Reporting unplanned extubation

Wide Variation in Unplanned Extubation Rates Related to Differences in Operational Definitions

OBJECTIVES

Unplanned extubation (UE) rate is a patient safety metric for which there are varied and inconsistently interpreted definitions. We aimed to test the sensitivity of UE rates to the application of different operational definitions.

METHODS

We analyzed neonatal intensive care unit (NICU) quality improvement data on UE events defined inclusively as "any extubation that was not performed electively, or not previously intended for that time." Unplanned extubations were classified as involving an endotracheal tube (ETT) that was either objectively "dislodged" or "removed" without proof of prior dislodgement. We used descriptive statistics to explore how UE rates vary when applying alternate UE definitions.

RESULTS

For 33 months, 241 UEs were documented, 70% involving dislodged tubes and 30% ETTs removed by staff. Among dislodged ETTs, only 9% were found completely externalized, whereas 77% were at an adequate depth but in the esophagus. Thirteen percent of events occurred outside the NICU and 13% were initially unreported. The overall UE rate was 4.9/100 ventilator days. If the least inclusive definition was used (i.e., counting only "self-extubations" by patients, requiring reintubation, and occurring within the NICU), 83% of UEs would have been excluded.

CONCLUSIONS

Most UEs in our NICU population involved staff either removing ETTs from the trachea or partly removing them after internal dislodgement. In settings where ETTs removed by staff are not counted, UE rates may be substantially lower and associated risks underestimated. An inclusive, patient-centric operational definition along with a standardized classification would allow benchmarking, while enabling targeted approaches to minimize locally predominant causes of UEs.

Quality appraisal of guidelines on physical restraints in intensive care units: A systematic review

BACKGROUND

Guidelines concerning the use of physical restraints in medical facilities have been published and amended over the years. However, the quality and suitability of these guidelines have not been appraised.

OBJECTIVES

This study aims to assess the suitability and quality of guidelines for the use of physical restraints in intensive care units with the AGREE-REX and AGREE Ⅱ instruments.

METHODS

A systematic search of electronic databases (e.g., EMBASE), cross-database search platforms (e.g., Clinical Key), guideline web portals (e.g., Guidelines International Network) and society websites (e.g., Society of Critical Care Medicine) was conducted from January 2011 to December 2020. The methodological quality was assessed using AGREE Ⅱ, and the recommendation quality and suitability were assessed using AGREE-REX instruments.

RESULTS

A total of eight guidelines were included. The criteria for overall quality and suitability of guidelines for the use of physical restraints were met by 50-72% and 59-76%, respectively. The "Values and Preferences" domain had the lowest score (38% ± 9%). The criteria for methodological quality of the guidelines were met by 50-83%. Two domains, "Applicability" and "Editorial Independence", achieved lower scores. There was a strong, positive correlation between the overall methodological quality of guidelines and the overall quality of recommendations (r = 0.968).

CONCLUSION

There is a potential feasibility of guideline adaptation for the management of physical restraints. In order to implement a physical restraint guideline, the following aspects should be considered: (i) minimize the use of physical restraints, (ii) analyze barriers and facilitators relative to the local context, (iii) consider any specifications, and (iv) modify recommendations to local situation or individual conditions of the patient.

A Quality Improvement Approach to Reduce Unplanned Extubation in the NICU While Avoiding Sedation and Restraints

Supplemental Digital Content is available in the text.

The unplanned extubation (UE), a common adverse event in the neonatal intensive care unit (NICU), may result in airway trauma, cardiopulmonary resuscitation, and, in extreme cases, death. As part of the Nationwide Children’s Hospital NICU’s effort to optimize NICU graduates’ neurodevelopmental outcomes, skin-to-skin care of intubated infants is encouraged, while sedation and restraints to prevent UE are strongly discouraged. This project aimed to decrease the UE rate from 1.85 to 1.5 per 100 endotracheal tube (ETT) days.

Caring for patients displaying agitated behaviours in the intensive care unit - A mixed-methods systematic review

BACKGROUND

Patient agitation is common in the intensive care unit (ICU), with consequences for both patients and health professionals if not managed effectively. Research indicates that current practices may not be optimal. A comprehensive review of the evidence exploring nurses' experiences of caring for these patients is required to fully understand how nurses can be supported to take on this important role.

OBJECTIVES

The aim of this study was to identify and synthesise qualitative and quantitative evidence of nurses' experiences of caring for patients displaying agitated behaviours in the adult ICU.

METHODS

A mixed-methods systematic review was conducted. MEDLINE, CINAHL, PsycINFO, Web of Science, Emcare, Scopus, ProQuest, and Cochrane Library were searched from database inception to July 2020 for qualitative, quantitative, and mixed-methods studies. Peer-reviewed, primary research articles and theses were considered for inclusion. A convergent integrated design, described by Joanna Briggs Institute, was utilised transforming all data into qualitative findings before categorising and synthesising to form the final integrated findings. The review protocol was registered with PROSPERO CRD42020191715.

RESULTS

Eleven studies were included in the review. Integrated findings include (i) the strain of caring for patients displaying agitated behaviours; (ii) attitudes of nurses; (iii) uncertainty around assessment and management of agitated behaviour; and (iv) lack of effective collaboration and communication with medical colleagues.

CONCLUSIONS

This review describes the challenges and complexities nurses experience when caring for patients displaying agitated behaviours in the ICU. Findings indicate that nurses lack guidelines together with practical and emotional support to fulfil their role. Such initiatives are likely to improve both patient and nurse outcomes.

Critically ill patients' experience of agitation: A qualitative meta-synthesis

BACKGROUND

Acute episodes of agitation are frequently experienced by patients during critical illness, yet what is not understood is the experience of agitation from the patient and family perspectives.

AIMS AND OBJECTIVES

To search existing literature, appraise it and then provide a synthesized interpretation to broaden the understanding of patients' and their families' experience of agitation during an adult critical care admission.

