 Hi everyone and thank you for joining us today. My name is Sarah Candle. I'm a pediatric intensivist and a quality and safety officer at Yale New Haven Children's Hospital. I'm going to be talking to you today about eliminating unplanned extubations in pediatrics. So I have no disclosures or conflicts of interest. I wanted to give you a quick overview of our hospital to paint a picture for you. We're a 209-bed children's hospital. We are level one trauma designated as well as magnet designated. We are the primary pediatric teaching site for Yale School of Medicine. And today I'm going to walk you through the situation we found ourselves in not too long ago and share our journey to zero unplanned extubations in critically ill children. The journey starts with patients. This is a word cloud with all the names of children affected by unplanned extubations within a 10-year time frame. They're often called self-extubations or dislodged tubes or accidental extubations. As you can see this was a common occurrence at our institution when we began this journey 10 years before. And what we know about unplanned extubations is that they're both a safety threat and an economic burden. It truly is an emergency situation when this occurs. Literature shows that two-thirds of pediatric patients require re-intubation and 20% have a significant cardiovascular collapse, meaning that they require CPR or vasoactive medications such as EPI. Roddy and his colleagues were able to demonstrate that each case added over $36,000 to an admission. We initially started looking into unplanned extubations in our pediatric ICU and we were alarmed to find we had high rates just to give you a little more background. To walk you through this run chart which shows unplanned extubations in the pediatric ICU from 2010 to 2015, you can see that our rate was 2.4 per 100 ventilator days. You can see across the x-axis is the number per year and up the y-axis is the rate adjusted for every 100 ventilator days. At the time there was no set benchmark but we now know that the acceptable benchmark is somewhere around one per 100 ventilator days. This is shown here in red. As you can see we were two and a half times the higher than acceptable rate. This was alarming to our group and likely this was an underrepresentation as a culture at this time was not to report these events. Often they were only known about via word of mouth. We knew we had work to do and so we started forming an airway steering committee. It was a multidisciplinary group with representation from executive leaders, quality and safety, providers, respiratory therapists, nursing staff, the supply chain, and even diagnostic imaging. We involved all areas where unplanned extubations occurred, the OR, the neonatal ICU, as well as the pediatric ICU. Our first question was to look at what the root cause of these events truly was. We found that it was multifactorial and involves securement factors such as the standardization of tape or device used, the type of tape which reference points were being utilized, patient specific factors such as the level of sedation restraints or secretions, and external factors specifically around moving patients, the procedures being done on patients, and even the overall culture that was occurring at the time. All of this played into the maintained maintenance of an airway or ET2. This is an example of the key driver diagram we generated. For those in the QI world you know it really represents a roadmap of where our efforts should focus. Our smart aim and primary goal was to decrease the rate of unplanned extubations to less than one per 100 ventilator days over a two-year period in all critical care areas. We identified four key drivers, the culture, the securement of the ET2, protocols around high-risk situations and sedation factors as our main drivers. You can see early interventions revolved around standardizing of the securement device reference points and coming up with a protocol for high-risk situations. We also joined a collaborative with the Children's Hospital's Solution for Patient Safety, which was also beginning work to reduce the serious safety threat. For those of you who may not be familiar with the Children's Hospital's Solution for Patient Safety, this is a group of over 130 Children's Hospitals, similar to the Patient Safety Movement Collaborative, and their work is to establish best practices and overall reduce harm. They put forth a working group to address unplanned extubations with a motto really of all teach, all learn, and it was with this platform that we were able to share ideas and collaborate with other centers about what worked and what didn't work to reduce unplanned extubations. We went through many plan-do study acts or PDSA cycles from which tapes to use, which securement devices, different bedside reminders, including even things such as magnets to alert patients and staff about which airway was critical or not. Some we kept and some we abandoned. Through these small tests of change, we learned what worked for us and our patients to help keep them safe. We found that one size did not fit all, but this is our current standard bundle for maintaining the ET tube. First, we use a standard reference of the teeth or gum and a standard securement depending on the age group. For example, in the neonatal ICU, we use a device for the newborn infants. For infants over in the pediatric ICU with a four to five tube size, we use a standard taping method. And for those with a tube size over five, again, we use a standard device. The second thing we did was to ensure that all events were reported. We also do a review of each unplanned extubation event. We use a short apparent cause analysis form, which is 10 