LaMonica Henrekin, BSN, RN, NE-BC
Peds ICU & Peds INT Nurse Manager
OSF Healthcare Children's Hospital of IL
Peoria, Illinois
Disclosure information not submitted.
Christel Cornell, BSN, RN, NE-BC
Patient Care manager
OSF HealthCare Children's Hospital of Illinois, United States
Disclosure information not submitted.
John Sanford, RRT-ACCS, RRT-NPS
RT Educator
OSF St Francis Medical Center, United States
Disclosure information not submitted.
Jackie Guiliani, RRT
Respiratory Therapist
OSf St Francis Medical Center, United States
Disclosure information not submitted.
Tammy Woods-duvendack, RN, PhD
Vice President Quality and Safety
OSF St Francis Medical Center, United States
Disclosure information not submitted.
Sandeep Tripathi, MD, MS
Associate Professor of Pediatrics
University of Illinois College of Medicine at Peoria
Peoria, Illinois
Disclosure information not submitted.
Title: Two Bundles and One Process: Decrease in Unplanned Extubation rates by Statistical Process Control
Introduction: Unplanned extubation (UE) is a risk for all intubated patients. In the Children's Hospital of Illinois, Pediatric ICU(PICU) and Neonatal ICU (NICU) had different patient populations and sedation practices, but both shared a common goal of decreasing UE rate. Under the auspices of Solutions for Patient Safety (SPS), this Quality Improvement (Q.I) project combined the efforts, knowledge base and resources of the two historical siloed units towards hospital wide decrease in the UE rates.
Methods: Two bundles based on SPS recommended elements were created for NICU and PICU to prevent UE. Standard monitoring (random audits/month) were utilized in both units. Primary outcome was UE/100 ventilator days. Control chart was created for overall, unit -wise, individual bundle element compliance and UE rate. A REDCap based Apparent Cause Analysis (ACA) was also performed for all events.
Results: 491 audits were done (194 PICU/297 NICU) from 11/19 to 06/21. The overall compliance was 89.5% (NICU 94.5%, PICU 81.9%). Compliance for both NICU and PICU showed an upward shift in central line and decrease in variation during the process. PICU had lower compliance but more process stability, while NICU had higher compliance but more variations. Among the individual bundle elements, NICU had 100% compliance with ‘correct size of securement device’, while ‘verification of ET tube position’ had 92.5% compliance. For PICU the highest compliance was for ‘dry and secure ET tube tape’ (98.6%), while the lowest compliance was for ‘extubation readiness assessment’ at 84.5%. 93.9% of all CXR in NICU and 88.6% of all audited CXR in PICU were annotated with ET tube position. The unplanned extubation rate for the hospital dropped from 2.27/100 airways days (AWD) (07/2020) to 0.58 per 100 AWDs in 04/2021. The SPS central line for UE was 0.62/100 AWD. A total of 24 ACAs were performed (NICU 17, PICU 7). 10 patients (43.4%) required reintubation. 7 patients had prior UE (31.8%). Multiple contributors were identified based on ACA including inadequate sedation (20.8%), kangaroo care (25.0%). 4 patients (18%) had UE while waiting for planned extubation.
Conclusion: This project demonstrates the impact of collaborative quality improvement with shared goals to decrease UE across different units with a use of a rigorous data driven process.