1. Smith, Joan R. PhD, RN, NNP-BC, FANN

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Large neonatal and pediatric collaboratives are working together and learning from one another with the goal to eliminate serious harm across individual hospitals and neonatal intensive care units (NICUs).1-3 These collaboratives employ high-reliability principles and quality improvement (QI) methods by standardizing care through implementation of evidence-based care bundles and an infrastructure that uses robust data collection, analysis, and transparency, while sharing with and learning from one another. Measurement is key to testing and implementing change; it tells a team whether or not their change is making an improvement. Measurement for QI differs from research in that it aims to bring new knowledge into daily practice, not to discover new knowledge. In addition, measurement is based on many sequential iterative and observable tests, also known as tests of change or plan-do-study-act (PDSA) cycles.4 There are 3 basic types of QI measurement: outcome, process, and balancing measures. Improvement teams often focus on outcome and process measures but fail to spend time discussing balancing measures. Balancing measures should be tracked to ensure that an improvement in one area is not negatively impacting another area. Balancing measures are important for all preventable harm work, including unplanned extubations (UEs).


Although a single universal definition of UE does not currently exist, a UE is typically any dislodgement of an endotracheal (ET) tube from the trachea that is unintentional and is one of several preventable harm topics that has gained much attention due to its adverse effects, including rapid cardiorespiratory deterioration. NICUs are defining and standardizing practices to prevent a UE from occurring. Interprofessional teams are critical in reviewing each UE and determining whether the UE meets the established criteria, whether or not there are potential causes that precipitated the event, and to provide lessons learned and closed-loop feedback to frontline staff in an effort to continuously improve. Precipitating factors that can lead to a UE include ET tube retaping/repositioning, patient care (eg, suctioning), patient movement, infant repositioning, procedures, weighing, loose tape device, or kangaroo care/holding. Historically, the mind-set toward UE for many NICU providers was indifferent, with the belief that infants who required mechanical ventilation were at risk for ET tube dislodgement and it was just part of being in the NICU (similar to the belief of a bloodstream infection many years ago). The thought was that if the ET tube dislodged, there was typically a trained neonatal provider readily available to reinsert the tube. Fortunately, today there has been a culture shift and healthcare team members recognize that UEs are preventable by proactively identifying at-risk infants and being vigilant in the care provided to reduce harm. As part of QI, teams track process and outcome measures and typically review each UE as an interprofessional team to determine potential causes/precipitating factors, risks, and whether or not the infant met the UE criteria. However, balancing measures are often not discussed, even though they are critical to ensure that an improvement in one area does not negatively impact another. An example of a balancing measure for UE that could negatively impact another area is the frequency of kangaroo care. Recently, in an effort to improve UE rates, some caregivers have become reluctant to encourage parents to hold or engage in kangaroo care. This is a travesty and interferes with developmental and family-centered care progress! For decades, developmental and family-centered care experts have worked to encourage caregivers to implement an evidence-based neurodevelopmental supportive care strategy, kangaroo care, because of its direct impact on the infant, parent, and infant-parent dyad. Reluctance to promote or offer kangaroo care to parents may be due to fear of infant safety, lack of experience, lack of time, lack of assistance, interrupted workflow, heavy nursing staff load, or fear of reprisal if an event occurs or if UE rates do not improve.


In order for providers to be equipped to successfully transfer ventilated infants to their mother or father for holding or kangaroo care, systematic training is required. A standardized training program aimed at safe kangaroo care transfer is a critical first step for caregivers to become confident and competent. Planning for kangaroo care, with parents, during the nurse's shift and monitoring the patient and plan can help alleviate uncertainty and nervousness. Kangaroo care is beneficial for NICU patients and can be performed safely, with beneficial impact on ventilated extremely low-birth-weight infants (<1000 g).5 Hands-on training with the use of simulation, lifelike mannequins, and structured scenarios can successfully build competence and confidence and allow for return demonstration and debriefing in a safe, nonpatient care environment.6 In addition, nurse, respiratory, and physician champions can serve as content experts and resources for high-risk 2-person transfers. Parents should also be educated on the benefits of kangaroo care and the potential risks and risk-reduction strategies the care team will use as they partner with them to ensure a safe transfer.


As improvement teams continue to pursue zero harm, all 3 measurement types (outcome, process, and balancing measures) are warranted to ensure that change is resulting in an improvement and untoward downstream effects are not negatively impacting another area of high importance. Similar to collecting and analyzing process and outcome data, balancing measure data should be collected, analyzed, and transparently displayed and shared with caregivers so that they can see their performance and know what to work on to improve. The goal is not only to eliminate harm but also to improve the outcomes of our most vulnerable patients and families.


-Joan R. Smith, PhD, RN, NNP-BC, FANN


St Louis Children's Hospital


St Louis, Missouri




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