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Background: Unplanned extubations (UPEs) are a cause of significant morbidity and mortality in neonates. Multiple successful interventions had been previously implemented in our NICU including standardized endotracheal tube (ETT) securement procedures, bedside checklists, and multi-disciplinary debriefing. In our unit greater than 65% of UPEs occur in neonates under 1.5kg who are particularly sensitive to small adjustments in tube position. We designed a novel approach to reducing UPEs in this patient population.


Design/Methods: We hypothesized that increased awareness of historical ETT position would both prevent unnecessary ETT position adjustments and encourage prophylactic adjustments to adjust for significant weight gain or loss. In December 2019, we implemented a novel intervention to provide readily accessible graphs of historical ETT tube position in each neonate with corrected gestational age <32 weeks. In successive cycles, education was provided to all members of the multidisciplinary team, the graph was refined into a readily printable format and changes were made to the unit workflow to ensure updated graphs were available at the bedside at every shift.

Results: UPE rates in 2019 prior to the intervention were 1.0 events per 100 vent days. In the 12 months following the intervention and refinements, the UPE rate decreased to 0.76 per 100 vent days. Balancing measures included the frequency of tube position changes, tube re-taping and chest x-rays which did not change or showed a decrease over the study period.

Conclusion(s): By providing ready access to information on historical ETT position, our unit fostered an environment of communication & safety with a sustained and decreasing rate of unplanned extubations.

Presented at the 2021 PAS Virtual Conference



Learning From the Past: A Novel and Sustainable Initiative to Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit

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