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Solutions for Patient Safety Fall 2020 Learning Session Abstracts

Quality Improvement Effort to Decrease Unplanned Extubations in a Cardiac Neonatal Intensive Care Unit

Kim, Faith MD*; Brooks, Cristina MN; Villaraza-Morales, Sylvia MSN; Daven, Jessica BSN; Bradley, Sonya AS; Chhipa, Aalya K. BSN; Brachio, Sandhya S. MD; Vargas, Diana MD§

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Pediatric Quality and Safety: March/April 2021 - Volume 6 - Issue - p e451
doi: 10.1097/pq9.0000000000000451

In the abstract “Quality Improvement Effort to Decrease Unplanned Extubations in a Cardiac Neonatal Intensive Care Unit,” published 29 March 2021, the affiliation for the author Sandhya S. Brachio was incorrectly listed. It has been updated to the correct affiliation, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, NY. Further, a figure was omitted, which has been added to the updated version of the article. The publisher regrets the errors.

Pediatric Quality & Safety. 6(3):e465, May/June 2021.


Unplanned extubations (UEs) can cause serious complications in neonates in the neonatal intensive care unit (NICU). In September 2017, NYP Morgan Stanley opened a 17-bed infant cardiac NICU in addition to the existing 58-bed general NICU.


To determine baseline UE rate and implement initiatives to decrease the baseline rate to <0.5 UE per 100 ventilator days and maintain this rate for at least a year.


Baseline UE data were collected in the infant cardiac NICU from October 2017 to January 2018. This quality improvement project was conducted over 20 months (February 2018–September 2019) and utilized a key driver diagram to identify and test 13 Plan-Do-Study-Act cycles. Initial cycles focused on standardization of tape securement and maintaining endotracheal tube (ETT) placement. Outcome measures and interdisciplinary debriefs after each UE informed subsequent cycles. Subsequent cycles focused on the communication of correct ETT depth, recognition and management of high-risk patients, and understanding the impact of an UE.


Baseline data in the infant cardiac NICU were 0.92 UE per 100 vent days. This decreased to a mean rate of 0.50 UE per 100 vent days.


Through implementation of initiatives using a multidisciplinary approach UE rates decreased, cycles which standardized securement and maintenance of ETTs have been incorporated into routine care. Single institution experience with different respiratory or ventilator management may not be applicable to other NICUs (eg, the majority are nasally intubated).

Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.