Prevention of neonatal unplanned extubations in the neonatal intensive care unit: a best practice implementation project

A Quality Improvement Project to Reduce Unplanned Extubations in the Neonatal Intensive Care Unit

BACKGROUND

Unplanned extubations (UEs) continue to be one of the most common adverse events in the neonatal intensive care unit (NICU). Management of endotracheal tubes (ETTs) can be particularly challenging in neonates due to the unique needs and physical characteristics of this patient population.

PURPOSE

The purpose of this quality improvement project was to decrease the rate of UEs from 0.76 to less than 0.5 per 100 ventilator days in an urban level III NICU in the Midwest, United States.

METHODS

A newly formed interprofessional team created an evidence-based, standardized, bedside nurse-led care bundle for intubations and ETT care in the NICU. This project also created standardized, clear, closed-loop communication for the transition of bedside staff at shift change.

RESULTS

The UE rate decreased from 0.76 to 0 per 100 ventilator days, reaching the goal of less than 0.5 per 100 ventilator days, during the 10-week project implementation period from December 2021 to February 2022.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Many NICUs focus on reducing UEs due to the impact on healthcare resource utilization, acute complications, and long-term outcomes for infants. The development of a standardized, nurse-led care bundle for ETTs decreased the rate of UEs. Future research is needed to study the potential for generalization to different units and beyond the scope of the neonatal population.

Decreasing Unplanned Extubations in the NICU, an Ongoing Quality Improvement Project

Unplanned extubations (UEs) can have devastating effects on neonates. The purpose of this quality improvement project is to decrease the number of UEs in Lankenau Medical Center's 22-bed Level III NICU. The UE rate had risen to 4.6 UEs per 100 ventilator days in 2016. Transitioning to a standardized bundle for intubated infants has decreased the UE rate to less than 2 per 100 ventilator days since 2018. The UE rate continues to be monitored for ongoing accountability and further staff education when rates increase.

Predictive value of the unplanned extubation risk assessment scale in hospitalized patients with tubes

BACKGROUND

Critical patients often had various types of tubes, unplanned extubation of any kind of tube may cause serious injury to the patient, but previous reports mainly focused on endotracheal intubation. The limitations or incorrect use of the unplanned extubation risk assessment tool may lead to improper identification of patients at a high risk of unplanned extubation and cause delay or non-implementation of unplanned extubation prevention interventions. To effectively identify and manage the risk of unplanned extubation, a comprehensive and universal unplanned extubation risk assessment tool is needed.

AIM

To assess the predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale in inpatients.

METHODS

This was a retrospective validation study. In this study, medical records were extracted between October 2020 and September 2021 from a tertiary comprehensive hospital in southwest China. For patients with tubes during hospitalization, the following information was extracted from the hospital information system: age, sex, admission mode, education, marital status, number of tubes, discharge mode, unplanned extubation occurrence, and the Huaxi Unplanned Extubation Risk Assessment Scale (HUERAS) score. Only inpatients were included, and those with indwelling needles were excluded. The best cut-off value and the area under the curve (AUC) of the Huaxi Unplanned Extubation Risk Assessment Scale were been identified.

RESULTS

A total of 76033 inpatients with indwelling tubes were included in this study, and 26 unplanned extubations occurred. The patients’ HUERAS scores were between 11 and 30, with an average score of 17.25 ± 3.73. The scores of patients with or without unplanned extubation were 22.85 ± 3.28 and 17.25 ± 3.73, respectively (P < 0.001). The results of the correlation analysis showed that the correlation coefficients between each characteristic and the total score ranged from 0.183 to 0.843. The best cut-off value was 21, and there were 14135 patients with a high risk of unplanned extubation, accounting for 18.59%. The Cronbach’s α, sensitivity, specificity, positive predictive value, and negative predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale were 0.815, 84.62%, 81.43%, 0.16%, and 99.99%, respectively. The AUC of HUERAS was 0.851 (95%CI: 0.783-0.919, P < 0.001).

CONCLUSION

The HUERAS has good reliability and predictive validity. It can effectively identify inpatients at a high risk of unplanned extubation and help clinical nurses carry out risk screening and management.

Application of a Risk Management Framework to Parent Sleep During Skin-to-Skin Care in the NICU

As NICU staff work to increase the frequency, duration, and comfort of skin-to-skin care (SSC) sessions, barriers to implementation are frequently encountered. Safety concerns are often raised when parents fall asleep during SSC intentionally or unintentionally. We present a risk management framework that we use in clinical practice to address risk related to parent sleep during SSC. Our approach is based on the steps of the Risk Management Life Cycle, which include the following: establish context, identify risk, analyze risk, respond to risk, and monitor and adapt response to risk. Clinicians may use this framework in clinical practice to manage risks related to prolonged SSC, specifically when parents relax and fall asleep during SSC.

Risk factors for unplanned extubation in ventilated neonates in South Korea

PURPOSE

Although unplanned extubation (UE) is a common occurrence in neonatal intensive care units (NICUs), the factors influencing UE have not been clearly identified in South Korea. Therefore, we investigated the incidence of UE along with its risk factors among neonates in the NICU.

DESIGN AND METHODS

This retrospective cohort study was conducted in a single NICU in B city. The electronic medical records of 137 ventilated neonates admitted between January 2017 and June 2018 were analyzed using an audit tool on extubation. Kaplan-Meier estimation and univariate and multivariate Cox proportional hazards models were used for statistical analyses.

RESULTS

The rate of UE was 32.1%, with an incidence of 6.56 per 100 ventilation days during the 18-month study period. Risk factors for UE were the use of sedatives or analgesics; no re-fixation of the endotracheal tube (ETT); suction frequency; a high nurse-patient ratio; and working night shifts (weekdays 5 p.m. to 8 a.m.), weekends, or holidays.

