Implementing an evidence-based standardized approach of care for ventilated neonatal patients will reduce unplanned extubations in the NICU, and Respiratory Therapy departments should take the lead in developing a performance improvement project.
By Awad Rafidi, BSRT, RRT, RRT-ACCS; and Cathy Rozansky DHSc, RRT
The medical field has continuously strived to advance the quality of care with minimal to no errors. The ever-evolving world of medicine has newer standards to uphold with persistent improvements that are typically recognized through trial and error. Quality care has become more expected by patients as the newer age of technology and patient-driven healthcare has surfaced. Expectations in the succession rates in healthcare can sometimes be compared to success rates in airplane flights.
To place this comparison in perspective, airline flights typically have few to none crashes or errors. This expectation stems from passengers believing the pilots and airliners have enough protocols and training to prevent such tragedies. The same thought process can be seen with patients in healthcare that trust hospital organizations, staff members, and physicians.
In this case, there is a known issue with an unplanned extubation (UE) in the Neonatal Intensive Care Unit (NICU). Patients in any intensive care unit (ICU) are already at risk for potential complications due to their mere presence in such an environment. A UE, or more commonly called self-extubated, is a recognized complication of having an artificial airway utilizing an endotracheal tube (ETT). Any unintentional dislodgement of the ETT is an UE. In simple terms, no physician order to extubate was written in the patient’s medical record. As respiratory therapists are generally noted as “owners” of the patient’s ETT, they play a key role in improvement initiatives.
Additionally, patients who may be intubated and being mechanically ventilated are at a much higher risk of infection, lengthened admission stay, cases of pneumonia, and mortality. Unplanned extubations can heighten these risks in addition to decreased cost-effectiveness.
The use of artificial respiration or mouth-to-mouth resuscitation was noted as far back as in the Old Testament in the Bible. In II Kings chapter 4 verse 34, Elisha brought a boy back to life through mouth-to-mouth breathing. Mouth-to-mouth, CPR, and artificial respiration has greatly evolved since the Old Testament times. The current state of artificial respiration and ventilation via the use of endotracheal tubes is advancing as technology increases. This medical innovation has appreciated vast adjustments to current day practices due to new knowledge and implementation of evidence-based medicine in the field of respiratory therapy.
Rate of Unplanned Extubations
Unplanned extubations has become a common adverse event in the NICU and has prompted organizations across the board to make this a quality indicator for patient safety, along with goal setting. The target goal for UEs in the NICU should be at a rate of less than 1 per 100 patient-intubated days, which is the benchmark for Pediatric ICUs. A more applicable rate for UEs in the NICU may be the suggested rate of 2 per 100 intubated days from the Vermont Oxford Network. This network is dedicated to the research of neonatal patients only and data is derived from patients in network hospitals.
Interventions for Improvement
To reduce the number of UEs, there has been profound research to identify key elements in the incidences that lead up to the event, including ways to decrease the number of events. Healthcare providers play a vital role in reducing UEs by implementing a Plan-Do-Study-Act (PDSA), which is a bundle of better practices and interventions.
Staff and administration use a four-step management method that focuses on any areas that need improvement and strategically apply the change necessary to achieve a goal. To help reduce extubations in the NICU, the following measures have been reviewed: increasing staff awareness of the problem, having two staff members involved in procedures with intubated patients, and methods of securing the ETT. With such measures being shown to be effective for clinical practices that provide higher quality care, organizations must implement these standards that identify with the highest possible results.
Education and Awareness
Education has always been the marker for improving quality care. Healthcare that is provided with quality in mind naturally improves when providers and licensed professionals, such as respiratory therapists, continue education.In the instance of reducing UEs among NICU patients, staff awareness and education have been shown to be beneficial.
