Summary

Mechanically ventilated neonates are prone to unplanned extubation (UE) or accidental extubation causing cardiorespiratory deterioration, hypoxia and need for resuscitation.1 Repeated reintubation may result in airway trauma, subglottic stenosis, prolonged ventilation, prolonged hospital stay and increased risk of infection.2 Studies have shown a variation in the rate of UE in neonatal intensive care unit (NICU) from 1.14 to 5.3 per 100 ventilation days.3 Reasons for the increased incidence of UE in neonates include longer duration of intubation, shorter neonatal tracheal length, less routine use of sedation, procedures such as suctioning, the use of uncuffed endotracheal tubes and the method of fixation due to fragile skin.4 Bedside activities such as weighing, kangaroo care, procedures like line placements, scans/imaging, phlebotomy and transportation of babies are potential risk factors for UE.3 5

The problem

UE is not uncommon in the NICU but we noticed multiple UEs in our NICU leading to re-intubations. This could have serious side effects like cardiorespiratory deterioration and airway trauma.

Aims

The aim of this quality improvement project (QIP) is to reduce the rate of UEs among intubated infants in a tertiary NICU over a period of 24 months.

Your improvements

We identified key drivers to reduce UE (figure 1). We introduced a plan-do-study-act (PDSA) cycle. The first cycle was retrospective data collection over a period of 24 months (September 2019 to August 2021) to identify risk factors and the rate of UE. Common causes for UE were handling during examination followed by vomiting with or without suctioning and during procedures including X-rays (figure 2). The rate of UE was 2 per 100 ventilation days. This data was presented at a local governance meeting and an action plan was developed. The action plan of change of ideas included staff education on risk factors for UE which were: (1) introduction of proforma for each UE, (2) incident reporting of all UEs and (3) dissemination of action plan in governance newsletter. Handling of infants during procedures was standardised by two-person holding technique during X-rays.

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Figure 1

Driver diagram of quality improvement. ETT, endotracheal tube; NICU, neonatal intensive care unit; UE, unplanned extubation.

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Figure 2

Reasons of unplanned extubations. NIPE, newborn and infant physical examination.

In PDSA cycle 2, prospective data was collected over 12 months (March 2022 to February 2023) and the monthly rate of UE was analysed (figure 3). The average rate of UE was 3.19 per 100 ventilation days. The increased rate was because of better data capture by incident reporting of all UEs. The common causes of UEs were different from cycle 1 except vomiting with or without suctioning. These were baby movement, cuddles with parents and while endotracheal tube (ETT) adjustment (figure 2). The reason for new causes was due to the robust implementation of the action plan of the previous cycle, for example, two-person handling during X-rays. Further action plans implemented include, (1) monitoring of ETT position/length of insertion in the new electronic patient record system every 12 hours by nursing staff, (2) surveillance of ETT fixation, (3) two-person holding technique during ETT manipulation, (4) reinforcing parental education on holding intubated babies prior to cuddles and (5) continued staff education by multidisciplinary teaching and simulation.

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Figure 3

Run chart of PDSA cycles showing monthly UE rates. ETT, endotracheal tube; PDSA, plan-do-study-act; UE, unplanned extubation.

In cycle 3 (March 2023 to October 2023), prospective data collection showed a reduction in the rate of UE to 1.75 per 100 ventilated days (figure 3). The use of non-invasive support for stabilisation of preterm infants and less invasive surfactant administration to reduce chronic lung disease may have contributed to a reduction in the number of ventilated days in cycle 3 of QIP. The action plan included: (1) continuing data monitoring of UE and (2) continuing staff education in particular rotating doctors in training. Figure 3 demonstrates a run chart of monthly rates of UE of all three cycles. Table 1 shows the baseline patient’s characteristics of all three cycles.

Learning and next steps

UE in NICU is unavoidable but the rate should be less than 1 per 100 ventilated days. This can be achieved by staff education and regular scrutiny of each UE. Rather than single change in idea, multiple actions implemented in each PDSA cycle have aided to improve the outcome. A shorter duration of PDSA cycles will help in tackling the risk factors sooner. Timely extubation is equally important to reduce the rate of UE. In our QIP, 34.7% in the first cycle, 45.4% in the second cycle and 22% in the third cycle were not re-intubated and managed either by non-invasive ventilation or self-ventilating in the air.

Vigilant data capture is extremely useful for surveillance of UE. The use of a driver diagram is imperative to discover various reasons contributing to UE and implement interventions to reduce the rate of UE. Further regular evaluation is key to keep the UE rate at a lower level. The challenge will be to sustainability of keeping the UE at the lowest rate.

The next step is real-time data monitoring of UE so the causation can be identified and addressed at the earliest to maintain the UE rate at a lower level.