/archdischild-2023-326679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To compare reintubation rates after planned extubation and unplanned extubation (UE) in patients in neonatal intensive care units (NICUs), to analyse risk factors for reintubation after UE and to compare outcomes in patients with and without UE. DESIGN Prospective, observational study nested in a randomised controlled trial (SEPREVEN/Study on Epidemiology and PRevention of adverse EVEnts in Neonates). Outcomes were expected to be independent of the intervention tested. SETTING 12 NICUs in France with a 20-month follow-up, starting November 2015. PATIENTS n=2280 patients with a NICU stay >2 days, postmenstrual age ≤42 weeks on admission. INTERVENTIONS/EXPOSURE Characteristics of UE (context, timing, sedative administration in the preceding 6 hours, weaning from ventilation at time of UE) and patients. MAIN OUTCOME MEASURES Healthcare professional-reported UE rates, reintubation/timing after extubation, duration of mechanical ventilation, mortality and bronchopulmonary dysplasia (BPD). RESULTS There were 162 episodes of UE (139 patients, median gestational age (IQR) 27.3 (25.6-31.7) weeks). Cumulative reintubation rates within 24 hours and 7 days of UE were, respectively, 50.0% and 57.5%, compared with 5.5% and 12.3% after a planned extubation. Independent risk factors for reintubation within 7 days included absence of weaning at the time of UE (HR, 95% CI) and sedatives in the preceding 6 hours (HR 1.93, 95% CI 1.04 to 3.60). Mortality at discharge did not differ between patients with planned extubation or UE. UE was associated with a higher risk of BPD. CONCLUSION In the SEPREVEN trial, reintubation followed UE in 58% of the cases, compared with 12% after planned extubation. TRIAL REGISTRATION NUMBER NCT02598609.
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Affiliation(s)
- Helene Yager
- Faculty of Health, Paris Est Creteil University, 94000 Creteil, Val de Marne, France
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Creteil, 94000 Creteil, Val de Marne, France
| | - Manon Tauzin
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Creteil, 94000 Creteil, Val de Marne, France
- Délégation de Recherche en Santé et Innovation, Centre Hospitalier Intercommunal de Creteil, 94000 Creteil, France
| | - Xavier Durrmeyer
- Faculty of Health, Paris Est Creteil University, 94000 Creteil, Val de Marne, France
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Creteil, 94000 Creteil, Val de Marne, France
| | - Darina Todorova
- Service de Néonatologie, Centre Hospitalier René-Dubos, 95300 Pontoise, France
| | - Laurent Storme
- Clinique de Médecine Néonatale, Hopital Jeanne de Flandres, CHRU de Lille, Pôle Femme Mère et Nouveau-né, Lille, 59000, France
- Centre d’Investigation Clinique Pédiatrique, Hopital Jeanne de Flandres CHRU de Lille, 59000 Lille, France
| | - Thierry Debillon
- Service de Néonatologie, CHU de Grenoble, Grenoble, France
- Université Grenoble Alpes, Grenoble, France
| | - Florence Casagrande
- Service de Néonatologie, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Camille Jung
- Délégation de Recherche en Santé et Innovation, Centre Hospitalier Intercommunal de Creteil, 94000 Creteil, France
| | - Etienne Audureau
- Service de Santé Publique, Unité de Recherche Clinique (URC Mondor), Assistance Publique-Hôpitaux de Paris AP-HP, Hopital Henri Mondor, F-94010 Creteil, France
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France
| | - Richard Layese
- Service de Santé Publique, Unité de Recherche Clinique (URC Mondor), Assistance Publique-Hôpitaux de Paris AP-HP, Hopital Henri Mondor, F-94010 Creteil, France
| | - Laurence Caeymaex
- Faculty of Health, Paris Est Creteil University, 94000 Creteil, Val de Marne, France
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Creteil, 94000 Creteil, Val de Marne, France
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García H, Ramos-Soto DI, Miranda-Novales G, Luna-Santos L. Prevalence of unplanned extubation in a tertiary care neonatal intensive care unit. J Trop Pediatr 2024; 70:fmae039. [PMID: 39394777 DOI: 10.1093/tropej/fmae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2024]
