Unless you’re a caregiver in one of the hospital’s intensive care units, the terms intubation and extubation might not mean much to you. But as manager of respiratory services, Bonnie Powell, lives and breathes these terms daily as she tracks the hospital’s most medically fragile patients.
Intubation is the term for placing a tube (that is attached to a mechanical ventilator) in a person’s windpipe to deliver air into the lungs. It’s often used in patients with respiratory disease, congenital anomalies or premature lungs to help them receive oxygen.
One of the biggest risks facing pediatric patients on a ventilator is an unplanned extubation. That’s why Akron Children’s is participating in an improvement collaborative on unplanned extubations as part of a nationwide pediatric pioneer cohort through Children’s Hospitals’ Solutions for Patient Safety (SPS). SPS is a collective network of more than 135 children’s hospitals whose goal is for no child to experience serious harm while in their care.
“SPS believes in setting competition aside and sharing our safety successes and failures,” Bonnie said. “Our goal is to learn and share ideas we may never have thought of to ensure every child is safe in our care.”
“Unplanned extubation happens when the breathing tube becomes accidentally dislodged,” Bonnie added. “These spontaneous extubations are more common in the neonatal patient population because NICU babies aren’t restrained or sedated like PICU (pediatric intensive care) patients.”
Research shows that unplanned extubations can cause increased lengths of stay, cardio-pulmonary collapse and trauma to the patient and family. As part of the cohort, all hospitals had to come up with standardized guidelines so they were testing similarly.
“We have standardized how we measure, tape and secure the tube at the lip of the patient. Movement is a big reason the tube gets dislodged,” said Bonnie. “It doesn’t always happen all at once, it can happen centimeter by centimeter over time, which is why we measure the tube daily and document it from the same location.”
Another protocol the hospital has implemented is using 2 caregivers for turning the baby, skin-to-skin care, holding, and weighing intubated patients. Bonnie says the hospital is looking to standardize the positioning of the patient during imaging, including making sure the midline, clavicle and chin are straight, in order to check for correct placement of the tube in the chest. Radiology technicians are also beginning to annotate the endotracheal tube measurement on the actual X-ray film.
The hospital has seen a steady decline in the number of unplanned extubations over the past 3 years. This decrease has been most significant in the Akron NICU.
“We went from 61 in 2016 to 34 in 2017 to 13 in 2018 in the NICU,” Bonnie said. “At the SPS National Learning Session it was shared that the regional goal is a 10% reduction over the next 2 years. Our team has set a 2019 goal of having only one unplanned extubation in each unit per month. This will be an easier goal for some units than others, but it’s a starting point.”
Bonnie credits the reduction in unplanned extubations to increased awareness and education among staff as well as patient families.
“When an unplanned extubation happens, we do an ACA (Apparent Cause Analysis) in real time at the bedside so the team can talk about what happened, why it happened and what could have been done differently,” she said. “People are realizing how important this is.”