Prevention of unplanned extubations in neonates through process standardization
| Autor: | Alison J. Carey, Diana Davis, David Cooperberg, M Frost, Endla K. Anday, T D Fontánez-Nieves |
|---|---|
| Rok vydání: | 2016 |
| Předmět: |
Male
medicine.medical_specialty Pediatrics medicine.medical_treatment Airway Extubation Patient Care Planning 03 medical and health sciences Patient safety 0302 clinical medicine Risk Factors Intensive Care Units Neonatal Patient-Centered Care 030225 pediatrics Preventive Health Services Intubation Intratracheal medicine Humans Intubation Staff Development 030212 general & internal medicine Neonatology Endotracheal tube business.industry Infant Newborn Obstetrics and Gynecology Gestational age Baseline data Quality Improvement Outcome and Process Assessment Health Care Pediatrics Perinatology and Child Health Female Level iii business |
| Zdroj: | Journal of Perinatology. 36:469-473 |
| ISSN: | 1476-5543 0743-8346 |
| DOI: | 10.1038/jp.2015.219 |
| Popis: | Unplanned extubation events (UPEs) in neonates are hazardous to patient safety. Our goal was to reduce UPE rate (#UPEs per 100 ventilator days) by 50% in 12 months at our 25-bed level III inborn unit. Baseline data were gathered prospectively for 7 months. Three Plan-Do-Study-Act (PDSA) cycles targeting main causes of UPEs were developed over the next 20 months. Causes of UPEs were analyzed using Pareto charts; and a U control chart was created with QI Charts©. Standard rules for detecting special cause variation were applied. Mean UPE rate decreased from 16.1 to 4.5 per 100 ventilator days, a 72% decrease, exceeding our goal. Analysis of U-chart demonstrated special cause variation, with eight consecutive points below the mean. Improvement was sustained throughout the study period. UPEs in neonates can be reduced with process standardization and frontline staff education, emphasizing vigilant endotracheal tube (ETT) maintenance. |
| Databáze: | OpenAIRE |
| Externí odkaz: |
|
Full text from SpringerLink