Abstract
Orotracheal intubation and mechanical ventilation (MV) have become routine practices in intensive care units. Unplanned extubation (UE) is one of the most important complications, particularly in premature infants and critically ill newborns. The objective of this study was to determine the prevalence of UE in a tertiary care neonatal intensive care unit (NICU). In this analytical cross-sectional retrospective study, all data, including perinatal data, indications for ventilatory support, days of MV at the time of UE, work shift, month of the event, reintubation, and postextubation complications, were obtained from the manual review of clinical charts. In total, 151 neonates, who received invasive MV, were included in this study. The prevalence of UE was 2.0/100 days of ventilation. The most affected were premature infants, with a gestational age of ≤ 32 weeks (54.7%) and a birth weight of ≤ 1500 g. The main cause for UE was deficient fixation of the endotracheal tube (ETT) (27.7%). Most UE events occurred during night shifts (48.1%). Reintubation was required in 83.3% of newborns. Immediate complications developed in 96.3% of the UE events, including desaturation (57.7%) and bradycardia (36.5%). The prevalence of UE was high, particularly in premature infants, with a high rate of reintubation and immediate complications. Standardized protocols for ETT care must be implemented to reduce these events.
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Affiliation(s)
- Heladia García
- Analysis and Synthesis of Evidence Research Unit, National Medical Center, Mexican Institute of Social Security, CP 06720 Mexico City, Mexico
| | - Dulce Ivonne Ramos-Soto
- Neonatal Intensive Care Unit, Pediatric Hospital, National Medical Center, Mexican Institute of Social Security, CP 06720 Mexico City, Mexico
| | - Guadalupe Miranda-Novales
- Analysis and Synthesis of Evidence Research Unit, National Medical Center, Mexican Institute of Social Security, CP 06720 Mexico City, Mexico
| | - Laura Luna-Santos
- Neonatal Intensive Care Unit, Pediatric Hospital, National Medical Center, Mexican Institute of Social Security, CP 06720 Mexico City, Mexico
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Krishnan P, Jawale N, Sodikoff A, Malfa SR, McCarthy K, Strickrodt LM, D’Agrosa D, Pickard A, Parton LA, Singh M. Synergizing Safety: A Customized Approach to Curtailing Unplanned Extubations through Shared Decision-making in the NICU. Pediatr Qual Saf 2024; 9:e729. [PMID: 38751892 PMCID: PMC11093562 DOI: 10.1097/pq9.0000000000000729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/24/2024] [Indexed: 05/18/2024] Open
Abstract
Background Unplanned Extubation (UE) remains an important patient safety issue in the Neonatal Intensive Care Unit. Our SMART AIM was to decrease the rate of UE by 10% from the baseline from January to December 2022 by emphasizing collaboration among healthcare professionals and through the use of shared decision-making. Methods We established an interdisciplinary Quality Improvement team composed of nurses, respiratory therapists, and physicians (MDs). The definition of UE was standardized. UE was audited using an apparent cause analysis form to discern associated causes and pinpoint areas for improvement. Interventions were implemented in a step-by-step fashion and reviewed monthly using the model for improvement. A shared decision-making approach fostered collaborative problem-solving. Results Our baseline UE rate was 2.3 per 100 ventilator days. Retaping, general bedside care, and position change accounted for over 50% of the UE events in 2022. The rate of UE was reduced by 48% by the end of December 2022. We achieved special-cause variation by the end of March 2023. Conclusions The sole education of medical and nursing providers about various approaches to decreasing unnecessary retaping was ineffective in reducing UE rates. Shared decision-making incorporating inputs from nurses, respiratory therapists, and MDs led to a substantial reduction in the UE rate and underscores the potential of systematic evaluation of risk factors combined with collaborative best practices.
