How Children's National slashed unintended extubations in the NICU by 60%

Exterior of Children's National
Children's National was able to reduce NICU unintended extubations by 60%. (Children's National Health System)

Accidentally dislodging a breathing tube on a baby in the NICU is the fourth-most common negative event in NICUs around the country and can lead to airway trauma, bleeding and cardiovascular collapse.

But a new study from Children's National Health System in D.C. found some simple solutions could cut the accidental extubations by up to 60% over 10 years.

Publishing their study in Pediatrics, researchers say they found that simply by standardizing the taping methods of tubes and changing X-ray placement practices helped to reduce how often babies needed to receive chest X-rays and saved an average of $1.5 million a year. Children’s launched the quality-improvement project in December 2010 with the goal of lowering unintended extubation (UE) rates below once per every 100 ventilator days.

"These babies have complex care needs, however lowering the rates of these life-threatening events came down to instituting a series of simple changes to standardize what we do, including how we tape the endotracheal tube to the child's mouth, how we position infants during X-rays and who we include on daily rounds when the medical team discusses intubated patients' care plans," Lamia Soghier, M.D., Children's NICU medical director and the study's senior author, said in a statement. "In addition to reducing UEs at Children's National, our quality-improvement techniques are being adopted by other institutions to safeguard their newborns' health."

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The project included other improvements by the NICU team including enhancing the accuracy of apparent cause analysis reports by recording complications and resuscitation medications given to children during a code event. Also, teams implemented a bedside huddle within 72 hours of a UE to determine contributing factors.

In addition, respiratory therapists were required to attend daily rounds for intubated babies, two staff members were required during any infant X-ray and uniform taping practices and tube placement were put into place.

Researchers looked at 249 UEs between May 2011 and December 2017, on infants with a median gestational age of 25 weeks and who spent a mean of 35 days on mechanical ventilation. Of these patients, 29% had prior UEs.

During the first phase of the project, these UEs decreased by 43% to 0.99 incidents per 100 ventilator days. Numbers stayed stable for the next three years but spiked again in mid-2015, so the team regrouped. This time, by reducing the frequency of chest x-rays, re-educating staff about proper positioning and identifying patients at high-risk for accidental extubations, UEs dropped to 0.68 per 100 ventilator days.

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In the second phase, the Children’s National went 75 days in the NICU with no UE at all. This not only improved safety, but it also lowered overall healthcare spending for the hospital.

“We reduced life-threatening unintended extubations to 0.68/100 vent days by instituting simple changes to standardize what we do, including how we tape the endotracheal tube to the child's mouth, how we position infants during X-rays & who we include on daily rounds,” Soghier tweeted.

Moving forward in the next phase of the project, the NICU is going to compare infants with UEs and without and measure how much sedation these infants were given, nurse-to-patient ratios and time spent participating in skin-to-skin with parents.