Reducing Unplanned Extubations Across a Children's Hospital Using Quality Improvement Methods

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.

Fig. 1.

Key driver diagram outlined the aims, 4 main drivers, and interventions of the project to reduce UEs. The solid boxes are those completed, while the dotted box represents drivers not yet completed. KDD, key driver diagram; CHSPS, Children’s Hospital’s Solutions for Patient Safety.

Fig. 2.

SPC chart demonstrates 8 successive points below the baseline mean during the implementation period, indicating special cause. Implementation of interventions including safety culture, bedside reminders, tape trials, joining national collaborative, standard securement, and high-risk protocols are marked. The solid line represents the baseline average, and red dotted lines represent the control limits while the gray line indicates the target rate. LCL, lower control limit; UCL, upper control limit; YNHCH, Yale-New Haven Children’s Hospital.

Fig. 3.

SPC charts demonstrating the rate of UEs in the pediatric (A) and neonatal (B) ICUs from 2015 to 2018. The pediatric ICU had a shift in the mean in May 2017, while the neonatal ICU had a shift early on in July 2015. The solid line represents the baseline average, and red dotted lines represent the control limits, while the gray line indicates the target rate. LCL, lower control limit; UCL, upper control limit.

Fig. 4.

SPC chart demonstrating the overall compliance with process bundles of care related to ET tube securement and monitoring. The solid line represents the baseline average and red dotted lines represent the control limits. LCL, lower control limit; UCL, upper control limit.