Patients with unplanned endotracheal extubation have a higher mortality rate if re-intubation is required. We expect unplanned extubation is reduced to 0% after implementation of quality improvement in our neonatal intensive care unit.
Implementation of quality improvement included: 1. Reform the fixation method of endotracheal tube. Elastic adhesive tape is divided into 3 phalanges or 2 phalanges with different length. We set up a table by weight to decide the number and length of phalanges, and take a video to demonstrate how to fix endotracheal tube by different phalanges of elastic adhesive tape. We replace a new elastic adhesive tape every 2 days or when wet tape is noted. 2. We revise “endotracheal tube care guide book”, and also formulate "security of endotracheal tube assessment form", to promote the nursing staff to confirm the depth of the endotracheal tube and to perform auscultation of breath sounds. 3 Promote the nursing staffs to use “N-PASS: Neonatal Pain, Agitation and Sedation Scale" to evaluate pain, restlessness for intubated babies. If N-PASS is ≧ 3 points, the physician is called to deal with this condition. We also use ISBAR tool at hand-off communication every shift. 4. Set up neonatal positioning guide and also encourage the use of pacifiers to achieve greater comfort of each intubated infant. 5. Consider early extubation according to VAP Buddle daily assessment. 6. Arrange education and training of patients’ safety.
There is improvement of the care of endotracheal tube after implementation of quality improvement. However, we found out that evaluation of N-PASS was difficult to be applied because attending physicians is worried that sedation analgesics easily lead to neonatal respiratory depression, which may result in delayed extubation. They recommended to use “containment” and oral sugar to pain relief. if fail, we will further consider use of sedatives.
After implementation of quality improvement, we still did not reach the target value of 0%. In February 2016, there was an unplanned endotracheal extubation occurred in the night. The physician assessed that there was no need for re-intubation, and nasal continuous positive pressure was decided to use. We carried out this case by RCA approach to explore the reasons and found that we did not have an endotracheal extubation program guideline. Therefore, this will be the future direction of improvement.
The project will continue to work to reduce unplanned endotracheal extubation, which aims to maintain patient safety, and improve quality of care, enhancing the communication and collaboration between healthcare teams.