Abstract & Commentary: Preventing Unplanned Extubations: Pulling out the Evidence
Abstract & Commentary
Preventing Unplanned Extubations: Pulling out the Evidence
By Ruth M Kleinpell, PhD, RN, Director, Center for Clinical Research and Scholarship, Rush University Medical Center; Professor, Rush University College of Nursing, Chicago, is Associate Editor for Critical Care Alert.
Dr. Kleinpell reports no financial relationship to this field of study.
Synopsis: In this survey of ICU practitioners' attitudes and perceptions about the causes and consequences of unplanned extubation, most considered it to be a risk to patient safety while a minority considered it to be a medical error.
Source: Tanios MA, et al. Can we identify patients at high risk for unplanned extubation? A large-scale multidisciplinary survey. Respir Care 2010;55:561-568.
This web-based survey assessed 1976 critical care practitioners' perceptions of the risks for unplanned extubation. Members of the American Association for Respiratory Care, the American Association of Critical Care Nurses, and the Society of Critical Care Medicine reported a number of factors associated with unplanned extubation, including outward migration of the endotracheal tube (ETT; reported by 73% of respondents), the patient tugging on the ETT (87%), removing a nasogastric tube (71%), absence of physical restraints (72%), a nurse/patient ratio of 1:3 (60%), trips out of the ICU for tests (59%), and light sedation (42%).
When presented with two clinical vignettes (deliberate self-extubation and accidental extubation), the majority of the 870 nurse, 605 physician, and 419 respiratory therapist respondents considered deliberate self-extubation by a low-risk patient to represent an airway accident and accidental extubation in a high-risk patient to represent an error in medical management. The results of the study provide information on risk factors for unplanned extubation that can be used to target prevention strategies to decrease the risk of adverse events.
Commentary
A significant percentage of ICU patients require endotracheal intubation and mechanical ventilation. Unplanned extubation is a recognized complication that poses risks to intubated patients. The findings of the study indicate that a number of factors are perceived to be risks for unplanned extubation by critical care clinicians. Half of all respondents perceived that the definition of a near-miss for unplanned extubation depended on the patient's medical condition. The majority (95%) viewed frequent near-misses as a threat to patient safety, while only 44% considered an unplanned extubation as a medical error.
It is estimated that between 1% and 14% of patients receiving mechanical ventilation experience an unplanned extubation.1,2 Although most studies have demonstrated that mortality is similar in patients experiencing unplanned extubation compared to controls, there is evidence that patients who require reintubation have a significantly longer duration of ventilation, longer ICU stay, and longer hospital stay.3 In one study of 100 patients who experienced unplanned extubation compared to 200 controls during a 5-year period in a medical surgical ICU, mortality was found to be decreased in those having an unplanned extubation compared to controls.4 In addition to the risk factors identified by critical care clinicians in the survey, several additional factors have been associated with unplanned extubation including agitation and greater use of benzodiazepines,2 as well as inadequate sedation, improper position of the ETT, and insecure ETT.5,6
While a significant percent of patients experiencing an unplanned extubation do not require reintubation, a factor associated with the need for reintubation after unplanned extubation is increasing age.4
Several quality improvement initiatives targeting reducing unplanned extubation in the ICU have demonstrated beneficial outcomes from educational interventions and implementation of protocols for securing endotracheal tubes.5,7 Preventive measures such as using an experienced transport team,8 avoiding unnecessary trips out of the ICU, and reducing unnecessary portable chest radiographs9 may help reduce the incidence of unplanned extubations. As weaning readiness can play a role in patients that intentionally self-extubate, evaluating the need for continued intubation is a necessary component of daily spontaneous breathing trial assessments. Pulling out the evidence for prevention of unplanned extubation is not difficult, but requires ensuring clinician awareness and the use of preventive measures, in addition to preventing prolonged unnecessary intubation.
References
- Vianna A, et al. Unplanned extubation in the intensive care unit: What are the consequences? Crit Care 2007;11:P66.
- Krayem A, et al. Unplanned extubation in the ICU: Impact on outcome and nursing workload. Ann Thorac Med
- Epstein SK, et al. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med2000;161:1912-1916.
- Krinsley JS, Barone JE. The drive to survive: Unplanned extubation in the ICU. Chest 2005;128:560-566.
- Rachman BR, et al. Reducing unplanned extubations in a pediatric intensive care unit. Int J Pediatrics 2009;8:1-5.
- Curry K, et al. Characteristics associated with unplanned extubations in a surgical intensive care unit. Am J Crit Care
- Richmond A, et al. Unplanned extubation in adult critical care. Crit Care Nurse 2004;24:32-37.
- Warren J, et al; American College of Critical Care Medicine. Guidelines for the inter- and intra-hospital transport of critically ill patients. Crit Care Med 2004;32:256-262.
- Hendrikse KA, et al. Low value of routine chest radiographs in a mixed medical-surgical ICU. Chest 2007;132:823-828.
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