(1345) Reducing Unplanned Extubation Rates in a PICU Through Consistent and Transparent QI Bundle Elements

Introduction: An unplanned extubation (UE), or unintended displacement of an endotracheal tube, is considered a preventable complication in PICUs contributing to increased morbidity and mortality. Solutions for Patient Safety (SPS) identified that prevention bundle utilization resulted in a UE rate reduction of 20%. Our PICU initiated 2 of the 3 components with similar success, but without sustained focus on the bundle elements, our UE rate increased in 2022 with a peak in January 2023 of 2.44 UE per 100 ventilator days. Our goal was to decrease our UE rate to < 1 UE per 100 ventilator days over 12 months through reimplementation of UE bundle elements and identifying unit-specific barriers to maintaining sustainable practices.

Methods: This quality improvement initiative utilized the Model of Improvement and identified champions from nursing, respiratory therapy (RT), and our clinician team. We determined key drivers and tiered our interventions into 4 PDSA cycles. PDSA cycle 1 focused on transparent safety culture and education. We included RTs in safety huddles, publicly posted the days since the last UE, and reinitiated prevention bundle education. PDSA cycle 2 focused on unit-wide education of sedation goals and reinforcing ETT re-taping adjustments with an EMR order. PDSA cycle 3 concentrated on enhancing safety culture through auditing ETT taping practices and multidisciplinary event debriefs to inform the apparent cause analysis (ACA). PDSA cycle 3 is focused on identifying high-risk patients and tiered mitigation planning.

Results: From January to August 2023, our PICU UE rate was 1.22 per 100 ventilator days. After our first PDSA began in September 2023, the UE rate decreased to 0.51 for the rest of 2023. Currently, our 2024 UE rate is 0.32 per 100 ventilator days.

Conclusions: The SPS UE Bundle elements have been shown to successfully reduce the rate of UEs in ICUs. However, without consistent ACA and hard-wired practices, we saw our UE rate increase. Through promotion of a just safety culture with transparent data and analysis, standardized education, and audits, we have seen a reduction in UE events. A key to this initiative's success has been our data-informed evaluation of unit-specific issues with the collaboration of a multidisciplinary team.