Title: Strategies to reduce extubation failure in the neonatal intensive care unit: A Quality improvement approach.

BACKGROUND: Extubation failure is common in neonatal intensive care units (NICUs), necessitating a systems-based approach to prevent this adverse event. We aimed to reduce the incidence of extubation failure among intubated neonates in the NICU from a baseline of 43.1% to 20% over 6 months. METHODS: The study had three phases: Pre-intervention, Intervention and Sustenance. During the pre-intervention phase, we conducted multiple cross-sectional surveys, chart reviews, and focused group discussions with resident doctors and nurses to identify systems-related factors contributing to extubation failure. Fishbone diagrams were developed to organize and visualize these factors. In collaboration with nurses and resident doctors, we co-designed potential interventions targeting three broad categories of systems-based causes found in the pre-intervention phase: preexisting nasal injury acquired due to noninvasive respiratory support through a nasal interface, accidental extubation, and inadequate humidification. Multiple Plan-Do-Study-Act (PDSA) cycles were conducted to test various change ideas. Extubation failure was the primary outcome indicator, defined as re-intubation within 7 days postextubation. Several process indicators were monitored as per the change being tested. From the learnings, we developed a context-specific pre-extubation checklist encompassing critical medical and systems-related factors associated with extubation failure. RESULTS: The rate of extubation failure decreased from 43.1% at baseline to 20% in the sustenance phase. Compliance with most interventions designed to prevent nasal injury, accidental extubation, and ensure adequate humidification improved substantially, rising from very low levels to over 80%. CONCLUSION: Utilizing quality improvement tools and a systems-based approach, we achieved a sustained reduction in extubation failure from 43.1% at baseline to 20%.