Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project

Infographic · Jun 2024 · 1 min read

In brief

Quality improvement initiative in a NICU reduced postoperative unplanned intubations by 76% through implementation of an extubation readiness checklist and non-opioid pain management protocol. The intervention also correlated with significantly decreased 30-day mortality without increasing pneumonia rates or hospital length of stay.

Extubation readiness checklists reduced unplanned NICU reintubations by 76% (0.27 to 0.07 events per patient) after pediatric surgery.
Shifting from opioids to non-opioid analgesics (acetaminophen) decreased postoperative respiratory complications without increasing pain.
Multidisciplinary QI targeting high-risk NICU patients lowered 30-day mortality from 6.5% to 0.7% (p<0.001).
Case review identified preventable causes; standardized protocols (extubation criteria, pain guidelines) drove sustained improvement.
No increase in pneumonia or length of stay despite reduced opioid use, validating safety of non-opioid postoperative analgesia.

Written by the GCMD Library team from the infographic.

Medical infographic with clean layout featuring four numbered panels arranged horizontally. Each panel contains anatomical cross-section illustrations in blue and pink tones showing fetal spinal anatomy and surgical technique. Bottom section displays outcome statistics with bar graphs and percentage data in blue highlighting boxes.

Peter Juviler, Jeffrey M. Meyers, Elizabeth Levatino, Jessica Axford, Erin Barker, Lynnie Correll, Andrew S. Decker, John Faria, Marjorie Gloff, Anthony Loria, Margo McKenna, Jan Schriefer, Timothy P. Stevens, Sarah Verna, Sarah Wegman, Kori Wolcott, Derek Wakeman

Background: Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year.

Methods/Intervention: A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods.

Results: Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019–June 2022, n = 145) compared to the pre-intervention group (January 2016–August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001].

Conclusions: Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness.

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