(1076) Reducing Unplanned Extubations in the Intensive Care Nursery – Sustaining the Gains

Unplanned extubation events (UPEs) in neonates are considered as a serious hazard to patient safety and have been associated with a wide range of serious life threatening consequences. However, data on outcomes of UPE, best prevention strategies in preterm and term newborns in the neonatal intensive care unit (NICU) and target rates of UPEs in this population are limited. The incidence of UPEs within NICUs is not well defined, and studies have reported rates ranging from 0.14 to 5.3 UPE per 100 ventilator days. Neonates are considered to be at higher risk for UPEs because of the challenges of securing an artificial airway on a small face with immature skin, longer intubation times, use of uncuffed endotracheal tubes (ETTs) and lack of routine use of sedation and paralysis while mechanically ventilated. Learners will gain insights into how to institute a quality improvement initiative to reduce UPEs in their unit.