For Dr. Jawad Javed, Medical Director and Division Head of Neonatology at OSF Healthcare Children’s Hospital of Illinois and Professor of Clinical Neonatology, improving monitoring of endotracheal tube (ETT) movement while implementing kangaroo care and improving unplanned extubation (UE) rates was a priority to ensure the safety of his facilities’ patients. Located in Peoria, Illinois, the 60-bed neonatal intensive care unit (NICU) is a level four with the American Academy of Pediatrics’ designation system. The comprehensive facility is set up with private rooms divided into neighborhoods, with each having between seven to ten rooms. Patients commonly range from 22 to 30 weeks’ gestation, and while Javed and his team belonged to the Vermont Oxford Network of data-driven quality improvement, the global burden of UEs still impacts his facility.
I sat down with Javed and his colleagues — Dr. Ashley Fischer, Quality Improvement Director and Associate Professor of Pediatrics, and John Sanford, Respiratory Therapist of Neonatology — to learn what it meant to integrate SonarMed™ airway monitoring system into their hospital for improving ETT monitoring, enhancing their kangaroo care offerings, and improving UE rates overall.
Jawad Javed: The patients — it’s why it's so important to for us to get a handle on our unplanned extubation rate and to ensure that we are doing more neuro-developmentally appropriate care.
Patient satisfaction for our parents was important — wanting to do kangaroo care and be involved. Having the confidence of holding their babies is a big thing. It didn't matter if they were preemies from 24 weeks up to term infants, whenever we used the device it worked efficiently for us. It gave parents confidence.
We presume that the ETT tended to move during critical moments, but there was no great way to measure and monitor if drifts occurred. There was no good way to determine if you're too high or too low, because the chest X -ray isn’t always the most effective way to diagnose. We wanted to monitor these ETT movements in real time and that's what the SonarMed™ system was able to do for us — give us real-time information as to where that (ETT) tip is.
We pride ourselves on getting that mom-baby connection to start off quickly, so we get into kangaroo care positions early in life. We encourage families to hold their children; however, this does come with increased risk of potential of an unplanned extubations.
We want to provide safer care to improve our unplanned extubation rate and take that metric to the next level. These major interventions* we participated in brought our unplanned extubation rate down from 2.1 to roughly around 1.3 and 1.4 events per 100 ventilator days. We made great headway with our team and a team-based approach, but had a hard time breaking that threshold of below 1.0.
*multiple UE bundle practices
Jawad Javed: Medtronic did a nice job with our onboarding process, and this was a big challenge with COVID-19 and difficulties trying to bring personnel into the hospital.
We went through a champions course initially with our respiratory therapist and our clinical nurse educators to go through the device in a more meticulous fashion, and this education was conveyed to the staff. Medtronic spent time with our group to help the onboarding of all of our staff — a lot of the staff concerns would have been there otherwise.
Because of the great planning and education that was done by John (Lead RT and educator) and his group, our nurse educators, and the Medtronic support working with our staff one-on-one, it removed a lot of obstacles.
Jawad Javed: When I learned about the device, we started with the situation-background-assessment-recommendation (SBAR) process of understanding why we needed it and then spoke extensively about what this device had to offer. We sent it to our products committee, and it was really a matter of where the foundational funding would come from — the capital budget that exists within our unit and the device fit within that process.
I presented to our products committee and executive board. We spoke highly about what this could do for us and strongly believed in the science that existed within the device — it could be a game changer.
The actual purchasing part of it wasn't too bad once we got the approvals. But from a value-based approach, looking at the cost of an unplanned extubation in a premature infant, it becomes cost effective to invest. Additionally, our patient experiences of babies being able to bond quickly with kangaroo care — we try to get these small preemies into the parents’ arms and support skin-to-skin bonding.
Ashley Fischer: For me, it’s families having skin-to-skin contact and performing kangaroo care confidently. But for the mothers — to feel more comfortable holding their child — is valuable. Over the last six to ten months, we still have been doing our kangaroo care and have been able to optimize that a little bit more for patients.
John Sanford: We've embraced the thought of having parents participate in kangaroo care or skin-to-skin care. We encourage this on daily rounds. We always do a patient assessment to see how the patient's doing and if they are able to tolerate getting the baby into the parents’ arms. We facilitate that as much as we can. We don't have too many limitations to keep the baby in the isolette, and even if they're on high-frequency ventilation, that doesn't automatically disqualify them from kangaroo care. But it is a little intimidating when getting the baby out. Making sure we keep the ETT in the proper place can be tense, stressful. Parents pick up on that, and they know when the caregivers are watching more closely.
When we're using the SonarMed™ device during those movements, it reassures us quite a bit and eases that tension while it's in place. While the parents are holding the baby, we tend to turn the monitor towards the parent, and they, too, can watch as that ETT migrates up and down.
It helps parents relax a bit more if the baby moves a little. For parents that have seen an unplanned extubation, it’s terrifying for them, so it's really heartbreaking to hear parents not wanting to participate in kangaroo care after they've had one of those episodes. It’s nice to have this monitor to help reassure them that the tube is where it should be and we're watching.
