Quality improvement project to reduce unplanned extubations in a paediatric intensive care unit

• Published in: BMJ open quality 2023-03, Vol.12 (1), p.e002060
• Main Authors: Ferreira, Joyce Caroline Dinelli, Nascimento, Milena Siciliano, Brandi, Simone, do Prado, Cristiane, Cintra, Cintia de Cassia, Almeida, João Fernando, Malheiro, Daniel Tavares, Capone, Antonio
• Format: Article
• Language: English
• Subjects: Airway Extubation - adverse effects; Airway Extubation - methods; Anesthesia; Child; Electronic health records; Extubation; Humans; Innovations; Intensive care; Intensive Care Units, Pediatric; Intubation, Intratracheal; Medical records; Multidisciplinary teams; Nursing; Paediatrics; Patient handling; Patient safety; PDSA; Pediatrics; Physical restraints; Physical therapists; Prevention; Quality Improvement; Quality Improvement Report; Quality of care; Respiration, Artificial - adverse effects; Surveillance; Ventilators
• ISSN: 2399-6641; 2399-6641
• DOI: 10.1136/bmjoq-2022-002060

BackgroundUnplanned extubations are recurrent adverse events in mechanically ventilated children and have been the focus of quality and safety improvement in paediatric intensive care units (ICUs).Local problemTo reduce the rate of unplanned extubation in the paediatric ICU by 66% (from 2.02 to 0.7).MethodsThis is a quality improvement project that was conducted in a paediatric ICU of a private hospital at the quaternary level. All hospitalised patients who used invasive mechanical ventilation between October 2018 and August 2019 were included.InterventionsThe project was based on the Improvement Model methodology of the Institute for Healthcare Improvement to implement change strategies. The main ideas of change were innovation in the endotracheal tube fixation model, evaluation of the endotracheal tube positioning, good practices of physical restraint, sedation monitoring, family education and engagement and checklist for prevention of unplanned extubation, with Plan–Do–Study–Act, the tool chosen to test and implement ideas for change.ResultsThe actions reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 2 years, totalling 743 days without any event. An estimate was made comparing cases with unplanned extubation and controls without the occurrence of this adverse event, which resulted in savings of R$955 096.65 (US$179 540.41) during the 2 years after the implementation of the improvement actions.ConclusionThe improvement project conducted in the 11-month period reduced the unplanned extubation rate to zero in our institution and sustained this result for a period of 743 days. Adherence to the new fixation model and the creation of a new restrictor model, which enabled the implementation of good practices of physical restraint were the ideas of change that had the greatest impact in achieving this result.