Prevention of unplanned extubations in neonates through process standardization.
Publication/Presentation Date
6-1-2016
Abstract
OBJECTIVE: 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.
STUDY DESIGN: 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.
RESULT: 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.
CONCLUSION: UPEs in neonates can be reduced with process standardization and frontline staff education, emphasizing vigilant endotracheal tube (ETT) maintenance.
Volume
36
Issue
6
First Page
469
Last Page
473
ISSN
1476-5543
Published In/Presented At
Fontánez-Nieves, T. D., Frost, M., Anday, E., Davis, D., Cooperberg, D., & Carey, A. J. (2016). Prevention of unplanned extubations in neonates through process standardization. Journal of perinatology : official journal of the California Perinatal Association, 36(6), 469–473. https://doi.org/10.1038/jp.2015.219
Disciplines
Medicine and Health Sciences | Pediatrics
PubMedID
26796128
Department(s)
Department of Pediatrics
Document Type
Article