Achieving unplanned extubation (UE) rates well below the national benchmark, Riley Children’s Health engages in a collaborative, multilevel accountability, and quality improvement initiative across three intensive care units—NICU, Pediatric ICU and pediatric cardiovascular ICU. Efforts to improve UE have been underway at Riley Children’s since 2013, three years before the Children’s Hospitals’ Solutions for Patient Safety (SPS) tapped Riley to participate with a handful of centers in a pilot program targeting unplanned extubation.
Based on the groundbreaking work of that pilot group, SPS introduced a UE bundle to its 145-plus hospital network in May 2018, setting a national benchmark goal rate of 0.95 UE per 100 ventilator days. Through the first half of 2022, the hospital-wide average was 0.53 with Riley’s Level IV NICU achieving a UE rate of 0.44.
Riley Children’s practices five exceptional initiatives to achieve a low UE rating:
1. Thorough case review by ICU teams following every UE; teamwork critical to success
Jayme Allen, MD, neonatologist and associate director of the Riley NICU, attributes part of the hospital’s success to the thorough case reviews that occur after every UE. Medical leaders from Riley ICUs gather with advanced practice providers and care partners from respiratory therapy (RT), nursing and other disciplines to dissect the circumstances and discuss potential solutions.
“When these cases offer something we can learn from, we’ve been open and willing to alter our practice,” said Dr. Allen. “I think that’s why we’ve been successful in keeping our UE rates low—teamwork at the bedside, consistent case review, quick response and a commitment to take action.”
2. “It takes two” tube guardian protocol in the NICU
When case reviews determined that the majority of UEs in Riley’s 60-bed NICU were occurring during direct patient care, the team developed the “It takes two” protocol. The initiative calls for a second team member to serve as a “tube guardian” during any type of procedure or patient care that requires circuit or head repositioning, including transfer to a family member’s arms.
“If a baby is on a ventilator and we’re doing something that may cause the infant to move, we strive to have another pair of hands and eyes on the tube, as a sole responsibility,” explained Dr. Allen. “It can be a challenge in a busy, high-volume unit like ours, but our RTs and nurses take it seriously and do a phenomenal job working together, and it’s made a big difference for us.”
3. Added patient safety measures to allow for quick response
The Riley NICU is equipped with an in-unit critical airway readiness box that includes supplies for quick response if airway management is needed. Endotracheal tube (ET) safety checks are performed every four hours in the PICU, also contributing to the low UEs.
4. Collaboration
Upon leaving the OR, patients are at higher risk for UEs until they are settled into the PICU. To help prevent UEs during this period, Riley’s RT team worked closely with anesthesiologists on a process to ensure ETs are secure when the patient leaves the OR. Similar collaboration between NICU RTs and radiology team members occurs when intubated infants receive chest X-rays. To maintain a secure ET, a NICU RT is always present during these X-rays.
5. Education
Team member education about circuit positioning and pinning are critical to Riley’s success, and ongoing case reviews reinforce the guidelines and promote sharing of knowledge. ICU teams also educate family members regarding ET safety.
“In exceeding the SPS benchmark goal year after year, our UE effort is considered a best practice because our rates are lower than other centers with similar patient volume and complexity” said Samer Abu-Sultaneh, MD, FAAP, pediatric critical care intensivist and medical director of respiratory care at Riley. “Decreasing incidences of UE has been about our critical care units working together and learning not just from each other, but also from other hospitals in the SPS network.”
UE rates remain low even with concurrent quality improvement initiatives
Riley is a pioneer in developing programs that promote ICU liberation, especially mechanical ventilation. While these initiatives focus on mobility and the early involvement of physical and occupational therapy, they haven’t impacted Riley’s ability to keep UE rates low.
“While early mobility, decreasing exposure to sedation and making sure families are able to hold their kids even when they are intubated have clear benefits to children, they carry the risk of UE. Our multi-professional team members work hard to mitigate these risks and continue to provide high quality care,” Dr. Abu-Sultaneh explained.
Dr. Allen said the UE initiative is an example of how Riley uses multi-professional expertise to drive improvements and promote patient safety.
“Our UE project is a great representation of the detailed steps we take to provide exceptional care to babies and children,” she said. “There are many pieces to this project that we’ve worked on to keep these rates low, and yet this effort is just one of the hundreds of things we do every day to take the best care of our patients.”