CONCLUSIONS

The rate of UE among neonates was found to be considerably higher than that of other countries. Among the various factors, nursing-related factors were most commonly associated with the risk of UE.

APPLICATION TO PRACTICE

Various prevention strategies, including complete ETT fixation, maintaining ETT placement, a low nurse-patient ratio, and close observation of the ETT may help reduce UE in the NICU.

Factors Influencing the Implementation of Foreign Innovations in Organization and Management of Health Service Delivery in China: A Systematic Review

Background: China has been encouraged to learn from international innovations in the organization and management of health service delivery to achieve the national health reform objectives. However, the success and effectiveness of implementing innovations is affected by the interactions of innovations with the Chinese context. Our aim is to synthesize evidence on factors influencing the implementation of non-Chinese innovations in organization and management of health service delivery in mainland China. Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched seven databases for peer-reviewed articles published between 2009 and 2020. Data were analyzed and combined to generate a list of factors influencing the implementation of foreign innovations in China. The factors were classified in the categories context, system, organization, innovation, users, resources, and implementation process. Results: The 110 studies meeting the inclusion criteria revealed 33 factors. Most supported by evidence is the factor integration in organizational policies, followed by the factors motivation & incentives and human resources. Some factors (e.g., governmental policies & regulations) were mentioned in multiple studies with little or no evidence. Conclusion: Evidence on factors influencing the implementation of foreign innovations in organization and management of health service delivery is scarce and of limited quality. Although many factors identified in this review have also been reported in reviews primarily considering Western literature, this review suggests that extrinsic motivation, financial incentives, governmental and organizational policies & regulations are more important while decentralization was found to be less important in China compare to Western countries. In addition, introducing innovations in rural China seems more challenging than in urban China, because of a lack of human resources and the more traditional rural culture.

Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit: The Elusive Benchmark

Unplanned extubation (UE) is a common adverse event in the neonatal intensive care unit (NICU). At our level IV NICU, we initiated a quality improvement project in 2012 to reduce UE rates from 7.47 to below 100 intubated days. We describe the strategies used.

Clinician Opinions and Approaches to Manage Risk Related to Safe Sleep During Skin-to-Skin Care

OBJECTIVE

To understand the opinions of clinicians about the risks, benefits, barriers, and facilitators to the practice of parent sleep during skin-to-skin care in hospital settings.

DESIGN

Cross-sectional survey.

SETTING

Online survey.

PARTICIPANTS

Clinicians who self-identified as infant care providers, that is, neonatal clinicians (N = 158).

METHODS

We sent an online survey invitation to neonatal clinicians through neonatal websites, conferences, and social media sites in the United States and used snowball recruitment. We used a risk management framework to analyze qualitative data. We used descriptive statistics and the chi-square and Fisher's exact tests to determine if opinions differed based on clinician and organizational characteristics.

RESULTS

Respondents' support of parent sleep during skin-to-skin care (yes/no) did not differ on the basis of whether the clinician had taken a formal course on skin-to-skin care, facilitated skin-to-skin care more than 100 times, or frequently promoted skin-to-skin care in current practice. Respondents who supported parent sleep (n = 93, 59% of respondents) reported greater implementation of risk control strategies than nonsupporters (n = 53 [57%] vs. n = 3 [5%]; p < .001), such as frequent monitoring of vital signs (n = 33 [35%] vs. n = 2 [3%]; p < .001), use of devices to support skin-to-skin care (n = 49 [53%] vs. n = 19 [29%]; p = .003), and proper positioning (n = 20 [22%] vs. n = 0 [0%]; p < .001). Nonsupporters more frequently reported that parent sleep during skin-to-skin care violates safe sleep recommendations, is habit forming for home, poses a fall risk, and jeopardizes the infant's airway.

CONCLUSION

Most respondents supported parent sleep during skin-to-skin care, but concerns regarding safety for the infant remained a barrier. The use of a risk management framework may help facilitate a systematic approach to improve the implementation of safe skin-to-skin practices.

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

Supplemental Digital Content is available in the text.

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.

Nurse Decision Making and Attitudes About Circuit Disconnection During Ventilator Therapy at a Swedish Neonatal Intensive Care Unit

BACKGROUND

There are many challenges to providing care to infants in need of ventilator therapy. Yet, few studies describe the practical handling of the ventilator circuit during nursing care.

PURPOSE

To describe neonatal intensive care unit (NICU) nurses' decision making regarding whether or not to disconnect the ventilator circuit when changing the infant's position and to investigate the grounds for their decisions.

METHODS

A descriptive questionnaire study with both quantitative and qualitative elements was conducted. In 2015, a convenience sample of nurses working in an NICU completed a questionnaire including both closed-ended and open-ended, free-text questions. Answers to the closed-ended questions were analyzed with descriptive statistics, whereas answers to the free-text questions were analyzed using qualitative content analysis.

RESULTS

Nurses' decisions on whether to disconnect or keep the ventilator circuit closed were based on the infant's needs for ventilator support. The nurses gave several reasons and motivations both for why they disconnected the circuit and for why they did not. The handling of the circuit and the reasons and motivations given were inconsistent among the nurses.

IMPLICATIONS FOR PRACTICE

This study highlights the need for continuous, repetitive education and training for NICU nurses, as well as demonstrating the importance of clear and distinct guidelines and working methods regarding the care of infants on ventilator support.

IMPLICATIONS FOR RESEARCH

Future research should continue to find ways of working and handling an infant on ventilator support that are least harmful to the infant.