123 - Brave enough to try, smart enough to stop: A lesson in knowing when to discontinue a new intervention

Publication Number: 3117.123

Megan A. Derrer, University of Tennessee Health Science Center College of Medicine, Collierville, TN, United States; Lauren M. Brodskiy, Le Bonheur Children's Hospital, Germantown, TN, United States; Ashley Cleveland, Le Bonheur Children's Hospital, Oakland, TN, United States; Marley M. Lemons, Le Bonheur Children's Hospital, Memphis, TN, United States; Sandeep Chilakala, uthsc, Germantown, TN, United States

Background: Unplanned extubations (UPE) are common in the NICU, with many institutions working to decrease their incidence. UPE can come with an array of adverse outcomes, from cardiovascular collapse to airway trauma. At our Level 4 NICU, we established a multidisciplinary Unplanned Extubation Taskforce in 2016 to decrease our rates of UPE. We are also members of the Solutions for Patient Safety (SPS) Collaborative. In 2025, we identified failure of the endotracheal tube (ETT) securement device as one of our largest contributors to UPE and sought innovative techniques and products to address this barrier.

Objective: To present the trial of a novel ETT securement device in our unit, and highlight the factors that led to the trial's discontinuation. We will not discuss the specific device.

Design/Methods: We followed the IHI model for improvement. We implemented and evaluated PDSA cycles and tests of change.

Results: Our UPE Taskforce's initial interventions were successful in decreasing our UPE rate from 1.745 per 100 vent days in 2022 to 1.25 per 100 vent days in 2024, with occasional spikes associated with new staff requiring education. We hoped to see a further decrease in our events with a new securement device, but expected there to be a learning curve with a new product. Significant preemptive work with the vendor and staff education was undertaken. There was an increase in UPE rate during the first PDSA cycle to 3.5 per 100 vent days; more collaboration with the vendor and intensive staff education was completed, with continued exacerbation in UPE rate to 4.5 per 100 vent days, up to 5 times our monthly average. After thorough discussion among Taskforce members and NICU leadership, the decision was made to discontinue the PDSA cycle and revert to the previous securement method. Subsequently, UPE rates declined to 0.5 per 100 ventilator days.

Conclusion(s): Our experience underscores the importance of continuous evaluation of new interventions to sustain progress, in our case with UPE. While the securement device itself may not be inherently flawed, its implementation in our unit was impacted by system level factors such as staff turnover and patient complexity. The decision to discontinue the PDSA cycle should not be viewed as a failure, but rather as a proactive measure to safeguard patient outcomes and refocus improvement efforts. This case highlights the value of adaptability and team collaboration in quality improvement initiatives.

Figure 1. Control chart demonstrating unplanned extubation rate


Figure 2. Key driver diagram of contributors to unplanned extubation
The key driver diagram focuses on a wide variety of potential contributors to unplanned extubation. This specific intervention placed emphasis on endotracheal tube securement device failure.

Figure 3. Fishbone of potential contributors to increase in rate of unplanned extubation
Beyond the new device itself, there are a number of system level, patient level, and other equipment factors that may have led to our increased number of unplanned extubations, which we explore here.