DESIGN

Qualitative meta-synthesis.

METHODS

A qualitative meta-synthesis based on a systematic literature search registered with PROSPERO. The search conducted between July and September 2019 was applied to ProQuest, Cumulative Index to Nursing and Allied Health, British Nursing Index, Cochrane Library, Ovid Medline, Web of Science, and PsycINFO databases. We appraised the selected literature and presented a synthesized interpretation. Analysis was based on the approach of Gadamerian hermeneutics. Due to the lack of data identified; the family experiences of agitation could not be addressed within the review.

RESULTS

In total, 8 studies were included capturing the experiences of 494 patients, aged between 18 and 92 years, with 225 (45%) women. The analysis generated three core themes: (a) What is real, what is not, (b) loss of communication and dependency, and (c) what helps, what does not. Fear of death, the emotion of anxiety, and feelings of pain alongside transient periods of fluctuating conscious levels provoked a feeling of intense vulnerability. The loss of effective communication and the feeling of dependence incite agitation and distress.

CONCLUSIONS

The patient's recollection of their critical illness can be completely or partially absent and disjointed with uncertainty around what is real and what is not. Family members observe the full effect of the patient's critical care illness and could be a wealth of untapped information.

RELEVANCE TO CLINICAL PRACTICE

Increasing awareness of the critically ill patients' experience of agitation highlights possible contributing factors to agitation development, such as staff interaction and communication skills, and the critical care environment.

Adverse events associated to the use of equipment and materials in nursing care of hospitalized patients

OBJECTIVE

To analyze the occurrence of adverse events associated to the use of equipment and materials in nursing care.

METHOD

Quantitative, descriptive study, using the electronic records of adverse events notifications in an accredited hospital.

RESULTS

A total of 1,065 adverse events were reported, of which 180 (16.9%) were related to the use of equipment and materials. The most frequent events were: loss of feeding tube (45.0%), loss of central venous catheter (15.5%), skin injury (10.5%) and accidental extubation (10.0%). The main causes and immediate actions recorded were: loss of feeding tube - removal of the tube by the patient (53.1%) and reinsertion of the device (83.9%); loss of central venous catheter - agitated or disoriented patient (32.1%) and insertion of peripheral venous catheter (46.2%); skin injury - agitated or disoriented patient (26.3%) and application of occlusive dressing (73.7%); and accidental extubation - weaning from sedation, disconnected sedation or inadequate doses of sedation (50.0%) and reintubation (50.0%). The degrees of harm were: mild (23.3%), severe (62.2%), very severe (13.9%) and extremely severe (0.6%).

CONCLUSION

The investigation of the occurrence of adverse events related to the use of equipment and materials in care can prevent and minimize harm to the patient.

Self-Extubation in Patients with Traumatic Head Injury: Determinants, Complications, and Outcomes

Background

Self-extubation is a common clinical problem associated with mechanical ventilation in trauma patients worldwide.

Objectives

This study aimed to evaluate the predisposing factors, complications, and outcomes of self-extubation in patients with head injury.

Methods

This was a retrospective cohort study.

Settings

The study was conducted in a trauma intensive care unit (TICU).

Patients

All intubated patients with head injury admitted to TICU between 2013 and 2015 were included in the study.

Interventions

Planned compared to selfextubation during weaning from sedation.

Measurements

Risk, predictors, and outcomes of self-extubation were measured.

Main Results

A total of 321 patients with head injury required mechanical ventilation, of which 39 (12%) had self-extubation and 12 (30.7%) had reintubation. The median Glasgow Coma Scale, head abbreviated injury score, and injury severity score were 9, 3, and 27, respectively. The incidence of self-extubation was 0.92/100 ventilated days. Self-extubated patients were more likely to be older, develop agitation (P = 0.001), and require restraints (P = 0.001) than those who had planned extubation. Furthermore, self-extubation was associated with more use of propofol (P = 0.002) and tramadol (P = 0.001). Patients with self-extubation had higher Ramsay sedation score (P = 0.01), had prolonged hospital length of stay (P = 0.03), and were more likely to develop sepsis (P = 0.003) when compared to the planned extubation group. The overall in-hospital mortality was significantly higher in the planned extubation group (P = 0.001). Age-adjusted predictors of self-extubation were sedation use (adjusted odds ratio [aOR]: 0.06; P = 0.001), restraint use (aOR: 10.4; P = 0.001), and tramadol use (aOR: 7.21; P = 0.01).

Conclusions

More than one-tenth of patients with traumatic head injury develop self-extubation; this group of patients is more likely to have prescribed tramadol, develop agitation, and have longer hospital length of stay and less sedation use. Further prospective studies are needed to assess the predictors of self-extubation in TICU.

The Conditions for Ethical Application of Restraints

Despite the lack of evidence for the effectiveness of physical restraints, their use in patients is widespread. The best ethical justification for restraining patients is that it prevents them from harming themselves. We argue that even if the empirical evidence supported their effectiveness in achieving this aim, the use of restraints would nevertheless be unethical, so long as well-known exceptions to informed consent fail to apply. Specifically, we argue that ethically justifiable restraint use demands certain necessary and sufficient conditions. These conditions are that the physician obtained informed consent for their application, that their application be medically appropriate, and that restraints be the least liberty-restricting way of achieving the intended benefit. It is a further question whether their application is ever medically appropriate, given the dearth of evidence for their effectiveness.

