Unintended Extubation Prevention Bundle in the Neonatal Intensive Care Unit

Abstract

Problem: Endotracheal intubation is a common procedure in the Neonatal Intensive Care Unit. Unintended extubation is defined as the accidental dislodgement of the endotracheal tube from the trachea and is a common adverse event in NICUs. Unintended extubation is associated with a multitude of profound consequences in neonates including airway trauma, intraventricular hemorrhage, pneumothorax, cardiovascular collapse, and death. In 2020, a Level VI Neonatal Intensive Care Unit had an unintended extubation rate of 1.2 per 100 ventilator days, exceeding the unit goal of less than 1 per 100 ventilator days. Purpose: The purpose of the quality improvement project is to implement an initiative outlining an unintended extubation bundle with an emphasis on management of high-risk procedures to reduce unintended extubation in a Level IV Neonatal Intensive Care Unit. Methods: A multidisciplinary team evaluated current literature along with previous unintended extubation events and developed a unintended extubation bundle that emphasized the presence of two licensed providers for all “high risk” procedures and, in addition all intubated infants greater than 35 weeks’ gestation were required to have mittens placed on their hands. Adherence to the bundle was tracked via random observation audits with verbal feedback, and success was determined thorough evaluation of by weekly run charts, over a 15-week timeframe. Results: Results of this quality improvement project were mixed. The nursing education goal of 100% of nursing staff was achieved. The process goal of 100% compliance to the unintended extubation bundle was not met. The unit unintended extubation rate remained unchanged at 1.2 per 100 ventilator days. Conclusions: Preventing unintended extubation in Neonatal Intensive Care Units remains a challenging problem but with supportive stakeholders and a strong commitment to organizational change, along with a concrete framework for implementation, success can be achieved. Evaluation of the implementation over a longer period of time may produce different results.