Implementing Improvement Strategies to Prevent Unplanned

Extubation in Neonatal Intensive Care Units

Michael Dexter, MA, RRT, CSSBB, CAP

Olivia Lounsbury, BS
The Johns Hopkins Children's Center

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 Michael Dexter, MA,
RRT, CSSBB, CAP
Manager, Clinical
Quality Improvement

Olivia Lounsbury, BS
Quality and Patient
Safety Program
Coordinator

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About Johns Hopkins Children’s Center

● Maryland’s largest pediatric hospital with 206

beds
○ 49– bed Neonatal Intensive Care Unit (NICU)
○ 28– bed Pediatric Intensive Care Unit (PICU)
○ 12 – bed Pediatric Cardiac Intensive Care Unit (PCICU)
● Designated Burn Center for all pediatric patients
in Maryland
● The only state-designated trauma center for
children in Maryland
● One of only two hospitals in Maryland to offer
pediatric ECMO (Extra Corporeal Membrane
Oxygenation)
● More than 65,000 patient visits to more than 30
pediatric subspecialties
● U. S. News and World Report
○ #1 in Maryland
○ #4 in Mid-Atlantic
○ #14 in the Nation
● Nationally Ranked in 6 Children’s Specialties
● Magnet-designated hospital
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Learning Outcomes

● Facilitate development of
quality structure.

● Evaluate and
integrate external best
practices.

● Facilitate the development of

action plans or projects.

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 Problem and Background

Standard
Adequately securement
sedate method Work as imagined (WAI)

● Neonatal Intensive Care Units Two clinicians

RN/RT position
(NICU) across the nation have for tube
double check
retaping
higher rates of unplanned
extubations (UE) due to:1,2
○ Length of trachea OR uses a different
○ Longer intubation times securement method
○ Poor adhesion to immature skin
○ Lack of routine sedation and paralysis for Sedation
goal hasn't
mechanism ventilation been Work as done (WAD)
updated

Retaping
often due RT is busy and isn't
to immature available for a
skin double check
1. da Silva, PS, Reis, ME, Aguiar VE, et al. Unplanned Extubation on the Neonatal ICU: A Systematic Review, Critical
Appraisal and Evidence-Based Recommendations. Resp Care, 2013.58 (7): p. 1237-45.

2. Nitkin, Christopher
Privileged R., MD. National
and Confidential: Copyright
© and Deakins, Kathleen,
Association for RRT NPS FAARC, ‘Preventing UnplannedExtubations in the
Healthcare Quality
Neonatal
RecipientsIntensive Care inUnit’
should not distribute whole American Academy
or part and no portion of Pediatrics,
of these materials vol
may be reused for141, 1, 550
any reason.
 JHCC NICU UE Rate

• During our monthly UE

workgroup meetings, each
UE undergoes an RCA
process to identify
improvement
opportunities and
prevention strategies.
• The data is collected from
the chart audits to identify
trends or common causes.

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Measurement of the Problem: UE

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ETT=Endotracheal Tube
Interventions for UE Quality Improvement (QI)

Problem Plan/Do Study/Act

Implemented laminated
1 Documentation of high- card with Card sometimes not
risk patients was easily a "kangaroo" to visible/blocked. Moved
missed. indicate high-risk to a more visible place.
patients.

Problem Plan/Do Study/Act

There was not a

2 Placed laminated cards
consistent approach for Staff were asked to
in the OR about
securing the ETT in place incident reports if
appropriate taping
patients returning from challenges continued.
method.
OR.

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Interventions for UE QI

Problem Plan/Do Study/Act

Frontline did not know

Collected information they should submit
3 The potential reasons electronically in incident incident report.
for UEs were not readily reporting system and Recruited our safety
known/discoverable. built an apparent cause specialist and nurse
analysis tool in Epic. managers to routinely
remind.

Problem Plan/Do Study/Act

Misplaced ETT would

Performed
often be
RN/RT documentation
identified during
audits.
4 Misplaced ETT were
Standardized discussion
radiology rounds, in
not identified early. which RTs did
of ETT depth
not participate. RTs
during multidisciplinary
will regularly attend
hand-off.
going forward.

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Interventions for UE QI

Problem Plan/Do Study/Act

Awareness of
5 There was minimal
Developed a visual aid
appropriate protocol for
awareness of the bundle re-taping was especially
for UE bundle
and awareness was not minimal. Re-educated
awareness. all staff on re-taping
sustained.
specifically.

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Reflection

Despite improvements in UE bundle reliability, our quality improvement

processes themselves were still not highly reliable....

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Measurement of the Problem: Meta-QI

Examined our own

QI processes
through a QI lens to
improve reliability.

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Interventions for Meta-QI

Problem Plan/Do Study/Act

Helpful but
1 Learnings were requires attendance.
Frontline staff were
discussed at Annotations about UE
not aware of
multiple learnings planned for
learnings from UEs. monthly unit
monthly meetings.
dashboards.

Problem Plan/Do Study/Act

Instead of reviewing
Noticed similar trends
2 It was difficult to find data each month with
between NICU and
trends in the data due few UE cases,
PICU. Sharing trends
to numerous data implemented a
between units for
sources. quarterly 'data deep
further advancement.
dive'.

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Interventions for Meta-QI

Problem

3 Relevant information
about the UE QI
workgroups was not Plan/Do Study/Act
easily accessible.

Helpful to synthesize all

Develop standard information in one
project plans that are place. Started 'tagging'
Problem shared between all ICU workgroup members on
UE workgroups. the document instead
of emailing.

4
Information was often
lost in emails.

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Interventions for Meta-QI

Problem Plan/Do Study/Act

We were always Developed an Excel RT auditors often

5 scrambling to find a sheet "audit sign up" worked on both NICU
workgroup member to calendar with slots and PICU. Merged the
help with the bundle through the end of the PICU and NICU Excel
audits. year. sheet 'sign up' calendar.

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 JHCC NICU UE Rate

Since implementing Kangaroo cards

these improvement
strategies, NICU UE Common Cause Analysis
rate per 100 vent
days decreased
from 0.44 to 0.19, a
57% improvement.

Reviewing near misses

• Staff documentation audits

• Visual tapping process

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Key Takeaways

• Quality improvement of your quality improvement processes

("meta-QI") is key to better align WAI and WAD.

• Develop holistic, integrated systems for data collection,

analysis, and reporting to better identify trends.

• Optimize all avenues for dissemination of learnings.

Privileged and Confidential: Copyright ©National Association for Healthcare Quality WAI = Work-As-Imagined
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WAD = Work-As-Done
 “The biggest room in the world is the
room for improvement.”
– Helmut Schmidt

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 Questions?

Please contact Olivia Lounsbury

olounsb1@jh.edu

THANK YOU!

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