Comparison of machine learning models for the prediction of mortality of patients with unplanned extubation in intensive care units

Unplanned extubation (UE) can be associated with fatal outcome; however, an accurate model for predicting the mortality of UE patients in intensive care units (ICU) is lacking. Therefore, we aim to compare the performances of various machine learning models and conventional parameters to predict the mortality of UE patients in the ICU. A total of 341 patients with UE in ICUs of Chi-Mei Medical Center between December 2008 and July 2017 were enrolled and their demographic features, clinical manifestations, and outcomes were collected for analysis. Four machine learning models including artificial neural networks, logistic regression models, random forest models, and support vector machines were constructed and their predictive performances were compared with each other and conventional parameters. Of the 341 UE patients included in the study, the ICU mortality rate is 17.6%. The random forest model is determined to be the most suitable model for this dataset with F₁ 0.860, precision 0.882, and recall 0.850 in the test set, and an area under receiver operating characteristic (ROC) curve of 0.910 (SE: 0.022, 95% CI: 0.867–0.954). The area under ROC curves of the random forest model was significantly greater than that of Acute Physiology and Chronic Health Evaluation (APACHE) II (0.779, 95% CI: 0.716–0.841), Therapeutic Intervention Scoring System (TISS) (0.645, 95% CI: 0.564–0.726), and Glasgow Coma scales (0.577, 95%: CI 0.497–0.657). The results revealed that the random forest model was the best model to predict the mortality of UE patients in ICUs.

Patient agitation and its management in adult critical care: A integrative review and narrative synthesis

AIMS AND OBJECTIVE

To critically review the evidence relating to the management of agitation within the Adult Critical Care Unit environment and identify any risks and benefits of current management strategies.

BACKGROUND

Admission to an Adult Critical Care Unit can be traumatic and potentially life altering for the patient. Patient agitation is common in Adult Critical Care Units and is associated with the potential for harm. Despite inherent safety risks, there is a paucity of evidence-based guidance underpinning the care of agitation in patients with critical illness.

STUDY DESIGN

Integrative review and narrative synthesis.

METHODS

A systematic procedure for searching and selecting the literature was followed and applied to databases including CINAHL, British Nursing Index, Cochrane Library, ProQuest, Ovid including EMBASE and MEDLINE. Selected manuscripts were analysed using a structured narrative review approach.

RESULTS

A total of 208 papers were identified and following a systematic deselection process 24 original articles were included in the review. It was identified that agitation in the setting of Adult Critical Care Unit is associated with high-risk events such as unplanned removal of life-supporting devices. There were consistent links to sepsis, previous high alcohol intake and certain medications, which may increase the development of agitation. Prompt assessment and early liberation from mechanical ventilation was a major contributing factor in the reduction in agitation. Administration of antideliriogenic mediation may reduce the need for physical restraint. There was repeated uncertainty about the role of physical restraint in developing agitation and its effective management.

CONCLUSIONS

Our review has shown that there is a dearth of research focusing on care of agitated patients in the Adult Critical Care Unit, despite this being a high-risk group. There are dilemmas for clinical teams about the effectiveness of applying physical and/or pharmacological restraint. The review has highlighted that the risk of self-extubation increases with the presence of agitation, reinforcing the need for constant clinical observation and vigilance.

RELEVANCE TO CLINICAL PRACTICE

The importance of ensuring patients are re-orientated regularly and signs of agitation assessed and acted upon promptly is reiterated. Early identification of specific patient profiles such as those with previous high alcohol or psychoactive drug habit may enable more proactive management in agitation management rather than reactive. The prompt liberation from the restriction of ventilation and encouragement of family or loved ones involvement in care need to be considered.

Two Different Endotracheal Tube Securing Techniques: Fixing Bandage vs. Adhesive Tape

Introduction:

Emergency physicians should secure Endotracheal tubes (ETT) properly in order to prevent unplanned extubation (UE) and its complications. Despite various available endotracheal tube holders, using bandages or tape are still the most common methods used in this regards.

Objective:

This study aimed to compare adhesive tape (AT) versus fixing bandage (FB) method in terms of properly securing ETT.

Methods:

This was an observational longitudinal trial. All patients older than 15-years-old admitted to the ED who had indication for ETT insertion were eligible. Patients were randomly assigned to one of the two groups in which AT or FB was applied. All patients were observed thoroughly in the first 24 hours after intubation. Using a pre-prepared checklist, encountered UE rate and other data were recorded.

Results:

Seventy-two patients with the mean age of 55.98 18.39 years were finally evaluated of which 38 cases (52.8%) were male. In total, 12% of patients in our study experienced unplanned extubation. Less than 12% of the patients experienced complete UE; there was no statistically significant difference between the two groups (p = 0.24). Comparison of UE with age showed no significant difference (p = 0.89). Male patients experienced more UE, but this was not statistically significant (p = 0.44).

Conclusion:

It is likely that whether the AT method or FB was applied for securing the ETT in emergency departments, there was no significant difference in rates of unplanned extubation.

Prognostic factors and outcomes of unplanned extubation

This study investigated the prognostic factors and outcomes of unplanned extubation (UE) in patients in a medical center’s 6 intensive care units (ICUs) and calculated their mortality risk. We retrospectively reviewed the medical records of all adult patients in Chi Mei Medical Center who underwent UE between 2009 and 2015. During the study period, there were 305 episodes of UE in 295 ICU patients (men: 199 [67.5%]; mean age: 65.7 years; age range: 18–94 years). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 16.4, mean therapeutic intervention scoring system (TISS) score was 26.5, and mean Glasgow coma scale score was 10.4. One hundred thirty-six patients (46.1%) were re-intubated within 48 h. Forty-five died (mortality rate: 15.3%). Multivariate analyses showed 5 risk factors—respiratory rate, APACHE II score, uremia, liver cirrhosis, and weaning status—were independently associated with mortality. In conclusion, five risk factors including a high respiratory rate before UE, high APACHE II score, uremia, liver cirrhosis, and not in the process of being weaned—were associated with high mortality in patients who underwent UE.

A mixed-methods systematic review protocol to examine the use of physical restraint with critically ill adults and strategies for minimizing their use

BACKGROUND

Critically ill patients frequently experience severe agitation placing them at risk of harm. Physical restraint is common in intensive care units (ICUs) for clinician concerns about safety. However, physical restraint may not prevent medical device removal and has been associated with negative physical and psychological consequences. While professional society guidelines, legislation, and accreditation standards recommend physical restraint minimization, guidelines for critically ill patients are over a decade old, with recommendations that are non-specific. Our systematic review will synthesize evidence on physical restraint in critically ill adults with the primary objective of identifying effective minimization strategies.