In a study from a Level-4 NICU that had an interdisciplinary group follow certain steps concluded that prevention guidelines, education, and UE event quality reviews contributed to a decrease in the UE rate. Furthermore the quality review completed by the RN, RT, and physician delves into the root cause of the UE. Subsequently deviations to the set guidelines can be determined. Follow-up education and awareness of the UE prevention strategies and having a heightened sense of the risk for UE would be indicated and completed on a recurring basis.
During the process of caring for intubated NICU patients, a visible display card that could be posted at the side or foot of the patient bed seemed to have the lowest UE rate, proving to be most beneficial. These visual reminders acknowledged certain risks that pertained to the UE. Specifically, including the wording of the risks onto the display card. Such risks would include any harm like infection that a reintubation may inflict on an infant. Also placing the number of days the patient has been on the ventilator will serve as a reminder for clinicians to be much more motivated and attentive to the importance of minimizing ventilator days, as the risk for complications can increase with each day.
The more staff involved with patient care, the lower the chances of error. One of the better practices from the PDSA process has been implemented by multidisciplinary staff to increase the number of staff members that are directly involved with the patient’s procedures.
Evidence has shown that there was a decrease in UEs over a span of nine months when compared to the baseline. The results from the quantitative evidence warranted acceptance of the guideline of having two licensed professional staff with the intubated patient during procedures, such as ETT securing or weighing. This PDSA cycle step had one of the lower rates of UE, next to the display visual idea step, by ensuring two staff members were present for any procedure or retaping. Arterial line placements, standard hygiene, and routine chest X-rays were just a few bedside events that were found to need more than one staff member. These procedural events were more prone to ETT dislodgment. An additional step in the PDSA process is to involve radiology technologists in the UE educational component.
As for the patient to staff ratio, there could possibly be a relation that indicates an increase of UEs with fewer staff. The ratio could directly affect the attentiveness to patient care, especially when dealing with neonatal patients that have little to no sedation and can be desynchronizing with the ventilator, potentially self-extubating. Nurse-to-patient ratio is another measure in the reduction of UE. A classification system measuring nursing workload of patient acuity level found a connection between the acuity level and the therapeutic intervention. Evidence was indicated in a study that an increased nursing workload pointed to a nearly fourfold increased risk of an UE. Administration can potentially revise and implement better staff-to-patient ratios or care plans that could lead to more quality care.
Another potential risk factor of an UE would be the method or device used for securing the endotracheal tube.
The older days of securing the ETT with tape could be viewed as an obsolete method. There are newer commercial securing devices that have been introduced to emphasize a decrease in UEs, ensuring a stronger reinforcement of loosening tubes. However, just as with anything new there must be proper education and familiarity to staff members. A culture change should always be followed with appropriate education, in-service classes, or internet module courses that are preferably done by the sales or clinical representatives that have introduced the new device. For instance, a study that involved securement methods, as a better practice step, introduced a commercial securing device and found that the UE rate had climbed significantly and may perhaps be linked to the change resulting in a lack of conformability to or expertise with the new device.6 This step in the bundle of PDSA could use more research in order to identify the discrepancies that need more attention.
Along with the device, the ETT type plays a role in tube dislodgement. Cuffed tubes create fewer chances for tube dislodgment while preventing possible aspiration and more accurate monitoring of ventilation. However, uncuffed was once more favored due to the lessened chances of complications surrounding tracheal mucosal injury, post extubation stridor, and ischemia, especially in premature infants.
High-Volume Low-Pressure (HVLP) cuffed endotracheal tubes aims to avoid those complications. The HVLP tubes are being more frequently used by pediatric intensivists and anesthesiologists, which brings the idea of neonatologists possibly using newer HVLP cuffed ETTs to prevent tube dislodgment.
Additionally, this topic would require continued research and protocols implemented for staff members to utilize when considering newer devices.
Respiratory therapists are instrumental in ETT securement and require expert knowledge of that task. For any new device, tape or endotracheal tube implemented, ideally there would be a classroom style course, web course, and lead supervisors reiterating correct use and placement of the implemented change for neonatal patients. A competency checklist would coincide with this protocol that can provide insight on the staff member’s adaptability and competency with the newer devices. Following such protocols for staff members involved with the use of the new device could assist in helping reduce UEs, rather than adding to the problem.