questions that the bedside team can answer to help categorize and understand vulnerabilities. The third thing we did is develop a protocol for high risk situations, including an airway guardian. An airway guardian is someone trained in the ET tube maintenance. They are responsible for the tube during these high risk situations, such as a movement of the patient. And this form would give an example of what the airway guardian would do. So two staff would always be present. And one is assigned as the airway guardian. They would ensure that the ventilator has enough slack, disconnect if needed to accommodate the position change. They would use a verbal cross check to ensure that everyone is aware about the tube. So as an example, they would say before we move Jane, I have 13 at the teeth and then confirm that the tube is at 13 at the teeth. The last thing we did was make sure that this was included in the standard operating procedure across the institution. So this highlights for everyone that this is part of our safety initiative for all airway devices and that staff continually cross check each other. The most recent intervention we've been working on is to standardize our chest x-ray film quality and to include the unplanned or to include the ET tube depth on the x-ray itself. So to ensure that it is standard, we make sure that all patients are midline and neutral with the chin in that neutral position. We ensure that there is no equipment obstructing the field and then the RT or RN will confirm where the tube is taped and ensure that this is documented on the film. Many of the interventions done have quickly spread across the hospital and truly have become part of our airway campaign. This is an example of our keep your eyes on the little guys signs. These are on ventilators and doorways throughout the critical care areas and notify the staff quickly if there's an emergent situation or repositioning is needed. So what has been our assessment of all this unplanned extubation work? Is it working? Here is one of several control charts that I'll show you. First to orient you, remember that our prior slide had showed our rate of 2.4 per 100 ventilator days. I've displaced this up in the corner. The bigger graph in the middle is the more recent data up to December 2019. Across the bottom is the date and across the y-axis is the unplanned extubation per 100 ventilator days. You can see our centerline started near 0.7 and that we've shifted down to 0.3 per 100 ventilator days. This is across the entire hospital. Most recently, we have shifted back up to 0.5, but we've always been below our goal of one per 100 ventilator days over the last five years. This graph is also annotated about interventions that we have done and when we have done them. I will now walk you through each unit. You can see in our NICU, which is spread out over two campuses, our rate continues to be low. Our centerline is 0.34 currently and has been that way for many quarters. We did have a few spikes and we've gone back to look at those individually. Specifically, we had one around kangaroo care and we found that there had been changes in practice related to that. So our team worked together with the new needle ICU and have adjusted the practice for kangaroo care and have since brought the rate back down. This is the run chart for our pediatric ICU over the last five years and you can see our centerline started slightly higher but still less than one per 100 ventilator days and decreased to about 0.5. We were also very proud to report that we went one year in the pediatric ICU with no events. This was a huge celebration for our team. It showed us that it truly was possible to get to zero unplanned extubation events. We also realized through this work, though, that sustaining this was a challenge and we have again spiked up into 0.5 per 100 ventilator days. So to review the lessons that we have learned and provide some guidance around recommendations in starting your journey, we realized that this really is a true team sport. You need buy-in from all players, both the frontline staff and leaders. It's very important to have leader rounding. Often I felt like the airway police. I would walk into a room and people would start telling me about where the tube is taped and when it was re-taped. But it really was necessary to be present and for people to be able to understand why this was so important. We have learned a lot about understanding variation. We knew one size did not fit all and we needed to standardize the procurement and minimize variation as much as possible. We also appreciate the small tests of change and the challenges with sustainability. When people ask what the biggest driver of change is, I would really say it's been the change in our safety culture. So the main focus of creating a successful safety culture was to understand where we were and where we needed to be. There was a multitude of concepts and strategies that we utilized as part of our culture change work. The overall goal of building a culture of safety, where that was the priority, our true north metric that would bring us to preventing patient harm. We immediately realized this was a team sport. It could not be a squeeze or a push from one end, but that from involved the frontline staff, physician, nursing, respiratory therapy, and even the patients and families. Safety is not something you can delegate as leaders. We're individually responsible to make safety happen and promote it within our areas. I want to give a big thank you to such a great team. It's been a wonderful team to work with and such a great journey to be involved in. And I thank you all for your time and attention and look forward to discussing more with you. Thank you.