Abstract
BACKGROUND: Unplanned extubation (UE) is the fourth most common adverse event in neonatal intensive care units (NICUs) and remains a significant global challenge. Standardizing endotracheal tube (ETT) maintenance could reduce UE rates to 0.5-1.0 events per 100 non-tracheostomy ventilation days. This quality improvement (QI) project aimed to reduce the UE rate to below 1.0 event per 100 non-tracheostomy ventilation days within 12 months. METHODS: Using a QI methodology, we conducted four Plan-Do-Study-Act (PDSA) cycles, including frequent ETT securement evaluations, ETT stabilization during procedures, audits of chest radiographs, and the use of a silk tie for ETT reinforcement. Statistical process control charts monitored progress. RESULTS: Baseline UE rate was 1.73 events per 100 non-tracheostomy ventilation days. The first three PDSA cycles (January 2019-May 2020) produced a non-significant signal for reduced UE to 0.88. After introducing the silk suture tie in PDSA cycle 4, the rate significantly declined to 0.58 and was sustained from October 2020 to December 2021. A further special cause variation occurred from February to December 2022 with UE reduction to 0.06. CONCLUSIONS: A multidisciplinary approach and silk suture tie intervention significantly reduced and sustained one of the lowest reported UE rates, enhancing ETT securement and patient safety. IMPACT: Unplanned extubation (UE) events are not uncommon in the neonatal intensive care unit. This project demonstrates that the lowest reported UE rates in neonatal ICUs are possible without incurring additional costs or requiring new securement devices. The success of this project underscores the importance of standardizing care, reducing variability, and fostering a multidisciplinary, collaborative approach. The silk tie enhancement for ETT stabilization offers a practical, scalable solution to prevent UEs and improve neonatal care.