Physical Restraints and Sedation
Unlike in the adult world where restraints are much more common for prevention of self-extubation, studies showing benefit for ventilated NICU patients and UE may have conflicting information.
In a systemic review, two studies showed there was no difference with infant extubations and restraints, while two other studies showed restraints benefiting as a prevention measure for intubated NICU patients. One study showed that the absence of restraints contributed to an UE in 58% of all patients and the other study stated that head restraints helped more for restless infants. Nevertheless, the study further noted that methodological shortcomings slanted the clarification of these results.
Another area that is in need for further studies for clarifications of flawed methodological data would be the administration of sedation in NICU patients. Data is varying or lacking for NICU sedative use and UE prevention. Yet, there are a couple of studies that indicate the use of sedatives were not related to added occurrences of UEs. Others make claims that UE rates seem higher when patients did not receive any sedative. Hence an apparent need for detailed research to justify sedation administration is warranted. When compared to adult patients, sedatives are essential to ICU management and time needed for disease healing processes while ensuring ventilator synchrony.
There are many factors that can conflict with any new protocol or standard of care for hospital organizations. Staff turnover rates, improper techniques, unorganized educational courses, and fewer readily available resources can all skew the overall quality measurement. In addition, devastating adverse events can increase costs for hospital organizations. The costliness of the complications that may stem from an UE can be detrimental to any hospital financial report.
Quality improvement programs should still be able to identify and correct any gaps or errors to a department’s protocols by having constant reviewing and auditing. For instance, respiratory therapy managers and supervisors can work alongside nurse managers and clinical educators of a NICU for real-time analysis of an UE. Interdisciplinary caregivers and physicians of different specialties can also be consulted and provide information on how improvement measurements can indicate positive changes for specific cases.
Examining the cause of the extubation in addition to the patient’s medical history can give more insight on what improvements can be made. Some ETTs may have been improperly secured or the tape’s integrity may have been worn out by being wet or loosened. Furthermore, discussing how treatment continued for those patients that had an UE can play a role in the statistical categories for quality care. While some neonates required a reintubation procedure, others may have benefited from a noninvasive approach like nasal continuous positive airway pressure or high-flow nasal cannula. In a recent study, post-UE data resulted in successful extubation in about 24% of the cases reviewed by utilizing non-invasive ventilation or supplemental oxygen therapy.
Spontaneous weaning trials on infants that are ready for extubation can also reduce accidental incidences. Assessments should be made daily, if not every shift, to ensure that prolonged ventilator days for patients are not causing adverse events such as infections and an UE. In fact, these assessments can be reviewed and charted by the respiratory therapists that are managing care for the NICU patients. In other words, is the ETT needed? A study concluded that respiratory therapist-driven weaning protocols showed to have an increase in ventilator-free days. Respiratory therapists can potentially wean these patients through facility protocols prior to probable adverse events that lead to an UE. Thus, increasing the quality improvement markers to signify that the department and facility are taking proper precaution to assure evidence-based protocols are resulting in quality care.
To summarize, this research and possible execution of protocols would be most helpful for intubated NICU patients by reducing potential harms that include but are not limited to the risk of infection, reintubation, lengthened hospital admission, and mortality. Implementing an evidence-based standardized approach of care for ventilated neonatal patients will reduce UEs in the NICU. The PDSA bundle of better practice steps include increasing staff awareness of the problem, having two staff members involved in procedures with intubated patients, and methods of endotracheal tube securement. Quality improvement measurements that can be applied to a facilities overall scoring for patient care can be overseen by departmental management auditing and analysis. Overseeing what next steps are needed for specific patients will ensure suitable treatment plans are in place based on respiratory therapist-driven protocols and team member communications.