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Affiliation(s)
- Parvathy Krishnan
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Nilima Jawale
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
- Department of Pediatrics, State University of New York Upstate Medical University
| | - Adam Sodikoff
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Susan R. Malfa
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Kathleen McCarthy
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Lisa M. Strickrodt
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Diana D’Agrosa
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Alexandra Pickard
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Lance A. Parton
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
| | - Meenakshi Singh
- From the Department of Neonatal-Perinatal Medicine, Westchester Medical Center, and New York Medical College, Valhalla, N.Y
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Kim F, Eckels VB, Brachio SS, Brooks C, Ehret C, Gomez G, Shui JE, Villaraza-Morales S, Vargas D. Use of an airway bundle to reduce unplanned extubations in a neonatal intensive care unit. J Perinatol 2024; 44:314-320. [PMID: 38242961 DOI: 10.1038/s41372-024-01879-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Following the opening of an infant cardiac neonatal intensive care unit, our aim was to determine a baseline UE rate and implement initiatives to target a goal less than 0.5 UEs/100 ventilator days. METHODS We utilized the Model for Improvement. Key stakeholders included neonatal providers, nurses, and respiratory therapists. We focused on the creation of an airway bundle that addressed securement methods, communication and education. RESULTS From October 2017 to January 2018, our baseline UE rate was 0.92 UEs/100 ventilator days. Subsequent to the implementation of an airway bundle with high compliance, we observed a significant change in the centerline (0.45 to 0.02 UEs/100 ventilator days) during the spring of 2021, followed by a period of 480 days with no UEs. CONCLUSION In a unit where UEs were infrequent events, high compliance with an airway bundle led to a significantly sustained decrease in our UE rates.
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Affiliation(s)
- Faith Kim
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA.
- Columbia University Irving Medical Center, New York, NY, USA.
| | - Victoria Blancha Eckels
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Sandhya S Brachio
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
| | - Cristina Brooks
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Caitlin Ehret
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Gloria Gomez
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Jessica E Shui
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sylvia Villaraza-Morales
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Diana Vargas
- Division of Neonatology, Department of Pediatrics, NewYork- Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
- Columbia University Irving Medical Center, New York, NY, USA
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8
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Chahin N, Yitayew MS, Shaver L, Reed JL, Ridore M, Santoro J, Moores RR, Soghier L, Short B, Hendricks-Muñoz KD. A quality improvement strategy to reduce unintended extubation in the very low birth weight infant: A case report. J Neonatal Perinatal Med 2024; 17:199-207. [PMID: 38457156 DOI: 10.3233/npm-230063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Unintended extubations remain a common complication across neonatal intensive care units, with very low birthweight infants being the most vulnerable of them all. Ongoing efforts across different institutions exist with the goal of reducing the rate of unintended extubations to keep a median rate of <2 events per 100 ventilator days as defined by the Vermont Oxford Network. Our objective was to reduce unintended extubations in the very low birthweight infant in a large delivery hospital to ≤2/100 ventilator days. METHODS A collaborative group was formed between two academic health institutions targeting training and implementation of the Children's National unintended extubation system, focusing on endotracheal tube securement methods and surveillance protocols. RESULTS The unintended extubation rate decreased from 3.23 to 0.64 per 100 ventilator days. Changes were implemented from 2018-2020 with a sustained reduction in the unintended extubation rate of 1.54 per 100 ventilator days. Most events occurred between 12 : 00 pm -4 : 00 pm and the commonest cause was spontaneous (25%) followed by dislodgment during repositioning (19%). CONCLUSION Very low birth weight infants present a challenge to endotracheal tube maintenance due to their developmental and anatomical changes during their neonatal intensive care unit stay. Successful reduction of unintended extubations in the very low birthweight infant can be achieved by adaptation of successful protocols for older infants.
