Presenter Status
Fellow
Abstract Type
QI
Primary Mentor
Dena Hubbard, MD
Start Date
10-5-2021 11:30 AM
End Date
10-5-2021 1:30 PM
Presentation Type
Poster Presentation
Description
Background/Project Intent (Aim Statement): The objective of this quality improvement project is to decrease unplanned extubations in a Level IV NICU to an annual rate of2020.
Methods (include PDSA cycles): 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 agecycles, we provided education to all members of the multidisciplinary team, we enlisted the Information Technologies Department to create an online application to easily print the relevant information, and we collaborated with unit managers to devise a sustainable and minimally disruptive change to 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 overall UPE rate decreased to 0.7 per 100 vent days. Balancing measures included the frequency of tube position changes, tube re-taping or chest x-rays which did not change or showed a decrease over the study period.
Conclusions: 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. This intervention helped to identify neonates at high-risk before an unplanned extubation occurred so that medical providers could intervene preventively. By collaborating with Information Technologies and unit managers, we were able to devise an approach that is sustainable and with only minimal alterations to unit workflow.
MeSH Keywords
endotracheal intubation; low birth weight infant; quality improvement
Additional Files
Learning from the Past_ A Novel Approach to Reducing Unplanned Ex.pdf (191 kB)Abstract
Included in
Health Information Technology Commons, Higher Education and Teaching Commons, Medical Education Commons, Pediatrics Commons, Science and Mathematics Education Commons
Learning from the Past: A Novel Approach to Reducing Unplanned Extubations in the Neonatal ICU
Background/Project Intent (Aim Statement): The objective of this quality improvement project is to decrease unplanned extubations in a Level IV NICU to an annual rate of2020.
Methods (include PDSA cycles): 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 agecycles, we provided education to all members of the multidisciplinary team, we enlisted the Information Technologies Department to create an online application to easily print the relevant information, and we collaborated with unit managers to devise a sustainable and minimally disruptive change to 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 overall UPE rate decreased to 0.7 per 100 vent days. Balancing measures included the frequency of tube position changes, tube re-taping or chest x-rays which did not change or showed a decrease over the study period.
Conclusions: 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. This intervention helped to identify neonates at high-risk before an unplanned extubation occurred so that medical providers could intervene preventively. By collaborating with Information Technologies and unit managers, we were able to devise an approach that is sustainable and with only minimal alterations to unit workflow.