METHODS

Two authors will independently search from inception to July 2016 the following: Ovid MEDLINE, CINAHL, Embase, Web of Science, Cochrane Library, PROSPERO, Joanna Briggs Institute, grey literature, professional society websites, and the International Clinical Trials Registry Platform. We will include quantitative and qualitative study designs, clinical practice guidelines, policy documents, and professional society recommendations relevant to physical restraint of critically ill adults. Authors will independently perform data extraction in duplicate and complete risk of bias and quality assessment using recommended tools. We will assess evidence quality for quantitative studies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and for qualitative studies using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) guidelines. Outcomes of interest include (1) efficacy/effectiveness of physical restraint minimization strategies; (2) adverse events (unintentional device removal, psychological impact, physical injury) and associated benefits including harm prevention; (3) ICU outcomes (ventilation duration, length of stay, and mortality); (4) prevalence, incidence, patterns of use including patient and treatment characteristics and chemical restraint; (5) barriers and facilitators to minimization; (6) patient, family, and healthcare professional perspectives; (7) professional society-endorsed recommendations; and (8) evidence gaps and research priorities.

DISCUSSION

We will use our systematic review findings to produce updated guidelines on physical restraint use for critically ill adults and to develop a professional society-endorsed position statement. This will foster patient and clinician safety by providing clinicians, administrators, and policy makers with a tool to promote minimal and safe use of physical restraint for critically ill adults.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015027860.

[Model for unplanned self extubation of ICU patients using system dynamics approach]

PURPOSE

In this study a system dynamics methodology was used to identify correlation and nonlinear feedback structure among factors affecting unplanned extubation (UE) of ICU patients and to construct and verify a simulation model.

METHODS

Factors affecting UE were identified through a theoretical background established by reviewing literature and preceding studies and referencing various statistical data. Related variables were decided through verification of content validity by an expert group. A causal loop diagram (CLD) was made based on the variables. Stock & Flow modeling using Vensim PLE Plus Version 6.0 b was performed to establish a model for UE.

RESULTS

Based on the literature review and expert verification, 18 variables associated with UE were identified and CLD was prepared. From the prepared CLD, a model was developed by converting to the Stock & Flow Diagram. Results of the simulation showed that patient stress, patient in an agitated state, restraint application, patient movability, and individual intensive nursing were variables giving the greatest effect to UE probability. To verify agreement of the UE model with real situations, simulation with 5 cases was performed. Equation check and sensitivity analysis on TIME STEP were executed to validate model integrity.

CONCLUSION

Results show that identification of a proper model enables prediction of UE probability. This prediction allows for adjustment of related factors, and provides basic data do develop nursing interventions to decrease UE.

ICU director data: using data to assess value, inform local change, and relate to the external world

Improving value within critical care remains a priority because it represents a significant portion of health-care spending, faces high rates of adverse events, and inconsistently delivers evidence-based practices. ICU directors are increasingly required to understand all aspects of the value provided by their units to inform local improvement efforts and relate effectively to external parties. A clear understanding of the overall process of measuring quality and value as well as the strengths, limitations, and potential application of individual metrics is critical to supporting this charge. In this review, we provide a conceptual framework for understanding value metrics, describe an approach to developing a value measurement program, and summarize common metrics to characterize ICU value. We first summarize how ICU value can be represented as a function of outcomes and costs. We expand this equation and relate it to both the classic structure-process-outcome framework for quality assessment and the Institute of Medicine's six aims of health care. We then describe how ICU leaders can develop their own value measurement process by identifying target areas, selecting appropriate measures, acquiring the necessary data, analyzing the data, and disseminating the findings. Within this measurement process, we summarize common metrics that can be used to characterize ICU value. As health care, in general, and critical care, in particular, changes and data become more available, it is increasingly important for ICU leaders to understand how to effectively acquire, evaluate, and apply data to improve the value of care provided to patients.

[Risk factors for deliberate self-extubation]

PURPOSE

This study was conducted to analyze intubation survival rates according to characteristics and to identify the risk factors affecting deliberate self-extubation.

METHODS

Data were collected from patients' electronic medical reports from one hospital in B city. Participants were 450 patients with endotracheal intubation being treated in intensive care units. The collected data were analyzed using Kaplan-Meier estimation, Log rank test, and Cox's proportional hazards model.

RESULTS

Over 15 months thirty-two (7.1%) of the 450 intubation patients intentionally extubated themselves. The patients who had experienced high level of consciousness, agitation. use of sedative, application of restraints, and day and night shift had significantly lower intubation survival rates. Risk factors for deliberate self-extubation were age (60 years and over), unit (neurological intensive care), level of consciousness (higher), agitation, application of restraints, shift (night), and nurse-to-patient ratio (one nurse caring for two or more patients).

CONCLUSION

Appropriate use of sedative drugs, effective treatment to reduce agitation, sufficient nurse-to-patient ratio, and no restraints for patients should be the focus to diminish the number of deliberate self-extubations.

Extubation force depends upon angle of force application and fixation technique: a study of 7 methods

BACKGROUND

Endotracheal tubes are frequently used to establish alternate airways. Precise placement of the tubes must be maintained to prevent serious complications. Several methods for fixation of endotracheal tubes are available. Available methods vary widely in form and functionality. Due to the unpredictable and dynamic nature of circumstances surrounding intubation, thorough evaluation of tube restraints may help reduce airway accidents such as tube dislodgement and unplanned extubation.

METHODS

Seven different tube-restraint combinations were compared against themselves and one another at a series of discrete angles (test points) covering a hemisphere on the plane of the face. Force values for tube motion of 2 cm and 5 cm (or failure) were recorded for 3 pull tests, at each angle, for each method of tube fixation.