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Affiliation(s)
- N Chahin
- Children's Hospital of Richmond at VCU and School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - M S Yitayew
- Children's Hospital of Richmond at VCU and School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - L Shaver
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - J L Reed
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - M Ridore
- Holtz Children's Hospital, Jackson Health System, Miami, FL, USA
| | - J Santoro
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - R R Moores
- Children's Hospital of Richmond at VCU and School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - L Soghier
- Children's National Hospital, Washington, DC, USA
| | - B Short
- Children's National Hospital, Washington, DC, USA
| | - K D Hendricks-Muñoz
- Children's Hospital of Richmond at VCU and School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
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9
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Bastos de Souza Júnior NW, Rosa TR, Cerântola JCK, Ferrari LSL, Probst VS, Felcar JM. Predictive factors for extubation success in very low and extremely low birth weight preterm infants. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2023; 59:204-213. [PMID: 37781349 PMCID: PMC10540158 DOI: 10.29390/001c.87789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 08/30/2023] [Indexed: 10/03/2023]
Abstract
Background Although invasive mechanical ventilation (IMV) has contributed to the survival of preterm infants with extremely low birth weight (ELBW), it is also associated with unsatisfactory clinical outcomes when used for prolonged periods. This study aimed to identify factors that may be decisive for extubation success in very low birth weight (VLBW) and extremely low birth weight (ELBW) preterm infants. Methods The cohort study included preterm infants with gestational age (GA) <36 weeks, birth weight (BW) <1500 grams who underwent IMV, born between 2015 and 2018. The infants were allocated into two groups: extubation success (SG) or failure (FG). A stepwise logistic regression model was created to determine variables associated with successful extubation. Results Eighty-three preterm infants were included. GA and post-extubation arterial partial pressure of carbon dioxide (PaCO2) were predictive of extubation success. Infants from FG had lower GA and BW, while those from SG had higher weight at extubation and lower post-extubation PaCO2. Discussion Although we found post-extubation PaCO2 as an extubation success predictor, which is a variable representative of the moment after the primary outcome, this does not diminish its clinical relevance since extubation does not implicate in ET removal only; it also involves all the aspects that take place within a specified period (72 hours) after the planned event. Conclusion GA and post-extubation PaCO2 were predictors for extubation success in VLBW and ELBW preterm infants. Infants who experienced extubation failure had lower birth weight and higher FiO2 prior to extubation.
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10
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Liu K, Liu Z, Li LQ, Zhang M, Deng XX, Zhu H. Predictive value of the unplanned extubation risk assessment scale in hospitalized patients with tubes. World J Clin Cases 2022; 10:13274-13283. [PMID: 36683639 PMCID: PMC9851005 DOI: 10.12998/wjcc.v10.i36.13274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/21/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Critical patients often had various types of tubes, unplanned extubation of any kind of tube may cause serious injury to the patient, but previous reports mainly focused on endotracheal intubation. The limitations or incorrect use of the unplanned extubation risk assessment tool may lead to improper identification of patients at a high risk of unplanned extubation and cause delay or non-implementation of unplanned extubation prevention interventions. To effectively identify and manage the risk of unplanned extubation, a comprehensive and universal unplanned extubation risk assessment tool is needed.
AIM To assess the predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale in inpatients.
METHODS This was a retrospective validation study. In this study, medical records were extracted between October 2020 and September 2021 from a tertiary comprehensive hospital in southwest China. For patients with tubes during hospitalization, the following information was extracted from the hospital information system: age, sex, admission mode, education, marital status, number of tubes, discharge mode, unplanned extubation occurrence, and the Huaxi Unplanned Extubation Risk Assessment Scale (HUERAS) score. Only inpatients were included, and those with indwelling needles were excluded. The best cut-off value and the area under the curve (AUC) of the Huaxi Unplanned Extubation Risk Assessment Scale were been identified.
RESULTS A total of 76033 inpatients with indwelling tubes were included in this study, and 26 unplanned extubations occurred. The patients’ HUERAS scores were between 11 and 30, with an average score of 17.25 ± 3.73. The scores of patients with or without unplanned extubation were 22.85 ± 3.28 and 17.25 ± 3.73, respectively (P < 0.001). The results of the correlation analysis showed that the correlation coefficients between each characteristic and the total score ranged from 0.183 to 0.843. The best cut-off value was 21, and there were 14135 patients with a high risk of unplanned extubation, accounting for 18.59%. The Cronbach’s α, sensitivity, specificity, positive predictive value, and negative predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale were 0.815, 84.62%, 81.43%, 0.16%, and 99.99%, respectively. The AUC of HUERAS was 0.851 (95%CI: 0.783-0.919, P < 0.001).