Healthcare will always be on a constant incline of improving care and increasing positive patient outcomes. Reflecting on these facts, we can see that an evidence-based approach of standardized protocols would decrease instances of unnecessary reintubations by reducing the root causes of an UE and complying with a benchmark targeted goal of a UE rate of 1-2 per 100 ventilator days.
- Respiratory Therapy Departments should take the lead in developing a performance improvement project regarding UEs in all ICUs.
- Form a committee of interprofessional team members including anesthesiologists.
- Partner and work with Quality Department leaders to engage physicians in the project.
- Work with ICU Medical Directors for ventilator weaning guidelines.
- NICU specific ventilation practices deserve review to provide evidence-based neonatal ventilation strategies to reduce intubated ventilator days.
- Unit-based RN and RT education and re-education on the UE project.
- Promotion and support of project from key hospital leaders (C-suite).
Awad Rafidi, BSRT, RRT, RRT-ACCS, is a respiratory therapist in the Adult Pulmonary Care Department at Baptist Medical Center-Jacksonville, Jacksonville, Florida. Cathy Rozansky, DHSc, RRT, is Manager of Adult/Pediatric Pulmonary Care and Pulmonary Function Laboratory Departments at Baptist Medical Center-Jacksonville and Wolfson Children’s Hospital, Jacksonville, Florida. For more information, contact editor@RTmagazine.com.
- Pasztor A. 2017 Marked safest year in commercial aviation history. The Wall Street Journal. 2018, January 1. https://www.wsj.com/articles/2017-marked-safest-year-in-commercial-aviation-history-1514859860?mod=article_inline. Accessed September 15, 2019.
- Mitharwal SM, Yaddanapudi S, Bhardwaj N, Gautam V, Biswal M, Yaddanapudi L. Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes. American Journal of Infection Control, 2016; 44(7). doi: 10.1016/j.ajic.2016.01.021.
- Azevedo L, Park M, Salluh J et al. Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study. Critical Care. 2013; 17. https://ccforum.biomedcentral.com/articles/10.1186/cc12594. Accessed September 15, 2019.
- Merkel L, Beers K, Lewis MM, Stauffer J, Mujsce DJ, Kresch MJ. Reducing unplanned extubations in the NICU. Pediatrics. 2014; 133(5): e1367-1372. doi: 10.1542/peds.2013-3334.
- Powell BM, Edeltraud G, Volsko TA. Reducing unplanned extubations in the NICU using lean methodology. Respir Care. 2016;61(12):1567-1572.
- Stokowski LA. “Preventing Unplanned Extubation in Neonatal Intensive Care.” MedScape, June 19, 2014, www.medscape.com/viewarticle/826678.
- Crezeé KL, DiGeronimo RJ, Rigby MJ, Carter RC, Patel S. Reducing unplanned extubations in the NICU following implementation of a standardized approach. Respir Care. 2017; 62(8): 1030-1035. doi:https://doi.org/10.4187/respcare.04598.
- Barber JA. Unplanned extubation in the NICU. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2013; 42(2): 233-238. http://www.jognn.org/article/S0884-2175(15)31265-X/fulltext. Accessed March 1, 2019.
- Litman RS, Maxwell LG. Cuffed versus uncuffed endotracheal tubes in pediatric anesthesia: The debate should finally end. Anesthesiology. 2013; 118(3): 500-501. https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2034553. Accessed September 15, 2019.
- da Silva PS, Reis ME, Aguiar VE, Fonseca MC. Unplanned extubation in the neonatal ICU: A systematic review, critical appraisal, and evidence-based recommendations. Respir Care. 2013; 58(7):1237-1245. http://rc.rcjournal.com/content/58/7/1237#ref-15. Accessed March 1, 2019.
- Gupta P, Giehler K, Walters RW, Meyerink K, Modrykamien AM. The effect of mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: Impact on clinical outcomes. Respir Care. 2014; 59(2): 170-177. http://rc.rcjournal.com/content/59/2/170. Accessed February 1, 2019.