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  • Original Article
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Prevention of unplanned extubations in neonates through process standardization

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.

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Acknowledgements

We acknowledge all the nursing staff, neonatal fellows and neonatal nurse practitioners at Hahnemann University Hospital who contributed to the development and implementation of this quality improvement project.

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Correspondence to T D Fontánez-Nieves.

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The authors declare no conflict of interest.

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Fontánez-Nieves, T., Frost, M., Anday, E. et al. Prevention of unplanned extubations in neonates through process standardization. J Perinatol 36, 469–473 (2016). https://doi.org/10.1038/jp.2015.219

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