The Science Journal of the American Association for Respiratory Care

2012 OPEN FORUM Abstracts


Jennifer Cerasoli1, Sarah Young1, Janice Bennett1, Susan A. Roark1, Esther Taylor1, Francine Dykes2; 1NICU, CHOA, Atlanta, GA; 2Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Emory University, Atlanta, GA

Introduction: National patient safety guidelines focus on improving patient safety and reducing errors that reach the patient.Unplanned extubations expose patients to potential airway damage, ventilator associated pneumonia, and increased ventilator days which can escalate medical costs rapidly.Here we describe a quality study in which several practice changes were implemented in the NICU at Children’s Healthcare of Atlanta, (CHOA) to reduce our unplanned extubation rate. Methods:In October of 2010 we identified that our accidental extubation rate was significantly higher than other NICU’s with comparable patient populations. In an effort to improve this we put several practice changes into place .First, we increased the visual inspection of the landmark on the ETT, and adhesiveness of the securing device from Q12 to Q4. Second, Q7 day changes of the ETT securing device were implemented. Third, all patient positioning requires two caregivers. Fourth, all tubes are secured with the same brand of tape and secured in the same fashion.Fifth, all patients admitted with ETT’s secured without a NeoBar(Neotech,Valencia,Ca) will be converted to a NeoBar within 2 hours of admission. RCP’s and RN’s were extensively educated prior to implementing these changes in January of 2011.All accidental extubations are documented through an online notification system as well as accidental extubation forms to track specifics of each event. In conjunction with these practice changes CHOA formed a system task force to evaluate practices across three campuses including ETT securing methods, sedation usage, caregiver to patient ratio and patient holding by parents or staff while intubated. Results: The average unplanned extubation rate in the NICU at CHOA for 2010 was 7 extubations in 260 ventilator days, or 2.73 extubations per 100 ventilator days. Following the implementation of the practice changes described above the average rate for 2011 in our NICU decreased to 4 extubations in 271 ventilator days, or 1.38 extubations per 100 ventilator days. Conclusions: Reduction of unplanned extubations can be instrumental in minimizing medical errors and controlling costs. Here we demonstrate a significant reduction in unplanned extubation rates after increased staff education, improved monitoring, and multiple practice changes. Since the changes in practice occurred at the same time and were not monitored separately we cannot conclude that any one change resulted in improvement. Sponsored Research - None