2011 NACHRI Annual Leadership Conference Poster

Implementing Lean to Reduce Unplanned Extubations in the ICUs

Mirtha Gonzalez, MSN, ARNP, Director NICU and 2 North
Deborah Salani, ARNP, MSN, Director-Pediatric Intensive Care Unit
Maria Lina "Bing" Wood, ARNP, MSN, Administrative Director of Critical Care Services
Miami Children’s Hospital, Miami, FL

Learning Objectives:   After viewing this poster, attendees should be able to:

  1. Define UEs and review incidence and risk factors.
  2. Utilize Lean as a process improvement strategy to reduce UEs.  
  3. Strategize to prevent UEs in all ICU's.  

The purpose of this initiative was to reduce the rate of unplanned extubations in all ICUs (Neonatal, Pediatric, and Cardiac) by at least 25 percent. We hypothesized if all ICU teams worked together in collaboration with the respiratory department, and standardized how we practiced we could reduce our unplanned extubation events.
Initiative Description:
As a result of our Lean initiative, we identified the following Kaizen and Quick Hit opportunities: Kaizens:

  1. 25 unplanned extubations in 5 months (between Oct to February 2010).
  2. Eleven of the twenty UE were procedure related.
  3. 14 UE or 56 percent maybe caused by self-extubation.
  4. Variations in gauging difference for self extubations.

Quick hits:

  1. UE are not communicated to all stakeholders 100% of the time.
  2. Variations in taping/securement of ETT.
  3. No staffing allowances in acuity during the patient weaning phase from ventilator
  4. No handoff process between fellows and nursing and or between RN to RT.

The baseline data points were our UE rates for each of the ICU's. Recognizing that our rates of UE were high, we wanted to explore ways of preventing these events. The literature review revealed there were no pediatric studies evaluating a specific method for tube/patient care toward minimizing UEs.
Results/Outcomes or Potential Results/Outcomes:
We met our goal of reducing unplanned extubations for all combined ICU's by 39 percent. Both the PICU and NICU reduced the unplanned extubation rate by 50 percent or greater.
Lessons Learned:
Lessons learned - teamwork and collaboration were the key elements for our success. All ICU's including the nursing and medical teams, along with the radiology and respiratory departments worked together on this Lean initiative. We started this project by completing a Value Stream Map, which allows you to better understand your processes. Based on the findings from the VSM, we identified Kaizens and Quick Hits which included standardizing how we provide care to children who are intubated. Standardizing our care has allowed us to assisted in preventing unplanned extubations.
Future of Initiative/Next Steps:
We have planned a special picnic to celebrate our success. Recognizing our biggest challenge is to sustain our results. We communicate our unplanned extubation episodes in our weekly huddles and staff meetings.

Presenter Biography:

Mirtha Gonzalez, MSN, ARNP, Director NICU and 2 North
Miami Children’s Hospital, Miami, FL

Deborah Salani, ARNP, MSN, Director-Pediatric Intensive Care Unit
Miami Children’s Hospital, Miami, FL

Debbie Salani has practiced at Miami Children’s Hospital for 20 years in various capacities.  At the present time, Debbie is the Nursing Director of the Pediatric Intensive Care Unit.  She previously served as the Director of the Emergency Department.  Debbie has published extensively on Hematology/Oncology and Critical Care topics.  Debbie received a BS degree in Psychology from Marywood University in Pennsylvania and her BSN and MSN from the University of Miami, Magna Cum Laude. President and Chief Executive Officer for five years.  She previously served as Senior Vice President at City Children’s Hospital.  Jane has extensive experience working in a team environment to improve quality and safety and, under her leadership, Children’s Hospital has been recognized by Organization for its advancements.  Children’s Hospital has grown a total of 25 percent towards the goal of 50 percent.  The new team initiatives will be replicated in other departments.  As a recognized safety and quality expert Jane serves on the National Safety Board.  She received a M.S.N., M.B.A., from State University.

Maria Lina “Bing” Wood, ARNP, MSN, Administrative Director of Critical Care Services
Miami Children’s Hospital, Miami, FL

Maria Lina “Bing” Wood received her BSN from Mountain View College, obtained her MSN, ARNP from Florida International University. As an Administrative Director, she oversees the practice of nursing across the clinical settings and the alignment of nursing care in the critical care including Critical transport team and Pulmonary services. Bing has a distinguished career of over 30 years and has led the PICU team to achieve AACN Beacon Award, excellence in critical care and the ELSO award, excellence in Life Support in 2008. She has served on the NACHRI CPSP advisory council. A member of several professional organizations.

Related Files
Implementing Lean to Reduce - Eposter (Adobe PDF File)