Keeping Breathing Tubes In

Intensive care units make big progress to reduce unplanned extubations

By Karyn Enzweiler

Once it happens, you never forget. A breathing tube becomes dislodged unexpectedly. Monitors beep. Nurses, respiratory therapists and providers struggle to intubate again. CPR begins. For our tiniest patients, a mere half of a centimeter in tube placement can make all the difference for a shorter hospital stay, time on a ventilator, airway damage and even death. The stakes are high. The reward even greater.

The unplanned extubation team answers the call, but it takes a village to look after our patients’ airways, learn from one another and make a change. Today, teamwork is paying off across our intensive care units. Unplanned extubations are down 83 percent. In the Pediatric Intensive Care Unit (PICU), it’s been over 200 days since the last event. And with less harm, we’re saving an estimated $1.24 million for our patients and families.

Protectors of the Airways

The Performance Leadership Team added unplanned extubations to our hospital-wide serious harm metric in fiscal year 2020, though it’s been an ongoing improvement effort for years. The focused attention as an institutional goal helped it to shine and shifted the mindset that we could conquer variability to prevent these events from happening together. “This is my airway. I protect it,” became the motto of respiratory therapists, according to Mike Jaeger, RT, clinical manager. Jaeger has been overseeing the improvement work in the PICU that starts and ends with the frontline staff. “We needed to understand the day-to-day care, the current barriers. We needed to learn,” said Kristin Melton, MD, the physician lead for the improvement work. Julie Zix, RN, serves as the nursing lead on the team to round out our Operational Excellence model of physicians and nurses partnering to deliver better outcomes and experience for our employees, patients and families. But success hinged on frontline staff like Theresia Tuttle, a respiratory therapist of 26 years here, delivering key knowledge about each event and coming up with quality improvement ideas. After an unplanned extubation, Tuttle explains that bedside staff huddle to fill out a questionnaire on what happened and what the team can do better. Was the patient sedated appropriately? Did the patient’s hands touch the endotracheal or ET tube?

Every event is then presented to a larger team for a deeper look at the similarities and differences between events and to learn from one another. “Success wouldn’t have happened without the frontline being aware of the interventions, being in tune with the tubes and the risk associated with them and escalating the challenges that they see daily,” said Zix.

Better Outcomes, Better Care

One of the team’s observations—they noticed a lot of unplanned extubations happening in the Newborn Intensive Care Unit (NICU) during kangaroo care—a method of holding a baby that involves skin-to-skin contact and allows for critical parent bonding time. “We want this bonding experience, but we had to come up with ground rules,” said Angela Saunders, RT, clinical director. “You don’t think about holding a baby and 25 things being attached to her. A reflex of answering the phone or turning around to say something to your partner, now the baby is extubated.” The NICU team started kangaroo care simulations with high-fidelity dummies to show parents, physicians and nurses how to safely transfer a patient who is intubated in a practice setting. Staff also trialed tape and the best technique to secure the tubes. Staff came up with standard holding practices and patient positioning for chest X-rays. Staff put a card alert system in place to warn the care team if a patient was more at risk for an unplanned extubation. Staff instituted readiness discussions on the night shift to identify patients likely to have their breathing tube removed within 48 hours. “An unplanned extubation is traumatizing. By taking care of these tubes, we are instilling a sense of confidence with our families,” said Jaeger.

Gary Herbert would agree. A patient advocate of five years and a former Cincinnati Children’s parent, Herbert has given the family point-of-view on the team, helping to think through how to engage parents or guardians in the decision-making and care and involve them in education at the bedside. “Caregivers have a lot of knowledge about what happens leading up to an unplanned extubation. We can further educate them about what to look for,” Herbert said.

Unplanned Extubation Team

Kristin Melton, MD, medical director lead Julie Zix, MSN, RN, clinical director lead Mike Jaeger, RT manager lead Shannon Alten, RT III Shanon Brannen, RT, manager Tammy Casper, clinical program manager Whitney Cooley, RT III Karen Foley, data management specialist Julie Fugazzi, RN III Maria Geiser, patient safety consultant Jennifer Gronauer, RT, education specialist II Ryan Hall, RT II Gary Herbert, patient family advocate Josh Isabell, RT Mary Noonan, RT, manager Lori Passey, RT II Anita Pryor, RN, education specialist II Caitlin Ryan, clinical quality specialist II Angela Saunders, RT, clinical director Jennifer Saupe, education director Theresia Tuttle, RT III Whittney Brady, DNP, RN, executive champion Dave Mayhaus, PharmD, MS, executive champion

All Teach, All Learn

We’ve shared our successes. We’ve learned from the success of other hospitals in Ohio and across the nation and plan to continue to learn until we get to zero serious harm. Each month, we report our outcomes and measures to the Children’s Hospitals Solutions for Patient Safety (SPS), a network of hospitals working together to reduce patient harm In FY20, we had 34 fewer unplanned extubations than the year prior. Our fortitude to improve even earned the team recognition in SPS’s Shine report as a top performer.

“People are seeing that if we practice good work habits, results will happen,” said Jaeger. “It’s exciting. People are looking for the next initiative to see what we can do to reduce events even further.” For Tuttle, she couldn’t be prouder to champion this work and do her part to keep ET tubes in place until we have a plan to safely take them out.

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