CONCLUSION The HUERAS has good reliability and predictive validity. It can effectively identify inpatients at a high risk of unplanned extubation and help clinical nurses carry out risk screening and management.
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Affiliation(s)
- Kun Liu
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Zheng Liu
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lin-Qian Li
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Meng Zhang
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xue-Xue Deng
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Hong Zhu
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu 610041, Sichuan Province, China
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11
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Nair V, Loganathan PK, Smith H, Lal MK. Outcomes of Preterm Infants Who Experienced Unplanned Extubation. Respir Care 2022; 67:1320-1326. [PMID: 35790395 PMCID: PMC9994326 DOI: 10.4187/respcare.10005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unplanned extubation (UE) is associated with adverse outcomes. The aim of the study was to compare the clinical outcomes in preterm infants who experienced at least one UE to those who did not experience any UE. METHODS The matched cohort study compared ventilated preterm infants < 32 weeks who experienced UE to those who did not experience any UE. The main outcomes were duration of mechanical ventilation after matching, duration of hospital stay, retinopathy of prematurity (ROP) requiring intervention, and bronchopulmonary dysplasia (BPD). RESULTS Forty-seven infants were included in each group. The groups were matched for mechanical ventilation duration before UE, birth gestation, and birthweight. The duration of mechanical ventilation after matching (adjusted odds ratio [aOR] 14.8 [11.2-18.4], P = <.001), the total length of stay in the hospital (aOR 16.4 [3.7-29.2], P = .01), and severe ROP (aOR 6.7 [1.7-27.0], P = .007) were significantly higher in infants who experienced UE. After adjusting for mechanical ventilation duration, UE was not associated with ROP or BPD. However, infants who spent longer time on mechanical ventilation had higher odds of developing ROP (aOR 1.1 [1.0-1.2], P = .004) and BPD (aOR 1.5 [1.1-2.1], P = .01). Sensitivity analysis including infants who had UE and managed on noninvasive respiratory support showed significant association between UE and the outcomes of duration of mechanical ventilation, hospital length of stay, ROP, and BPD. CONCLUSIONS Infants who experienced UE had higher odds of spending longer time on mechanical ventilation and spent significantly more days in the hospital.
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Affiliation(s)
- Vrinda Nair
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom; and Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, England, United Kingdom.
| | - Prakash Kannan Loganathan
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom; Clinical Academic Office, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, England, United Kingdom; and Department of Physics, University of Durham, Durham, England, United Kingdom
| | - Helena Smith
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom
| | - Mithilesh Kumar Lal
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom
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12
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Experiences of a Regional Quality Improvement Collaborative to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit. CHILDREN 2022; 9:children9081180. [PMID: 36010071 PMCID: PMC9406401 DOI: 10.3390/children9081180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022]
Abstract
Background: Unplanned extubations (UEs) occur frequently in the neonatal intensive care unit (NICU). These events can be associated with serious short-term and long-term morbidities and increased healthcare costs. Most quality improvement (QI) initiatives focused on UE prevention have concentrated efforts within individual NICUs. Methods: We formed a regional QI collaborative involving the four regional perinatal center (RPC) NICUs in upstate New York to reduce UEs. The collaborative promoted shared learning and targeted interventions specific to UE classification at each center. Results: There were 1167 UEs overall during the four-year project. Following implementation of one or more PDSA cycles, the combined UE rate decreased by 32% from 3.7 to 2.5 per 100 ventilator days across the collaborative. A special cause variation was observed for the subtype of UEs involving removed endotracheal tubes (rETTs), but not for dislodged endotracheal tubes (dETTs). The center-specific UE rates varied; only two centers observed significant improvement. Conclusions: A collaborative approach promoted knowledge sharing and fostered an overall improvement, although the individual centers’ successes varied. Frequent communication and shared learning experiences benefited all the participants, but local care practices and varying degrees of QI experience affected each center’s ability to successfully implement potentially better practices to prevent UEs.