RESULTS

All methods showed variation in the force required for tube motion with angle of force application. When forces were averaged over all test points, for each fixation technique, differences as large as 132 N (30 lbf) were observed (95% CI 113 N to 152 N). Compared to traditional methods of fixation, only 1 of the 3 commercially available devices consistently required a higher average force to displace the tube 2 cm and 5 cm. When ranges of force values for 5 cm displacement were compared, devices span from 80-290 N (18-65 lbf) while traditional methods span from 62-178 N (14-40 lbf), highlighting the value of examining forces at the different angles of application. Significant differences in standard deviations were also observed between the 7 techniques indicating that some methods may be more reproducible than others.

CONCLUSIONS

Clinically, forces can be applied to endotracheal tubes from various directions. Efficacies of different fixation techniques are sensitive to the angle of force application. Standard deviations, which could be used as a measure of fixator reliability, also vary with angle of force application and method of tube restraint. Findings presented in this study may be used to advance clinical implementation of current methods as well as fixator device design in an effort to reduce the incidence of unplanned extubation.

Clinical quality improvement: eliminating unplanned extubation in the CCU

PURPOSE

This article aims to explore coronary care unit (CCU) extubation structures, processes and outcomes. There were 13 unplanned-extubation cases (UE) among 251 intubated patients (5.2 per cent) in a cardiologist-led CCU in 2008. Seven did not require re-intubation, implying possible earlier extubation. A quality improvement project was undertaken with a goal to eliminate CCU UE within 12 months.

DESIGN/METHODOLOGY/APPROACH

Using the clinical practice improvement (CPI) method, the most significant root causes were missing sedation/analgesia protocol, no ventilator weaning protocol and absent respiratory therapist during the CCU morning rounds. Non-physician directed sedation/analgesia and ventilation weaning protocols were created and put on trial in Plan-Do-Study-Act cycles before formal implementation. Arrangements were made to allocate a respiratory therapist to the CCU daily for morning rounds.

FINDINGS

For 12 months after fully implementing the interventions, UE incidence dropped from 5.2 per cent to 0.9 per cent (p = 0.006). There were no adverse outcomes, re-intubation and/or readmission to CCU within 48 hours.

PRACTICAL IMPLICATIONS

Through a multi-disciplinary CPI approach, adopting non-physician directed protocols has successfully streamlined and improved airway management in mechanically ventilated patients in a cardiologist-led CCU.

ORIGINALITY/VALUE

There is little published data on improving intubated patient care in cardiologist-led CCUs. Previous studies centered on intensive care units managed by critical care specialists.

Physical restraints practice in adult intensive care units in Egypt

Physical restraints are commonly used in intensive care units to reduce the risk of injury and ensure patient safety. However, there is still controversy regarding the practice of physical restraints in such units. The purpose of this study was to investigate the practices of physical restraints among critical care nurses in El-Mansoura City, Egypt. The study involved a convenience sample of 275 critically ill adult patients, and 153 nurses. Data were collected from 11 intensive care units using a "physical restraint observation form" and a "structured questionnaire." The results revealed that physical restraint was commonly used to ensure patient safety. Assessment of physical restraint was mainly restricted to peripheral circulation. The most commonly reported physically restrained site complications included: redness, bruising, swelling, and edema. The results illustrated a lack of documentation on physical restraint and a lack of education of patients and their families about the rationale of physical restraint usage. The study shed light on the need for standard guidelines and policies for physical restraint practices in Egyptian intensive care units.

Unplanned extubation in critically ill adults: clinical review

AIMS AND OBJECTIVES

To investigate and synthesize the evidence on the incidence and consequences of unplanned extubation (UE) in intensive care unit (ICU) patients, and on risk factors for UE.

BACKGROUND

ICU patients generally spend considerable time being intubated via the endotracheal route. Non-planned endotracheal tube removal, either deliberate or accidental, may pose significant safety risks for them. As UE is among the most studied critical incidents in the ICU, evaluation and summary of existing findings could provide important implications for clinical practice. SEARCH STRATEGIES, INCLUSION AND EXCLUSION CRITERIA: Observational studies published between 1990 and 2012 in English-language journals indexed by Cumulative Index for Nursing and Allied Health Literature (CINAHL), PubMed, Web of Science and the Cochrane Library were searched for studies on UE of critically ill adults. Thirty-three articles were considered eligible for inclusion.

CONCLUSIONS

UE incidence varies considerably among reports, with self-extubation representing the majority of cases. Agitation, especially when combined with inadequate sedation, and decreased patient surveillance are the major risk factors for UE. Inexperienced personnel and improper tube fixation may also be important, while physical restraint use remains controversial. UE can be followed by serious complications, mainly aspiration, laryngeal oedema and increased risk for pneumonia. Need for re-intubation is a major determinant of patient outcomes. Implementation of educational or quality improvement programs is expected to advance personnel's knowledge about risk factors for UE, promote skills on safe, standardized procedures for patient care and increase compliance with them.

RELEVANCE TO CLINICAL PRACTICE

Identifying risk factors for UE and minimizing UE incidence through appropriate preventive strategies are prerequisites for improving nursing care quality and patient safety in the ICU.

[Effects of rotated endotracheal tube fixation method on unplanned extubation, oral mucosa and facial skin integrity in ICU patients]

PURPOSE

The study was done to compare effects of two endotracheal tube (ET tube) fixation methods (rotated fixation versus conventional) on unplanned extubation and skin integrity for orally intubated patients in intensive care units.

METHODS

The research design was a non-equivalent control group with repeated measures design. Participants were 80 patients; 40 participants assigned to each group. ET tube for the experimental participants fixed with rotated method every morning. Unplanned extubation was assessed by bedside nurses using the unplanned extubation report form. Oral mucosa and facial skin integrity were assessed using oral assessment guide and facial skin integrity assessment guide at day 3, 7, 10 and 14.

