Building the Driver Diagram: A Mixed-Methods Approach to Identify Causes of Unplanned Extubations in a Large Neonatal ICU.

BACKGROUND: The key driver diagram (KDD) is an important tool used by improvement teams to guide and frame their work. Methods to build a KDD when little relevant literature or reliable local data exist are poorly described. This article describes the process used in our neonatal ICU (NICU) to build a KDD to decrease unplanned extubations (UE) in chronically ventilated infants. METHODS: Twenty-seven factors hypothesized to be associated with UE in our NICU were identified. An expert panel of 33 staff members completed three rounds of a modified Delphi process administered through an online interface. After the third round, panel members provided suggestions for interventions to target all factors meeting criteria for consensus. These qualitative data were analyzed by inductive thematic analysis. A follow-up survey to all panel members was used to assess the feasibility of this process for future use. RESULTS: After three Delphi rounds, 14 factors met consensus and eight main interventions were identified through thematic analysis. These data were used to build a KDD for testing. All participants who completed the follow-up survey (20/20) stated willingness to participate in this process in the future and 18/20 (90%) stated they would be "more willing" or "much more willing" to support interventions developed using this process. CONCLUSION: A novel mixed-methods approach was used to generate a KDD combining a Delphi process with thematic analysis. This approach provides improvement teams a rigorous and reproducible method to understand local context, generate consensus KDDs, and improve local buy-in for improvement interventions.

Increasing Volume-Targeted Ventilation Use in the NICU.

BACKGROUND: In preterm infants who require mechanical ventilation (MV), volume-targeted ventilation (VTV) modes are associated with lower rates of bronchopulmonary dysplasia compared with pressure-limited ventilation. Bronchopulmonary dysplasia rates in our NICU were higher than desired, prompting quality improvement initiatives to improve MV by increasing the use of VTV. METHODS: We implemented and tested interventions over a 3-year period. Primary outcomes were the percentage of conventional MV hours when any-VTV mode was used and the percentage of conventional MV hours when an exclusively VTV mode was used. Exclusively VTV modes were modes in which all breaths were volume targeted. We evaluated outcomes during 3 project periods: baseline (May 2016-December 2016); epoch 1 (December 2016-October 2018), increasing the use of any-VTV mode; and epoch 2 (October 2018-November 2019), increasing the use of exclusively VTV modes. RESULTS: Use of any-VTV mode increased from 18 694 of 22 387 (83%) MV hours during baseline to 72 846 of 77 264 (94%) and 58 174 of 60 605 (96%) MV hours during epochs 1 and 2, respectively (P < .001). Use of exclusively VTV increased from 5967 of 22 387 (27%) during baseline to 47 364 of 77 264 (61%) and 46 091 of 60 605 (76%) of all conventional MV hours during epochs 1 and 2, respectively (P < .001). In statistical process control analyses, multiple interventions were associated with improvements in primary outcomes. Measured clinical outcomes were unchanged. CONCLUSIONS: Quality improvement interventions were associated with improved use of VTV but no change in measured clinical outcomes.

Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations.

BACKGROUND: Patient safety events result from failures in complex health care delivery processes. To ensure safety, teams must implement ways to identify events that occur in a nonrandom fashion and respond in a timely manner. To illustrate this, one children's hospital's experience with an outbreak of unplanned extubations (UEs) in the neonatal ICU (NICU) is described. METHODS: The quality improvement team measured UEs using three complementary data streams. Interventions to decrease the rate of UE were tested with success. Three statistical process control (SPC) charts (u-chart, g-chart, and an exponentially weighted moving average [EWMA] chart) were used for real-time monitoring. RESULTS: From July 2015 to May 2016, the UE rate was stable at 1.1 UE/100 ventilator days. In early June 2016, a cluster of UEs, including four events within one week, was observed. Two of three SPC charts showed special cause variation, although at different time points. The EWMA chart alerted the team more than two weeks earlier than the u-chart. Within days of discovering the outbreak, the team identified that the hospital had replaced the tape used to secure endotracheal tubes with a nearly identical product. After multiple tape products were tested over the next month, the team selected one that returned the system to a state of stability. CONCLUSION: Ongoing monitoring using SPC charts allowed early detection and rapid mitigation of an outbreak of UEs in the NICU. This highlights the importance of continuous monitoring using tools such as SPC charts that can alert teams to both improvement and worsening of processes.