title: Reducing Unplanned Extubations in the NICU Using Lean Methodology.
abstract: BACKGROUND
  Unplanned extubations can lead to iatrogenic injury and have the potential to contribute to serious safety events. We adopted lean methodology to reduce the unplanned extubation rate in a Level 3b NICU. We hypothesized that the use of a rapid-cycle PDSA (plan, do, study, act) initiative would reduce the unplanned extubation rate.
  
  
  METHODS
  Baseline unplanned extubation data were collected from November 1, 2012 to June 6, 2014. A voice of the customer survey ascertained perceptions regarding unplanned extubation causes and impact on care. The confidential survey contained 2 open-ended and 4 closed-ended questions and was distributed to a random sample of nurses and respiratory therapists. A fishbone diagram helped to identify opportunities. Six improvements were identified and rolled out in 2 phases using didactic and kinesthetic techniques. Phase 1 standardized the process for turning intubated infants, assessing endotracheal tube (ETT) placement with growth, and communicating tube position with caregivers. Phase 2 addressed respiratory plans of care, correcting ETT migration, establishing ETT re-securement methods, and standardizing position during radiography. The Fisher exact test was used to determine differences in the number of unplanned extubations per 100 intubated days. Descriptive statistics were used to report survey results. Statistical significance was established at P < .05.
  
  
  RESULTS
  A 68% (17 of 25) survey response rate was realized. Baseline data revealed 3.8 unplanned extubations/100 intubated days, and 2.7 unplanned extubations/100 intubated days occurred in the post-improvement phase (P = .01). We noted a statistically significant decrease in the number of intubated days between the pre- and post-improvement groups (P < .001).
  
  
  CONCLUSIONS
  Staff underestimated the prevalence of unplanned extubations but recognized the need for improvement. Rapid cycle PDSA significantly reduced the unplanned extubation rate. The decrease in intubated days may have been a by-product of the post-improvement phase improvements, which encouraged practice changes.
authors.affiliation: Department of Respiratory Care, Akron Children's Hospital of the Mahoning Valley, Boardman, Ohio. bpowell2@chmca.org.
authors.forename: Bonnie M
authors.initials: BM
authors.lastname: Powell
authors.affiliation: Center for Operations Excellence.
authors.forename: Edeltraud
authors.initials: E
authors.lastname: Gilbert
authors.affiliation: Department of Nursing Administration, Akron Children's Hospital, Akron, Ohio.
authors.forename: Teresa A
authors.initials: TA
authors.lastname: Volsko
mesh_terms: D060666:Airway Extubation / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data*; D015931:Intensive Care, Neonatal / Q000379:methods*; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010347:Patient Care Planning
keywords: accidental extubation; lean methodology; process improvement; self-extubation; unplanned device removal; unplanned extubation