Prevention of unplanned extubations in neonates through process standardization

Journal of Perinatology : Official Journal of the California Perinatal Association
T D Fontánez-NievesA J Carey

Abstract

Unplanned extubation events (UPEs) in neonates are hazardous to patient safety. Our goal was to reduce UPE rate (#UPEs per 100 ventilator days) by 50% in 12 months at our 25-bed level III inborn unit. Baseline data were gathered prospectively for 7 months. Three Plan-Do-Study-Act (PDSA) cycles targeting main causes of UPEs were developed over the next 20 months. Causes of UPEs were analyzed using Pareto charts; and a U control chart was created with QI Charts(©). Standard rules for detecting special cause variation were applied. Mean UPE rate decreased from 16.1 to 4.5 per 100 ventilator days, a 72% decrease, exceeding our goal. Analysis of U-chart demonstrated special cause variation, with eight consecutive points below the mean. Improvement was sustained throughout the study period. UPEs in neonates can be reduced with process standardization and frontline staff education, emphasizing vigilant endotracheal tube (ETT) maintenance.

References

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Citations

Feb 25, 2018·Journal of Paediatrics and Child Health·Laurene AydonMary Sharp
Jan 12, 2019·The Journal of Maternal-fetal & Neonatal Medicine : the Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians·Priscila FerrazRuth Guinsburg
Feb 6, 2017·Journal of Perinatology : Official Journal of the California Perinatal Association·S Mbi NdakorJ M B Pinheiro
Feb 4, 2019·Pediatric Surgery International·Yuji Wakimoto, Sathyaprasad Burjonrappa
Jul 25, 2019·Pediatric Quality & Safety·Sarah B KandilMatthew Grossman
Feb 7, 2021·Journal of Perinatology : Official Journal of the California Perinatal Association·Leeann R PavlekMohannad Moallem
Feb 11, 2021·Revista brasileira de enfermagem·Giovanna Mercado TorresSabrina Guterres da Silva Galetto
Jul 25, 2021·Journal of Pediatric Nursing·Jung Eun Cho, Jung Hee Yeo
Apr 28, 2019·Pediatrics·John P GalioteLamia Soghier
May 14, 2020·Journal of Patient Safety·Sussan Mbi NdakorJoaquim M B Pinheiro

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