They can feel that sense of security now with that monitor in line. Parents are more apt to participate in kangaroo care if they can keep an eye on that airway.
John Sanford: Actually, having the device has cut down on repeated ETT movement orders as it’s this dance that we sometimes do with the X-rays. Hopefully we're cutting down on the number of X-rays that we're getting because we can look at the monitor and see where the tube is then decide whether we need to adjust tape position or not. †
You’re adding those encounters more every time you tape and re-tape, either with something slipping out or the tape failing, so you decrease the number of times you're moving those in and out.
Ashley Fischer: We're not doing routine monitoring with X-rays for ETT placement — it’s just really needed if there's a clinical change.
John Sanford: Our suctioning procedures have changed with the device. We use safe suction distance measurements for every baby that's intubated, so we've got to add more length to get down to the tip of the airway (with the inline sensor). We do that calculation and post it for the nurses, which also gets passed into a report for the RTs. The device displays a percent of occlusion in the airway, so we have a frequency that we go in and assess for our patients if they need to be suctioned. In between, if we notice the monitor is alarming and showing a percent of occlusion as well as if it was to the point where we can see if our baby was desaturating or having a bradycardic component, we go in and do additional suctioning.
Sometimes we may pass on deep suctioning of our patient because it isn't necessary. A nice feature on the monitor is listening to breath sounds without putting a stethoscope on the baby's chest. If we turn that feature on and the breath sounds are clear, heart rate, and stats we're doing fine with everything else stable, we may differ away from the invasive suctioning to another point of care.
Ashley Fischer: When we were learning about the SonarMed™ device as we trialed it for a day on a patient in a private room, the nurse was asking me what the alarm sounded like, right then the alarm went off and the patient was experiencing occlusion. The patient then started coughing with hacking noises, and we realized we should try suctioning.
Abigail Scaggs: There are three main alarms that you can set specific to a patient, and we provide some guidance around those levels:
• Movement of the tip of the ETT
• Specific severity of obstructions
• Circumference around the tip of the tube
Jawad Javed: We trialed different things, and a lot of collaborative efforts in our quality work with our respiratory therapist (RT) and nursing colleagues. We did a full audit of the bundled measures for a root cause analysis of all UE events.
Ashley Fischer: Before implementing SonarMed™, we’ve been able to reduce our unplanned extubation rate to 1.5 per 100 ventilator days for the last six months and we've noticed the bedside staff realizes how much movement has occurred with the ETT.
This allows more focus on watching the ETT tip during movement when we’re conducting X-rays during transport. By ensuring everybody in the unit had a uniform way of doing their X-rays, ensuring heads were midline and straight, but that it is held in a proper position. Then working with our peripherally inserted central catheter (PICC) line positioning during that same time. We are able to work with our radiologists to annotate the X-ray exactly where that ETT tip was.
We did more education with our fittings and ensuring they had optimal fit during X-ray. All those things made some difference, and we dropped it to about 1.4, but you can see in April to June of 2020, we had three outliers as the result of a couple of really big feisty babies that were difficult to control and monitor.
John Sanford: We have five monitors, and we’ve quickly outpaced those five monitors. We’re in the process of getting additional monitors. But a tough decision. We don't have a priority to the patients; if there's a monitor that's available, it goes to an intubated patient. We have five monitors right now on our unit. We try to push the monitors towards a patient that has already had an unplanned extubation or a patient that has a tenuous airway. We don't want any repeat offenders.
Even some of the bigger neonates that we noticed have strong and purposeful movements with their hands — something that has worried us or caught our attention — we may try to steer the monitor towards that patient.
Jawad Javed: For the NICU, we did what we could do with our team-based quality approach. We tried different modalities to bring that unplanned extubation rate down as best as we could. We made headway — going from 2.1 to 1.4 and 1.3 — but it was a tremendous amount of work from our amazing staff and crew. Taking it to the next level was a game changer for us to get below the 1.0 mark.
Getting below 0.6, which was not our expectation, helped us see continued success and cultural change that’s evolved within our unit as a result even while not having the full number of devices — it’s been astonishing.
My message is that the technology is a potential game changer for the area of unplanned extubations — if you really want to make a significant dent. Now we're looking at other populations in the PICU as there's a lot of interest to try to get a handle on these because of the cost burden that exists there.
Jawad Javed: For me, honestly, the patient care is always first and foremost. To see what the families are doing around kangaroo care is incredible. When you work so hard to move a metric number even a few points, it's so much effort. To provide this kind of device moves that bar to a different level to support the team’s efforts while watching that cultural transformation — it’s astounding.
It's great to be able to utilize this. We started a neonatal fellowship program in our institution, so getting our fellows to work on the research aspects of this device is going be very fascinating over the coming months and years — to see how much we can push the folds of the metrics and what we can get off of this device while pushing towards a zero unplanned extubation rate.
†The SonarMed™ Airway Monitoring System should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment.
††This testimonial is based on one facility's experience. Experiences vary.
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