Multidisciplinary QI collaboration in decreasing pediatric unplanned extubation

Abstract:

Introduction: Unplanned Extubations (UE) are common, preventable adverse events in the neonatal and Pediatric intensive care units that can cause serious complications. Risk factors include inadequate sedation, poor ETT securement, clinician inexperience, and high staff workload. Quality improvement strategies, like the Solutions for Patient Safety (SPS) UE bundle, can help reduce UE rates.

Methods: A multidisciplinary team used the Define, Measure, Analyze, Improve, and Control (DMAIC) framework to decrease the UE rate to ≤0.90 events per 100 ventilator days within 12 months, without significantly increasing the incidence of ETT-related pressure injuries. This aim aligned with SPS's goal of ≤0.95 UE events per 100 ventilator days.

Results: The baseline UE rate over 12 months was 1.13 events per 100 ventilator days (n=1410 total ventilator days). The first intervention implemented the UE bundle via the K-Card over 6 months and performed compliance audits, reducing the UE rate to 0.63 (n=1277 total ventilator days, 61% bundle compliance). The second intervention introduced the UE Apparent Cause Analysis (ACA) huddle over a second 6-month period, further reducing the UE rate to 0.44 (n=1590 total ventilator days, 94% bundle compliance, 86% ACA huddle compliance). One month after the first intervention, a centerline shift in the U-Control chart set a new baseline UE rate of 0.46 (n=1734 total ventilator days) over eight months. During the Control phase, the UE rate was sustained at 0.46 (n=3588 total ventilator days) for 19 months. Post-intervention, five ETT-related pressure injuries were noted, resulting in an incidence rate of 1.4%, compared to 0.7% in the pre-intervention period.

Conclusions: Implementing the UE bundle via the K-Card and standardizing the ACA huddle process at the bedside reduced UE events in Mayo Clinic’s neonatal and pediatric ICUs without significantly increasing the ETT-related pressure injury incidence rate. Ongoing education and staff engagement are essential for sustaining these improvements.

Biography:

Dr. Yu Kawai is an assistant professor at the Mayo Clinic College of Medicine and is the Quality Medical Director and an intensivist in the Pediatric ICU and the Pediatric Cardiothoracic Surgery ICU. He is the co-chair of the American Delirium Society (ADS) Pediatric Delirium Special Interest Group and an active member of the ADS Education Committee. Locally, he leads the Pediatric Sepsis, Delirium, Mobility, and Sedation Teams. He also engages in numerous multidisciplinary QI projects, including efforts to reduce unplanned extubations, CLABSIs, and other iatrogenic conditions.