Unplanned Extubations (UEs) are the fourth-most common adverse event in the nation\u2019s Neonatal Intensive Care Units (NICU) and can lead to airway trauma, bleeding, and cardiovascular collapse (Kambestad, 2019). Exposure to one or more UE is associated with a nearly one-week increase in the duration of mechanical ventilation, an additional 10 days in the hospital, and\/or patient demise (Sadowski, 2004).<\/p>\n
KP San Francisco\u2019s NICU had 4 UEs occurred out of less than 300 total ventilator days in 2023, averaging a rate of 1.3 UE per 100 ventilator days, while the national benchmark for like units is <1 UE per 100 ventilator. In response, a multidisciplinary team worked to develop and implement a UE prevention bundle with the aim of reaching and maintaining the <1\/100 UE rate goal for 2024.<\/p>\n
After an apparent cause analysis (ACA) using the UE questionnaire of the 4 UE events, a multidisciplinary team identified the need to develop and implement a UE prevention bundle with the aim of reaching and maintaining the <1\/100 UE rate goal. UE prevention practices across comparable NICUs in the region were compiled and a literature review of articles through PubMed, Cochrane, and CINAHL for bundle components was conducted. Findings support the implementation of a UE Prevention Bundle that consisted of 8 different pieces. A performance improvement plan using the Plan Do Study Act (PDSA) was developed to support bundle education, implementation, and ongoing compliance. The UE Prevention bundle was rolled out on March 1st, 2024. KPSFO has had 0 UE since bundle implementation and surpassed the goal of 1.0 UE per 100 ventilator days on November 1st, 2024.<\/p>\n","protected":false},"excerpt":{"rendered":"
Unplanned Extubations (UEs) are the fourth-most common adverse event in the nation\u2019s Neonatal Intensive Care Units (NICU) and can lead to airway trauma, bleeding, and cardiovascular collapse.<\/p>\n","protected":false},"author":1,"featured_media":2945,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_custom_body_class":"","_custom_post_class":"","footnotes":"","_links_to":"","_links_to_target":""},"categories":[56],"tags":[],"ncal_area":[92],"site_only":[],"report_year":[58],"class_list":["post-1719","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exemplary-professional-practice","ncal_area-san-francisco","report_year-58","entry","has-media"],"yoast_head":"\n