Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews

Impact of the restraint decision tree for physical restraint use in South Korean neurointensive care units

BACKGROUND

Nurses in neurointensive care units (NCUs) commonly use physical restraint (PR) to prevent adverse events like unplanned removal of devices (URDs) or falls. However, PR use should be based on evidenced decisions as it has drawbacks. Unfortunately, there is a lack of research-based PR protocol to support decision-making for nurses, especially for neurocritical patients.

AIM

This study developed a restraint decision tree for neurocritical patients (RDT-N) to assist nurses in making PR decisions. We assessed its effectiveness in reducing PR use and adverse events.

STUDY DESIGN

This study employed a baseline and post-intervention test design at a NCU with 19 beds and 45 nurses in a tertiary hospital in a metropolitan city in South Korea. Two-hundred and thirty-seven adult patients were admitted during the study period. During the intervention, nurses were trained on the RDT-N. PR use and adverse events between the baseline and post-intervention periods were compared.

RESULTS

Post-intervention, total number of restrained patients decreased (20.7%-16.3%; χ2 = 7.68, p = .006), and the average number of PR applied per restrained patient decreased (2.42-1.71; t = 5.74, p < .001). The most frequently used PR type changed from extremity cuff to mitten (χ2 = 397.62, p < .001). No falls occurred during the study periods. On the other hand, URDs at baseline were 18.67 cases per 1000 patient days in the high-risk group and 5.78 cases per 1000 patient days in the moderate-risk group; however, no URD cases were reported post-intervention.

CONCLUSIONS

The RDT-N effectively reduced PR use and adverse events. Its application can enhance patient-centred care based on individual condition and potential risks in NCUs.

RELEVANCE TO CLINICAL PRACTICE

Nurses can use the RDT-N to assess the need for PR in caring for neurocritical patients, reducing PR use and adverse events.

Development of an evidence-based nursing practice program for preventing unplanned endotracheal extubations in the intensive care unit: A Delphi method study

AIMS

This study aims to develop an evidence-based nursing practice program to prevent unplanned endotracheal extubation (UEE) among adult patients in the intensive care unit (ICU).

DESIGN

This study uses the Delphi method to develop an evidence-based nursing practice program.

METHODS

A comprehensive review of 18 databases and evidence-based websites was conducted to gather, assess and synthesize evidence on preventing UEEs in adult patients. Using this synthesized evidence, a questionnaire was formulated for further investigation. Subsequently, input was solicited from experts through Delphi surveys to establish an evidence-based nursing practice protocol for preventing UEEs in adult ICU patients. Consistency in consultation results guided subsequent rounds of consultation.

RESULTS

The developed program comprised 43 evidence items categorized into nine dimensions, including risk assessment for unplanned extubation, sedation, analgesia, delirium, balloon management, psychosocial care, early extubation, catheter immobilization and protective restraints. Two rounds of expert inquiry yielded recovery rates of 94.7% and 100% for the first and second questionnaires, respectively. Kendall W values ranged from .224 to .353 (p < .001).

CONCLUSION

This study developed an evidence-based nursing practice program to prevent UEE in adult ICU patients, employing evidence-based practices and Delphi expert consultation methods. However, further validation of the program's effectiveness is warranted.

REPORTING METHOD

Findings were reported according to the Standards for Reporting Qualitative Research checklist.

PATIENT OR PUBLIC CONTRIBUTION

Nurses contributed to the study by participating in investigations.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The program developed in this study offers an evidence-based framework for preventing unplanned extubation in hospitals, thereby reducing its incidence and enhancing the quality of nursing care.

A Quality Improvement Initiative to Increase Confirmation of Prehospital Endotracheal Tube Placement at Emergency Department Transfer of Care

OBJECTIVES

Rates of prehospital unplanned extubation (UE) range from 0 to 25% and are the result of many factors, including patient movement. Transfer of care of intubated patients to the emergency department (ED) involves significant patient movement and represents a high-risk event for UE. Frequent confirmation of endotracheal tube (ETT) placement is imperative for early recognition of UE and to minimize patient harm.

METHODS

Local Practice-Our baseline rate of verbal ETT position confirmation with a member of the ED team during ED transfer of care was 74%. Our goal was to increase this practice to >90% in six months. This project was completed in partnership with Toronto Paramedic Services. Prehospital electronic patient care records (ePCRs) were reviewed weekly to determine the proportion of intubated patients who had ETT placement confirmed in the ED at transfer of care. Interventions-Pre- and post-project paramedic focus groups were conducted to identify potential drivers, change ideas, and project feedback. Three staggered interventions were introduced over five months: (1) memorandums to paramedics, ED chiefs and respiratory therapy leads, (2) individualized paramedic feedback e-mails, and (3) ePCR changes and closing rules.