RESULTS

There was no difference in the unplanned extubation rate between the two groups. Oral mucosa impairment scores for the rotated fixation method were significantly lower at day 7 (p=.044), 10 (p=.048) and day 14 (p=.037). Also facial skin integrity impairment scores for the same group were significantly lower at day 7 (p=.010), 10 (p=.003), and 14 (p=.002).

CONCLUSION

Results of the study suggest that the rotated fixation method is effective for these patients, to prevent impairment of oral mucosa and facial skin integrity. Further research is needed to prevent unplanned extubation.

Self/unplanned extubation: safety, surveillance, and monitoring of the mechanically ventilated patient

The purpose of this article is to provide an appreciation for a significant risk to quality of care affecting patients receiving mechanical ventilation: unplanned extubation. A summary of the current literature provides evidence-based recommendations for how to minimize this potentially dangerous complication. In addition, recommendations for proceeding after unplanned extubation are made.

Development and evaluation of an appraisal form to assess clinical effectiveness of adult invasive mechanical ventilation systems

BACKGROUND

Rapid developments in intensive care medicine have made mechanical ventilation an essential method in the resuscitation and comprehensive treatment of critical care patients. This study aimed to develop and evaluate an appraisal form assessing the clinical effectiveness of adult invasive mechanical ventilation systems.

METHODS

An appraisal form was designed according to the effectiveness evaluation theory of the American Weapons Systems Effectiveness Industry Advisory Committee (WSEIAC) along with literature review and expert panel review. Content validity of the preliminary form was analyzed in a cohort of 200 patients. Exploratory and confirmatory factor analysis was used to assess appraisal form validity. Discriminate validity of different ventilation outcomes was analyzed by t test. Test/retest reliability and inter-scorer reliability were evaluated with 30 patients after a 2-week interval by Cronbach's alpha.

RESULTS

Exploratory factor analysis showed eigenvalues for 3 dimensions (availability, dependability, capability) to be 7.85, 4.43, and 4.22, respectively. Cronbach's α for internal consistency of the appraisal form was 0.957, and 0.922, 0.961 and 0.937, respectively, for the 3 dimensions. Test-retest reliability of 3 dimensions was 0.976, and 0.862, 0.857, 0.885, respectively. Intra-class correlation coefficient verified test-retest reliability; ICC 0.976 and 0.862, 0.857, 0.885 for 3 dimensions, respectively.

CONCLUSIONS

The appraisal form for clinical effectiveness of adult invasive mechanical ventilation systems has high reliability and validity and may be used in clinical setting.

[Physical restraint use in critical care units. Perceptions of patients and their families]

INTRODUCTION

The use of physical restraints in Intensive Care Units (ICU) is common although little is known about patients' and relatives' perceptions of this use.

OBJECTIVES

1) To analyze the prevalence and use of physical restraints in a general adult ICU; 2) to know the perceptions of patients who experienced use of physical restraints and; 3) to know the perceptions of relatives of patients who used physical restraints.

METHODS

This descriptive study, which used both quantitative and qualitative methods, was carried out in an adult ICU. For the first objective, all the patients (101) who had used any kind of physical restraint were analysed. For the second and third objectives, 30 patients and 30 relatives were interviewed using the guidelines of Strumpf & Evans as modified by Hardin (1993). All interviews were recorded, fully transcribed and then submitted to a language content analysis using the method of Hsieh & Shannon.

RESULTS

The only physical restraint used was the wrist restraint with a prevalence of 43.47%. Seventy-two percent of patients wore the restraint ≤12h and 28%>12h. Analysis of the patient interviews revealed 4 main themes: acceptance of the restraint conditioned by beliefs and information provided; feelings and sensations caused by the use of the restraint; alternatives proposed and future repercussions. Three themes emerged from the interviews with relatives: impressions caused by the use of the restrictions; reasons for accepting or rejecting them; alternatives to the use of restraints.

CONCLUSIONS

Most patients used physical restraints for a short period of time and only the wrist restraint was used. Patients using physical restraints and their relatives expressed a wide range of feelings and sensations, with no negative future repercussions. In general, they agreed with the use of restraints although more precise information would lead to greater acceptance.

Risk factors and outcomes after unplanned extubations on the ICU: a case-control study

Introduction

Unplanned extubation (UE) is a frequent event during mechanical ventilation in critically ill patients and might be associated with increased morbidity and mortality. However, detailed knowledge of risk factors and outcomes after UE is lacking.

Methods

A case-control study was performed with a case to control ratio of 1:4. Incidence density sampling was applied. Seventy-four cases and 296 control patients were included.

Results

Seventy-four UEs occurred in 69 patients, comprising 2% of all mechanically ventilated patients. Multivariable regression analysis revealed that the first and second categories of the Ramsay Sedation Scale score were associated with a high risk for an UE (odds ratios (ORs) 30 and 25, respectively). Male sex, subunit of the intensive care unit (ICU), length of stay in the ICU and midazolam use at time of UE were also risk factors for an UE. Patients with an UE had lower hospital mortality than mechanically ventilated patients without UE, 10% versus 30%, respectively. Forty-seven percent (n = 35) of the patients with an UE had to be reintubated.

Conclusions

The present study shows that the first and second categories of the Ramsay Sedation Scale were associated with a high risk for an UE. Also, male sex and use of midazolam at time of UE were identified as risk factors for an UE. However, compared with mechanically ventilated controls, no increased mortality was shown for UE patients. In UE patients without the need for subsequent reintubation, mortality was very low.

[Nursing interventions for the prevention of accidental extubation]

The objective was to analyze results of the incidence of accidental extubation associated with nursing care.

METHOD

Retrospective observational study, the intervention ahead, measured before and after the deployment of a guide extubations accidental The population of 142 patients, 72 patients in the retrospective phase and 70 in phase ahead, totaling 3771 days of ventilation. Data collected from prontuários.

