John P. Galiote, M.D.Neonatologist at Children’s National-Virginia Hospital Center NICU

Collaboration and Teamwork Allowed Reduction in Unintended Extubations in Neonatal ICU Interview with:

John P. Galiote, M.D.Neonatologist at Children’s National-Virginia Hospital Center NICU

Dr. Galiote

John P. Galiote, M.D.
Neonatologist at Children’s National-Virginia Hospital Center NICU

Michelande Ridoré, MS, NICUQuality improvement lead at Children’s National 

Ms. Ridoré

Michelande Ridoré, MS, NICU
Quality improvement lead at Children’s National

Lamia Soghier, M.D., MEd, Children’s National NICU medical director

Dr. Soghier


Lamia Soghier, M.D., MEd, Children’s National NICU Medical Director What is the background for this study? What are the main findings?

Response: Our study emphasizes the importance of team work and real-time communication in a quality-improvement project within the neonatal intensive care unit (NICU) setting.

Through bedside huddles, weekly reviews of apparent cause analysis reports reducing the frequency of X-rays and the creation of an Airway Safety Protection Team, we were able to focus not only on  reducing unintended extubations, but also on the quality-improvement project’s effect on our staff. Adhering to simple quality principles enabled us to ensure that all members of our staff were heard and had a positive effect on the progress of our project. This allowed us to implement and sustain a series of simple changes that standardized steps associated with securing and maintaining an endotracheal tube (ET). Unintended extubations are the fourth-most common adverse event in the nation’s NICUs. Continual monitoring via this quality-improvement project allowed us to intervene when our rates increased and further pushed our unintended extubation rate downward. What should readers take away from your report?

Response: It is crucial to treat these events seriously and to consider steps to minimize tube dislodgement. We were able to successfully reduce these events at Children’s National, so we know it can be done and that these safety improvements can be maintained. What recommendations do you have for future research as a result of this work?

Response:  We would like to explore the effect of sedation on unintended extubations. Our goal, in essence, is to come up with a way to give just enough sedation to keep the tube in place but not too much – so that our babies recover faster. We are also collaborating with our NICU colleagues at the Children’s Hospital of Richmond to spread the word. They approached us and asked how we achieved these low rates; they came to visit us here in Washington, D.C., to see the quality-improvement project in person. We worked with them on standardizing their protocols for taping the ET tube, and we have remained in constant contact. Their unintended extubation rates were high for several years and now, thanks to this collaboration, Children’s Hospital of Richmond has seen a dramatic decrease in their rates. This successful research collaboration was presented at the PAS 2019 meeting in Baltimore. Also, under the leadership of Dr. Galiote, Virginia Hospital Center in Arlington has initiated a similar initiative in their NICU. Is there anything else you would like to add?

Response: We have been contacted by NICU leaders located in other states who are interested in using our protocol and high-risk Zell scoring system. We are hoping to continue to spread the word and are thankful for your help.


Pediatrics May 2019, VOLUME 143 / ISSUE 5
Quality Reports

Reduction in Unintended Extubations in a Level IV Neonatal Intensive Care Unit
John P. Galiote, Michelande Ridoré, Jessica Carman, Lisa Zell, Karen Brant, Cheyenne Gayle, Billie L. Short, Darren Klugman,Lamia Soghier

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Last Updated on May 6, 2019 by Marie Benz MD FAAD