Unplanned Extubations in the NICU
If you are a NICU nurse, you’ve likely been in this scenario: the unit is quiet, you’re going about your shift, when out of nowhere the ventilator starts alarming. Next, the cardiac/apnea monitor blinks red in rhythm with high pitched chimes. You quickly assess the situation, and the feeling sinks in that your once intubated patient is now possibly, unintentionally extubated. Maybe you were handing a baby over to an eager parent for some much needed “kangaroo care” or you were doing your due diligence by changing old tapes to better secure your patient’s endotracheal tube (ETT). Whatever the case may be, accidental extubations are on the short list of NICU nurse nightmares.
Intubation is a life-saving intervention required for many NICU diagnoses and provides a stable, patent airway for the delivery of mechanical ventilation in high acuity patients. Much like central lines and feeding tubes, ETTs require specific placement to function properly. A malpositioned ETT can lead to complications ranging from atelectasis to pneumothorax requiring surgical intervention. Monitoring the securement and position of an ETT is often the responsibility of the bedside nurse and respiratory therapist (RT). A number of activities like re-securing an ETT or even handling a patient can precede its dislodgement. When this occurs, it is considered an unplanned extubation.
Despite the best intentions of the caregiver, unplanned extubations DO happen. They are considered one of the most common sources of preventable harm in NICUs when compared with IV infiltrates, HAIs, and adverse drug events. Unplanned extubations can lead to severe cardiopulmonary deterioration and are the source of over half of emergent intubations. We know they can lead to long-term damage, even sentinel events, but it doesn’t mean that we stop handling our intubated patients or letting our parents hold their babies.
So how we do we keep unplanned extubations from happening as much as possible? Do we know our practices are effective if we don’t know why unplanned extubations happen, when, and how often? Answering those questions starts with data collection. The collection of data on unplanned extubations is not consistent among NICUs nor is it mandatory due to several factors. One factor is the lack of a unified definition of what qualifies as an unplanned extubation in the first place. There is also a justifiable fear surrounding data collection due to the threat of legal repercussions to the caregiver. Despite these barriers, the occurrence of unplanned extubations is starting to be considered a quality indicator by sources like the U.S. News and World Report—so maybe it’s time put aside our fears and reconsider.
Our level IV NICU does not currently collect data on unplanned extubations. Previous attempts at collecting data proved to be inconsistent and unreliable. This prevents us from being able to quantitatively assess whether current practices are working and what our number actually is, but where to begin? The best place to start is always at the bedside. Respiratory therapists and nurses are the first responders when an unplanned extubation occurs, so a team consisting of RTs and nurses was formed. First, we determined who would collect data. The RT and nurse would debrief immediately after the unplanned extubation once the patient is stable. Because the nurse is usually consumed with hands-on care at this time, it was determined the RT should gather this information and record it.
It was important to the team that the process be user-friendly and simple. We created a data collection tool starting with the basics: name, DOB, gestational age, and date/time of the event. This could help us answer some important questions:
- Do most of these occur during lunch hours or possibly during shift change when there are fewer hands on deck?
- Are the majority of these micro-preemies or are they older, active babies?
We then needed to identify the activity during which the unplanned extubation occurred. Activities included re-securing the ETT, adjusting ETT placement, transferring a patient to be held, removed by the patient, etc. Simple checkmarks could be placed in the corresponding boxes with room for additional comments if necessary. We also included areas for date of the last chest x-ray, and finally, we wanted to know if resuscitation was necessary.
Current research identifies an average of one to three unplanned extubations per one hundred ventilator days so our next task will be to set a realistic goal for our unit. We can then evaluate our practices to identify strengths and weakness. No one wants unplanned extubations to happen. We have a large, dedicated unit that already goes to great lengths to keep our patients safe, but we are open to change. Through a streamlined process of data collection, we are looking forward to finding out not just what we can improve on, but what we are doing right.