RESULTS

52.78% used tracheal tube and 62% were between 71 and 90 years with an average of days of ventilation of 26.5 days,. There were six (3.27) extubations before and two (1.03) after the deployment of guia. CONCLUSION, there was a decrease in the incidence of accidental extubation in the period studied, but one can not attribute this difference to the guide because other studies are needed.

Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations

OBJECTIVE

The aim of this study was to update the state of knowledge of unplanned extubations in the pediatric population. The main topics addressed in the current literature on unplanned extubations were: 1) incidence; 2) risk factors; 3) risk factors for reintubation after unplanned extubations; and 4) strategies to prevent unplanned extubations. Based on this review we summarize and propose best practices in preventing unplanned extubations.

DATA SOURCE

MEDLINE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for bibliography for the period spanning from January 1966 to March 2009. We used the following key words: unplanned extubation, accidental extubation, self extubation, unintentional extubation, unexpected extubation, inadvertent extubation, spontaneous extubation, and treatment interference.

STUDY SELECTION

Eleven pediatric articles were eligible for data abstraction. Study quality was assessed using four levels of aggregate evidence adapted from the American Academy of Pediatrics.

DATA SYNTHESIS

Unplanned extubations occurs at a rate of 0.11 to 2.27 events per 100 intubation days. Risk factors associated with unplanned extubations were age (younger patients), inadequate tube fixation, agitation, copious secretions, performance of patient procedures, and nursing workload. Reintubation rates ranged from 14% to 65% of unplanned extubations. Three cohort studies evaluated the effectiveness of strategies in reducing unplanned extubations. One study reported the institution of a standardized algorithm of goal-directed sedation, whereas two studies evaluated the implementation of a continuous quality-improvement program. These studies reported significant reductions in unplanned extubations rate after program implementation. Methods of securing the endotracheal tube varied across studies and the use of physical restraints yielded conflicting findings.

CONCLUSIONS

There are few studies assessing unplanned extubations in pediatric intensive care units. The available quality studies have shown that improvement of quality components is effective in reducing unplanned extubations. Although further rigorous studies are needed to establish strong recommendations on unplanned extubations prevention, we present a summary of recommendations based on review of the current literature.

Intervenção e atividades propostas para o diagnóstico de enfermagem: ventilação espontânea prejudicada

Este estudo teve como objetivo investigar as intervenções e atividades de enfermagem propostas pela literatura para o diagnóstico de enfermagem ventilação espontânea prejudicada. Trata-se de uma revisão integrativa da literatura, nos bancos de dados MEDLINE e LILACS, utilizando os unitermos: Ventilação Mecânica, Diagnóstico de Enfermagem, Cuidados Intensivos e Cuidados de Enfermagem. A amostra foi constituída de 15 artigos, em oito deles foram identificados 20 cuidados que poderiam se relacionar às intervenções e atividades de enfermagem aplicadas ao paciente em ventilação mecânica, propostas na Classificação das Intervenções de Enfermagem. Entre esses cuidados, apenas oito equivaleram-se às intervenções prioritárias. Mas, nas intervenções sugeridas existem atividades para praticamente todos os cuidados desta revisão. Este estudo demonstrou que, apesar da importância dos cuidados aplicados aos pacientes em ventilação mecânica, estes, não são considerados como específicos da enfermagem, e a maioria não está presente na literatura.

[Unplanned extubations in patients in the ventilator weaning phase in the intensive care unit: Incidence and risk factors]

OBJECTIVES

To identify the incidence of unplanned extubations (UE) in a general intensive care unit (ICU) and associated risk factors.

METHODS

An analytical, observational and prospective study was performed in an eight-bed general ICU over a 6-month period. The participants consisted of 79 consecutive patients who underwent mechanical ventilation for 12 h or more and who were under the ventilator weaning phase. The variables studied were age, days of endotracheal intubation, length of stay in the ICU, weaning phase and the APACHE II prognostic score; the degree of sedation and/or agitation was evaluated using Riker's Sedation-Agitation Scale. The incidence density of UEs was calculated and the variables measured in the extubated and non-extubated groups were compared using the Mann Whitney U-test.

RESULTS

Among the 79 patients studied, UE occurred in 15 (18.9%). Of these events, 76.9% occurred during the ventilator weaning phase. There were 11 cases (73.3%) of self-extubations, three cases (20%) of accidental removal and one case (6.6%) of endotracheal tube obstruction. Age equal to or less than 60 years was a risk factor. No relationship was found with the remaining factors studied: days of hospital stay, days of endotracheal intubation or APACHE score.

CONCLUSIONS

Patients at risk for UE were younger and showed agitation on the Riker scale. UEs usually occurred during the ventilator weaning phase.

Unplanned extubation in a paediatric intensive care unit: impact of a quality improvement programme

Unplanned tracheal extubation is an important quality issue in current medical practice as it is a common occurrence in paediatric intensive care units. We have assessed the effectiveness of a continuous quality improvement programme in reducing the incidence of unplanned extubation over a 5-year period. After a 2-year baseline period, we developed action plans to address the issues identified. Following implementation of the programme, the overall incidence of unplanned extubation decreased from 2.9 unplanned extubations per 100 intubated patient days in the first year to 0.6 in the last year (p = 0.0001). This reduction was the result of a decrease in unplanned extubation in children younger than 2 years of age. Although mortality was similar to that of children who did not experience an unplanned extubation, those with an unplanned extubation had a significantly longer duration of mechanical ventilation, longer stay in the intensive care unit, and longer hospital stay. We found that the implementation of a continuous quality improvement programme is effective in reducing the overall incidence of unplanned extubations.

