Unplanned extubations
A new interprofessional team took on the difficult task of decreasing unplanned
extubations in the NICU in 2013. An unplanned extubation is the accidental removal or
dislodgement of the endotracheal tube, a breathing tube used for patients who cannot
otherwise breathe on their own. The quality improvement team brought together a
committee of nurses, neonatal nurse practitioners, respiratory therapists, physicians and
occupational and physical therapists to develop interventions and staff education that
would reduce the risk of these unplanned extubations.
The work involved educating staff on the rules of “two to move,” which incorporates
two staff members for any patient movement and intervention for intubated patients.
Town halls and workshops were held to inform the staff of the dangers of unplanned
extubations and the proper protocol should an incident occur, which includes informing
the assistant clinical director on call. Through a series of PDSA or “plan do study
act” cycles, the team was able to develop an unplanned extubation bundle that led to
consistent practices and decreased extubations across the entire Newborn Center.
The team took a closer look at each of the neonatal intensive care units focusing on
common issues and issues specific to each NICU. This, along with sharing best practices,
enacting new protocols and educating the staff, helped decrease the rate of unplanned
extubations by 40 percent. The Newborn Center nursing staff was heavily involved
in these improvements through committee participation and testing of potential
improvement practices.
E X E M P L A R Y P R O F E S S I O N A L P R A C T I C E