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13
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Hatch LD, Scott TA, Slaughter JC, Xu M, Smith AH, Stark AR, Patrick SW, Ely EW. Outcomes, Resource Use, and Financial Costs of Unplanned Extubations in Preterm Infants. Pediatrics 2020; 145:peds.2019-2819. [PMID: 32376726 PMCID: PMC7263047 DOI: 10.1542/peds.2019-2819] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Unplanned extubations (UEs) in adult and pediatric populations are associated with poor clinical outcomes and increased costs. In-hospital outcomes and costs of UE in the NICU are not reported. Our objective was to determine the association of UE with clinical outcomes and costs in very-low-birth-weight infants. METHODS We performed a retrospective matched cohort study in our level 4 NICU from 2014 to 2016. Very-low-birth-weight infants without congenital anomalies admitted by 72 hours of age, who received mechanical ventilation (MV), were included. Cases (+UE) were matched 1:1 with controls (-UE) on the basis of having an equivalent MV duration at the time of UE in the case, gestational age, and Clinical Risk Index for Babies score. We compared MV days after UE in cases or the equivalent date in controls (postmatching MV), in-hospital morbidities, and hospital costs between the matched pairs using raw and adjusted analyses. RESULTS Of 345 infants who met inclusion criteria, 58 had ≥1 UE, and 56 out of 58 (97%) were matched with appropriate controls. Postmatching MV was longer in cases than controls (median: 12.5 days; interquartile range [IQR]: 7 to 25.8 vs median 6 days; IQR: 2 to 12.3; adjusted odds ratio: 4.3; 95% confidence interval: 1.9-9.5). Inflation-adjusted total hospital costs were higher in cases (median difference: $49 587; IQR: -15 063 to 119 826; adjusted odds ratio: 3.8; 95% confidence interval: 1.6-8.9). CONCLUSIONS UEs in preterm infants are associated with worse outcomes and increased hospital costs. Improvements in UE rates in NICUs may improve clinical outcomes and lower hospital costs.
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Affiliation(s)
- L. Dupree Hatch
- Division of Neonatology, Department of Pediatrics,,Center for Child Health Policy, and,Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Theresa A. Scott
- Division of Neonatology, Department of Pediatrics,,Center for Child Health Policy, and
| | | | | | - Andrew H. Smith
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics and
| | - Ann R. Stark
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and
| | - Stephen W. Patrick
- Division of Neonatology, Department of Pediatrics,,Center for Child Health Policy, and
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee;,Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee;,Tennessee Valley Geriatric Research Education and Clinical Center, US Department of Veterans Affairs, Nashville, Tennessee
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14
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Hatch LD, Rivard M, Bolton J, Sala C, Araya W, Markham MH, France DJ, Grubb PH. Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations. Jt Comm J Qual Patient Saf 2019; 45:295-303. [PMID: 30583986 PMCID: PMC6491248 DOI: 10.1016/j.jcjq.2018.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patient safety events result from failures in complex health care delivery processes. To ensure safety, teams must implement ways to identify events that occur in a nonrandom fashion and respond in a timely manner. To illustrate this, one children's hospital's experience with an outbreak of unplanned extubations (UEs) in the neonatal ICU (NICU) is described. METHODS The quality improvement team measured UEs using three complementary data streams. Interventions to decrease the rate of UE were tested with success. Three statistical process control (SPC) charts (u-chart, g-chart, and an exponentially weighted moving average [EWMA] chart) were used for real-time monitoring. RESULTS From July 2015 to May 2016, the UE rate was stable at 1.1 UE/100 ventilator days. In early June 2016, a cluster of UEs, including four events within one week, was observed. Two of three SPC charts showed special cause variation, although at different time points. The EWMA chart alerted the team more than two weeks earlier than the u-chart. Within days of discovering the outbreak, the team identified that the hospital had replaced the tape used to secure endotracheal tubes with a nearly identical product. After multiple tape products were tested over the next month, the team selected one that returned the system to a state of stability. CONCLUSION Ongoing monitoring using SPC charts allowed early detection and rapid mitigation of an outbreak of UEs in the NICU. This highlights the importance of continuous monitoring using tools such as SPC charts that can alert teams to both improvement and worsening of processes.
