Reducing Unintended Extubation Rates in the Children’s National Neonatal Intensive Care Unit (NICU): A Quality Improvement Project

Background: Unintended Extubations (UE) are the 4th most common adverse event in the Neonatal Intensive Care Unit (NICU). They are associated with hypoxia, hypercarbia, airway trauma, subglottic stenosis, intraventricular hemorrhage, and code events. Most notably patients experiencing UEs have almost double the length of stay compared to those who do not. The cost of care increases by $36,000 per patient per admission with each UE. As a quality index for the US News and World Report (USWNR), NICUs strive to keep the UE median rate below the threshold (< 1 events/100 …