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. 2024 Jan;59(1):45-52.
doi: 10.1016/j.jpedsurg.2023.09.029. Epub 2023 Sep 22.

Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project

Peter Juviler  1 , Jeffrey M Meyers  2 , Elizabeth Levatino  3 , Jessica Axford  2 , Erin Barker  2 , Lynnie Correll  4 , Andrew S Decker  5 , John Faria  6 , Marjorie Gloff  4 , Anthony Loria  3 , Margo McKenna  6 , Jan Schriefer  2 , Timothy P Stevens  2 , Sarah Verna  3 , Sarah Wegman  7 , Kori Wolcott  3 , Derek Wakeman  8
Affiliations

Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project

Peter Juviler et al. J Pediatr Surg. 2024 Jan.

Erratum in

Abstract

Background: Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year.

Methods/intervention: A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods.

Results: Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019-June 2022, n = 145) compared to the pre-intervention group (January 2016-August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001].

Conclusions: Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness.

Type of study: Prospective Quality Improvement.

Level of evidence: Level III.

Keywords: Neonate; Opioid stewardship; Pediatric surgery; Quality improvement; Unplanned intubation.

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Conflict of interest statement

Disclosures and conflicts of interest The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. DW has a patent pending that is not related to the content of this manuscript. The authors have no additional conflicts of interest to report.

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