2025 Community of Human and Organizational Learning 31st Annual Conference

Background: Decrease Unplanned Extubation (UE) rate and better understand work as done compared to work as imagined in Intensive Care Units (ICU).

Methods: Leadership rounding was implemented in late July after a leadership call-to-action meeting to discuss current state and foster engagement. Leadership rounding consisted of a nurse manager, respiratory manager and quality representative. A rounding tool was developed to maintain consistency and identify trends and gaps in care. Initial rounds focused on reviewing x-rays, accuracy of airway cards at bedside, integrity of the endotracheal tube tape (ETT) and gauging associate concerns about UE being addressed. Subsequent rounds incorporated a new order via Epic called “Endotracheal Tube Position” which provided one source of truth when determining proper ETT placement.

Results: Prior to implementation, January-July 2024, UE events occurred every 26 days. Since implementation of the leadership rounds in late July 2024, NCH-FL’s average between UE events has increased to 105 days. Additionally, our ICUs maintained 130 days without a UE event (Figure 1). At the end of 2024, our overall UE rate was 0.34 per 100 ventilator days allowing us to outperform our annual goal.

Conclusion: Leadership rounds that started in July 2024 proved to be effective through the end of the year and so far into 2025. Frontline engagement has increased, and associates feel more comfortable with voicing their concerns about ETT safety. The successes of UE leadership rounds are being adapted to focus on prevention of Unplanned Decannulation (UD) events, with UD leadership rounds beginning in 2025.