6161 Quality improvement project to prevent unplanned extubations in the neonatal unit

Objectives Dislodged endotracheal tubes (ETTs) leading to unplanned extubations (UEs) in the NICU is a patient safety concern. UEs are associated with hypoxia and intraventricular haemorrhage, and multiple reintubations lead to laryngeal/tracheal injury.1 Babies are ventilated for longer leading to prolonged hospital stays.2 An audit from the past 3 years (2020–2022) reported UE rates had risen from 1.25 to 1.72 UEs per 100 ventilator days. This quality improvement project (QIP) formed part of a 6-month (March-September 2023) QIP blended-learning course. Our SMART aim: reduce the frequency of UEs in ventilated babies over 3 months between July-September 2023. Methods The Model for Improvement was used to inform the QIP design. Diagnostic tools including a high-level process map, Fishbone diagram and Pareto chart (using 2022 UE data) were completed. Short 3-minute pitches describing the problem and diagnostics were presented to engage relevant stakeholders including parents, nurses, doctors, risk leads and educators. This helped to form suggestions and changes to be tested using Plan-Do-Study-Act (PDSA) cycles. Key themes identified were ETT safety awareness, ETT securement and patient comfort. Interventions included dissemination of information on ETT safety via emails and a departmental presentation, ward round reminders of ETT position and securement, and standardisation of sedation using a protocol. A core group was formed to deliver interventions. Our measure was the number of days between UE events. Inclusions: ventilated babies with an oral or nasal ETT. Exclusion: babies with a tracheostomy. Baseline data, from 20 UEs before interventions, were recorded in a run chart. Subsequent sampling was performed weekly. The monthly UE rate (number of UEs per 100 ventilator days) was also recorded during the project. Results The median baseline before interventions was 8 days between UE events. Over 3 months following interventions, there were 6 UEs. No significant change was shown on the run chart although fewer babies had repeated UEs compared to the preceding 3 months, and the median time for UEs post interventions increased to 12 days graph 1. The monthly UE rates during the QIP reduced from 3.11 to 0.96 per 100 ventilator days graph 2. Conclusion Following interventions, our results demonstrate some achievement in our improvement aim. We plan to sustain ongoing change by extending this project to Spring 2024 through further PDSAs with refinements to our interventions and implementing an education package including ward drop-in sessions on ETT securement and safety, ward round spot checks and simulations focusing on ETT safety. References Loughead JL, et al. Reducing accidental extubation in neonates. Jt Comm J Qual Patient Saf 2008;34(3):164–170 125. Carvalho FL, et al. Incidence and risk factors of accidental extubation in a neonatal intensive care unit. J Pediatr (Rio J) 2010;86(3):189–195.