[Field 5. Safety practices procedures for mechanical ventilation. French-speaking Society of Intensive Care. French Society of Anesthesia and Resuscitation]

Invasive or endotracheal mechanical ventilation can lead to numerous complications likely to burden morbidity and mortality of patients in the intensive care unit. Various safety practices for mechanical ventilation may involve intubation, the mechanical ventilation period, weaning and extubation, the use of tracheostomy as well as non-invasive ventilation. The main objective of safety practices described in this chapter is to prevent or avoid the main risks due to invasive mechanical ventilation.

Influence of Physical Restraint on Unplanned Extubation of Adult Intensive Care Patients: A Case-Control Study

Background Unplanned extubation commonly occurs in intensive care units. Various physical restraints have been used to prevent patients from removing their endotracheal tubes. However, physical restraint not only does not consistently prevent injury but also may be a safety hazard to patients.

Objectives To evaluate the effect of physical restraint on unplanned extubation in adult intensive care patients.

Methods A total of 100 patients with unplanned extubations and 200 age-, sex-, and diagnosis-matched controls with no record of unplanned extubation were included in this case-control study. The 300 participants were selected from a population of 1455 patients receiving mechanical ventilation during a 21-month period in an adult intensive care unit at a medical center in Taiwan. Data were collected by reviewing medical records and incident reports of unplanned extubation.

Results The incidence rate of unplanned extubation was 8.7%. Factors associated with increased risk for unplanned extubation included use of physical restraints (increased risk, 3.11 times), nosocomial infection (increased risk, 2.02 times), and a score of 9 or greater on the Glasgow Coma Scale on admission to the unit (increased risk, 1.98 times). Episodes of unplanned extubation also were associated with longer stays in the unit.

Conclusions An impaired level of consciousness on admission to the intensive care unit and the presence of nosocomial infection intensify the risk for unplanned extubation, even when physical restraints are used. To minimize the risk of unplanned extubation, nurses must establish better standards for using restraints.

The difficult airway in adult critical care

INTRODUCTION

The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer.

AIMS

This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed.

RESULTS

All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation.

CONCLUSIONS

Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.

Sedation breaks: are they good for the critically ill patient? A review

BACKGROUND

Tradition has led us to believe that a heavily sedated patient is a comfortable, settled, compliant patient for whom sedation will improve outcome. The current move witnessed in clinical practice today of limiting sedation has led health care in recent years to question the benefit and necessity of routine, continuous sedation for all patients requiring mechanical ventilation. However, as a result there has been a rise in the amount of agitation being reported as being experienced by patients with the daily withdrawal of sedation.

AIMS

The purpose of this paper is to review current arguments for and against perserving with agitation versus re-sedating, when it presents during the daily sedation breaks.

FINDINGS

Of the literature reviewed, the question to re-sedate the mechanically ventilated agitated patient during sedation breaks remains an issue of contention. Although there is evidence focusing on the psychological effects of long-term sedation and sedation breaks specifically, the complex nature of critical illness in some cases means that individualized care is of paramount importance and in-depth assessment is crucial when deciding to re-sedate in the face of undetermined agitation. Agitation has been closely linked with several incidents that can be detrimental to patient safety, such as removal of lines and unplanned self-extubation.

CONCLUSION

The recommendations of this review are that nurses should re-commence sedation if the patient becomes agitated following a sedation break.

The use of physical restraint in critical care

Critically ill patients are at high risk for the development of delirium and agitation, resulting in non-compliance with life-saving treatment. The use of physical restraint appears to be a useful and simple solution to prevent this treatment interference. In reality, restraint is a complex topic, encompassing physical, psychological, legal and ethical issues. This article briefly discusses the incidence of delirium and agitation in critically ill patients and examines in detail the method of physical restraint to manage treatment interference. The historical background of physical restraint is discussed and the prevalence of its use in critical care units across the world examined. Studies into the use of physical restraint are analysed, and in particular the physical effects on patients discussed. The use of physical restraint raises many legal, ethical and moral questions for all health care professionals; therefore, this study aims to address these questions. This article concludes by emphasizing areas of future practice development in intensive care units throughout the UK.

Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: A patient perspective

An important goal of the care for the mechanically ventilated patient is to minimize patient discomfort and anxiety. This is partly achieved by frequent use of chemical and physical restraints. The majority of patients in intensive care will receive some form of sedation. The goal and use of sedation has changed considerably over the past few decades with literature evidencing trends toward overall lighter sedation levels and daily interruption of sedation. Conversely, the use of physical restraint for the ventilated patient in ICU differs considerably between nations and continents. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. Recent literature suggests minimal use of physical restraint in the ICU, and that reduction programmes have been initiated. However, very few papers illuminate the patient's experience of physical and chemical restraints as a treatment strategy. In Part 1 of this two-part review, the evidence on chemical and physical restraints was explored with specific focus on definitions of terms, unplanned extubation, agitation, delirium as well as the impact of nurse-patient ratios in the ICU on these issues. This paper, Part 2, examines the evidence related to chemical and physical restraints from the mechanically ventilated patient's perspective.

Part 1. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: contributing factors

Chemical and physical restraints are frequently used in the intensive care unit (ICU) to control agitated patients and to prevent self-harm and unplanned extubations. Published work relating to the numerous issues of the care and treatment strategies for these patients remains conflicting and unclear. Literature regarding sedation and chemical restraint reveals a trend towards management with lighter sedation, use of sedation assessment tools and sedation protocols. It remains unclear which treatment is best for agitated and delirious patients, and the evidence on the effect of sedation is conflicting. A large portion of the literature on the use of physical restraint is from general hospital wards and residential homes, and not from the ICU environment. The purpose of this paper is to provide a summary of the existing literature on the use of physical and chemical restraints in the ICU setting. In Part 1 of this two-part paper, the evidence on chemical and physical restraints is explored with specific focus on definition of terms, unplanned extubation, agitation, delirium and the impact of nurse-patient ratios in the ICU on these issues. Part 2 of the paper examines the evidence related to chemical and physical restraints from the perspective of the mechanically ventilated patient.