RESULTS

The pre-project focus group identified several potential drivers, such as physical barriers, interprofessional relationships, and communication. ETT confirmation remained ≥90% for the last eight weeks and interventions resulted in special cause variation. Median cases without verbal confirmation between paramedics and ED staff reduced from 5/week (IQR 2.5, 6.5) to 1/week (IQR 0, 2). UE was identified in 0.6% (2/340) of patients with ETT confirmation. The post-project focus group noted improvements in perceived accountability, interprofessional relationships, and satisfaction with interventions.

CONCLUSION

Through a series of interventions, we improved the rate of ETT confirmation during ED transfer of care. Although rates of UE were low, improvement in ETT confirmation may lead to faster recognition of UE when it does occur thereby mitigating complications. The observed improvement was sustained after interventions ended.

Development and testing of a questionnaire assessing knowledge, attitudes, and practices to prevent unplanned oral extubation

BACKGROUND

The prevention of unplanned endotracheal extubation (UEE) is significant for the critical care of intensive care unit (ICU) patients.

AIM

To develop a questionnaire to assess the knowledge, attitude, and practice (KAP) of the nurses regarding of the prevention of UEE in ICU patients with transoral endotracheal intubation (TEI) and to test the validity and reliability of the questionnaire.

STUDY DESIGN

Items relevant to KAP were prepared following a literature review, and then screened using a Delphi expert consultation, pre-test, and factor analysis. The nursing staffs in four tertiary hospitals in Qinghai, Jiangsu, Gansu, and Shandong provinces were surveyed to test the reliability and validity of the questionnaire.

RESULTS

The questionnaire contained 76 items, including 10, 37, and 29 in the dimensions of knowledge, attitude, and practice, respectively. The scale-level content validity index (S-CVI) of the questionnaire was 0.96. The results of exploratory factor analysis (EFA) showed that the Kaiser-Meyer-Olkin value was 0.956, indicating that the sample was adequate and suitable for factor analysis. The result of the Bartlett spherical test was significant (p < .001), indicating that the questionnaire was suitable for further EFA. A total of six common factors were extracted by EFA with a cumulative variance interpretation rate of 85.52%, indicating that the questionnaire had good structural validity. The Cronbach's alpha was 0.981 for the whole questionnaire; and was 0.966, 0.996, and 0.981 for the dimensions of knowledge, attitude, and practice, respectively. The test-retest reliability for the questionnaire was 0.843.

CONCLUSIONS

The developed questionnaire has good reliability and validity and can be used as a scientific tool for the nursing leaders to prevent UEE in ICU patients with TEI.

RELEVANCE TO CLINICAL PRACTICE

The instrument provides a theoretical reference for establishing preventive strategies and management programs in clinical practice.

Impact of two endotracheal tube fixation on the incidence of peri-oral lesions: Elastic adhesive strips versus cord in a protective sheath. Study protocol for a cluster cross-over randomized trial

BACKGROUND

Endotracheal tube fixation in ventilated patients must be appropriate to ensure security during mechanical ventilation and prevent skin lesions. The incidence of endotracheal tube-caused pressure ulcers ranges from 7% to 45%. Various endotracheal tube fixations are used in intensive care units (ICUs) worldwide. By pressure exercised on the skin, these systems could lead to mucosal and skin peri-oral lesions. The main objective of this study is to evaluate the impact of the two fixation systems most commonly used in French ICUs (adhesive elastic band versus fixation cord with PolyVinyl Chloride (PVC) sheath) on the incidence of these peri-oral skin lesions.

METHODS

This studyis a multicenter, open-label, controlled, superiority, cluster cross-over randomized trial. 768 patients will be recruited in the 16 ICUs involved. The inclusion of patients will be carried out over two 12-month periods. Each site begins with one of the evaluated fixation systems: elastic adhesive tape or cord associated with a protective sheath. After a 4-month break, each site switches to the other fixation system. The primary outcome is the development of at least one peri-oral lesion during the first ten days of maintaining an orally inserted endotracheal tube. The presence of lesions is assessed by a blinded adjudication committee using photographs taken daily.

DISCUSSION

This study is the first multicenter, randomized trial designed to evaluate the impact of elastic adhesive tape versus fixation cord with PVC sheath on the incidence of peri-oral lesions. The results will provide data which could change and standardize care practices.

TRIAL REGISTRATION

https://www.clinicaltrials.gov. Reference number: NCT04819425.