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15
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Kandil SB, Emerson BL, Hooper M, Ciaburri R, Bruno CJ, Cummins N, DeFilippo V, Blazevich B, Loth A, Grossman M. Reducing Unplanned Extubations Across a Children's Hospital Using Quality Improvement Methods. Pediatr Qual Saf 2018; 3:e114. [PMID: 31334446 PMCID: PMC6581473 DOI: 10.1097/pq9.0000000000000114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/19/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Children who require an endotracheal (ET) tube for care during critical illness are at risk of unplanned extubations (UE), or the unintended dislodgement or removal of an ET tube that can lead to significant patient harm. A proposed national benchmark is 1 UE per 100 ventilator days. We aimed to reduce the rate of UEs in our intensive care units (ICUs) from 1.20 per 100 ventilator days to below the national benchmark within 2 years. METHODS We identified several key drivers including ET securement standardization, safety culture, and strategies for high-risk situations. We employed quality improvement methodologies including apparent cause analysis and plan-do-study-act cycles to improve our processes and outcomes. RESULTS Over 2 years, we reduced the rate of UEs hospital-wide by 75% from 1.2 to 0.3 per 100 ventilator days. We eliminated UEs in the pediatric ICU during the study period, while the UE rate in the neonatal ICU also decreased from 1.2 to 0.3 per 100 ventilator days. CONCLUSION We demonstrated that by using quality improvement methodology, we successfully reduced our rate of UE by 75% to a level well below the proposed national benchmark.
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Affiliation(s)
- Sarah B. Kandil
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Beth L. Emerson
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Michael Hooper
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Rebecca Ciaburri
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Christie J. Bruno
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Nancy Cummins
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Virginia DeFilippo
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Beth Blazevich
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Adrienne Loth
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Matthew Grossman
- From the Department of Pediatrics, Yale School of Medicine, New Haven, Conn
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16
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Hatch LD, Scott TA, Rivard M, Rivard A, Bolton J, Sala C, Araya W, Markham MH, Stark AR, Grubb PH. Building the Driver Diagram: A Mixed-Methods Approach to Identify Causes of Unplanned Extubations in a Large Neonatal ICU. Jt Comm J Qual Patient Saf 2018; 45:40-46. [PMID: 30077484 DOI: 10.1016/j.jcjq.2018.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/14/2018] [Accepted: 02/21/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The key driver diagram (KDD) is an important tool used by improvement teams to guide and frame their work. Methods to build a KDD when little relevant literature or reliable local data exist are poorly described. This article describes the process used in our neonatal ICU (NICU) to build a KDD to decrease unplanned extubations (UE) in chronically ventilated infants. METHODS Twenty-seven factors hypothesized to be associated with UE in our NICU were identified. An expert panel of 33 staff members completed three rounds of a modified Delphi process administered through an online interface. After the third round, panel members provided suggestions for interventions to target all factors meeting criteria for consensus. These qualitative data were analyzed by inductive thematic analysis. A follow-up survey to all panel members was used to assess the feasibility of this process for future use. RESULTS After three Delphi rounds, 14 factors met consensus and eight main interventions were identified through thematic analysis. These data were used to build a KDD for testing. All participants who completed the follow-up survey (20/20) stated willingness to participate in this process in the future and 18/20 (90%) stated they would be "more willing" or "much more willing" to support interventions developed using this process. CONCLUSION A novel mixed-methods approach was used to generate a KDD combining a Delphi process with thematic analysis. This approach provides improvement teams a rigorous and reproducible method to understand local context, generate consensus KDDs, and improve local buy-in for improvement interventions.
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