2012 OPEN FORUM Abstracts
PROFILE OF ACCIDENTAL EXTUBATIONS IN A 96 BED LEVEL III NICU.
Richard Williams1, C. Stromquist2, V. McKay2, S. Brooks2, A. Germain2, J. Machry2, B. Torres2; 1Respiratory Care, All Childrens Hospital, St Petersburg, FL; 2West Coast Neonatology, All Childrens Hospital, St Petersburg, FL
Background: Accidental extubation (AE) in a mechanically ventilated neonate is defined as an unexpected or non-elective removal of the endotracheal tube. In neonates, the incidence of AE reported in the literature ranges from 0.72 to 5.3/100 vent days. Accidental extubation is a concern because it may pose an increased risk to patient safety and trauma to the airway. The incidence of accidental extubations/100 vent days in the 96 bed level III NICU at All Childrens Hospital was unknown but perceived by staff to be high. It is important to know the incidence of AE and related causes in order to develop systems that improve patient safety and quality of care. Hypothesis: The incidence of AE in the NICU at All Childrens Hospital would be = 3.0/100 vent days. Materials/Methods: Using six sigma methodology, a systematic approach was taken to evaluate the incidence of AE in the NICU at All Childrens Hospital. A data collection tool was developed to track AE events for a period of 7 months from May to November 2011. The Respiratory Care staff was instructed to complete the form as soon as possible after an AE event. Completed forms were collected and processed by the Neonatal Coordinator using Excel and Minitab software. Data collection tool components included date/time, patient demographics, type of ventilator, endotracheal tube securing method, reason for reintubation and factors that contributed to the AE event. Results: During the 7 month data collection period, the All Childrens Hospital NICU had 47 AE events and 2081 vent days. The incidence of AE during this period was 2.3/100 vent days. Patient movement was the most frequent cause of AE. The rate of reintubation after AE was 83% (39/47) and the majority who required reintubation (35/39) were reintubated within 24 hours. Accidental extubation occurred most commonly in infants = 29 weeks who were 10-30 days old. During the observation period, the incidence of AE decreased from 3.0/100 vent days to 1.1/100 vent days. Conclusion: The incidence of AE at All Childrens Hospital was lower than expected; however, AE still represents a significant risk to patient safety. Quality improvement initiatives to reduce the incidence of AE should focus on a high risk population of preterm infants = 29 wks who are 10-30 days old. It is possible that overall staff awareness of AE surveillance may have contributed to the decrease in the incidence of events during the observation period. Sponsored Research - None Incidence of AE