Implementation Strategies Used to Reduce Unplanned Extubations in the Neonatal ICU
Bibliographic record
Abstract
Background: Unplanned extubation (UE) is the premature or unintended removal of an artificial airway and can cause worse patient outcomes. Study objectives were to describe implementation strategies used to reduce UE in the Hospital for Sick Children neonatal ICU (NICU) and their influence on UE rates, and contributing factors and patient characteristics of infants who had an UE, and compare them between the biological sexes. We hypothesized that the boys would experience more UEs and worse outcomes compared to the girls. Methods: The single-center retrospective cohort study included all infants who experienced UE (2007–2019). Outcomes consisted of implementation reduction strategies developed by using the plan-do-study-act quality-improvement methodology and UE characteristics, including patient (eg, sex, length of stay) and unplanned extubation situation characteristics (eg, events and/or procedures, repeats). Five plan-do-study-act cycles were implemented. Analyses included text summaries of all strategies, and quantitative descriptive and comparative statistics. Results: UE per 100 ventilator days decreased from 3.46 to 0.14. Key success factors included setting achievable goals; ensuring that strategies were evaluated and amended; maintaining consistency over the long-term; incorporating strategies in the NICU; having institutional support and validation; and having good communication. There were 302 UE in 257 infants, 141 boys (55%), average ± SD gestational age of 31 ± 6 weeks, and 31 (12%) had 45 repeated UEs. The only significant difference between the biological sexes was that more boys (129 [92%]) versus girls (94 [83%]) received the Hospital for Sick Children NICU endotracheal tube taping protocol ( P = .030). The incidence of UE occurred in a 2-peaked pattern, highest for those < 32 weeks and ≥ 32 weeks of gestational age. Infants < 32 weeks of gestational age and with repeated UE had longer durations of invasive mechanical ventilation and length of stay. For infants <32 versus => 32 weeks gestational age, the median (interquartile range) duration of mechanical ventilation was 38 (16–77) d versus 6 (3–13) d and hospital length of stay 61 (30–100) d versus 16 (10–41) d. For infants with repeated versus no repeated unplanned extubations, duration of mechanical ventilation was 69 (26–125) d versus 13 (4–52) d and hospital length of stay 90 (39–137) d versus 32 (12–75) d. Conclusions: Detailed well-planned UE reduction strategies significantly reduced the rate of UEs with key factors of success identified. UE characteristics and infant morbidity did not differ between the biological sexes. Infants < 32 weeks of gestational age and with repeated UE had a longer duration of mechanical ventilation and length of stay.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.031 | 0.082 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.003 | 0.002 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.001 |
| Open science | 0.002 | 0.002 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".