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Investigating influencing factors of physical restraint use in China intensive care units: A prospective, cross-sectional, observational study. Aust Crit Care 2018; 32:193-198. [PMID: 30001953 DOI: 10.1016/j.aucc.2018.05.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 05/05/2018] [Accepted: 05/06/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE In this study, we characterised the use of physical restraints in three intensive care units (ICUs) in a general hospital in Nantong, China. Additionally, we explored risk factors potentially related to physical restraint use. BACKGROUND Despite their numerous harmful effects, physical restraints are frequently used in ICUs worldwide. Few studies have investigated the factors that contribute to physical restraint use in Chinese hospitals. METHODS We conducted a prospective, cross-sectional, observational study of 312 patients in three ICUs at a general hospital in China. The quantitative data were collected during a 5-month period using a physical restraint observation form and patient records. The data obtained were analysed using descriptive statistics. The independent risk factors for physical restraint use were assessed using a logistic regression model. RESULTS Of the 312 patients in the three ICUs, 191 (61.2%) were restrained, and physical restraints were used more than once for 46 (24.1%) patients during their ICU stay. The median length of physical restrain use was 20 shifts (interquartile range = 10-36 shifts). Physical restraints were applied in 6664 of 12374 (53.9%) nurse shifts. The most common time at which physical restraints were applied was the beginning of the evening shift. According to the forward stepwise logistic regression analysis, delirium (P < 0.001), mechanical ventilation (P < 0.001), and age (P < 0.001) were independent risk factors for physical restraint use. The use of analgesics (P = 0.001) exerted an independent protective effect against physical restraint use. CONCLUSIONS The overall prevalence of physical restraint use in Chinese ICUs was higher than that reported in previous investigations. The patients' nursing notes lacked complete physical restraint records, reflecting a need for standard guidelines and policies for physical restraint use in hospital ICUs in China. In addition, in this study, we explored the risk factors related to physical restraint use and found that age, delirium, mechanical ventilation, and analgesic use are associated with physical restraint use.
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Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Crit Care Med 2017; 44:2079-2103. [PMID: 27755068 DOI: 10.1097/ccm.0000000000002027] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient." DESIGN A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions. RESULTS The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents. Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.
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Abstract
Ventilator-associated pneumonia is the most frequent intensive care unit (ICU)-related infection in patients requiring mechanical ventilation. In contrast to other ICU-related infections, which have a low mortality rate, the mortality rate for ventilator-associated pneumonia ranges from 20% to 50%. These clinically significant infections prolong duration of mechanical ventilation and ICU length of stay, underscoring the financial burden these infections impose on the health care system. The causes of ventilator-associated pneumonia are varied and differ across different patient populations and different types of ICUs. This varied presentation underscores the need for the intensivist treating the patient with ventilator-associated pneumonia to have a clear knowledge of the ambient microbiologic flora in their ICU. Prevention of this disease process is of paramount importance and requires a multifaceted approach. Once a diagnosis of ventilator-associated pneumonia is suspected, early broad-spectrum antibiotic administration decreases morbidity and mortality and should be based on knowledge of the sensitivities of common infecting organisms in the ICU. De-escalation of therapy, once final culture results are available, is necessary to minimize development of resistant pathogens. Duration of therapy should be based on the patient’s clinical response, and every effort should be made to minimize duration of therapy, thus further minimizing the risk of resistance.
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Affiliation(s)
- Kimberly A Davis
- Department of Surgery, Division of Trauma, Surgical Critical Care and Burns, Loyola University Medical Center, Maywood, IL, USA.
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Chuang ML, Lee CY, Chen YF, Huang SF, Lin IF. Revisiting Unplanned Endotracheal Extubation and Disease Severity in Intensive Care Units. PLoS One 2015; 10:e0139864. [PMID: 26484674 PMCID: PMC4617893 DOI: 10.1371/journal.pone.0139864] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 09/16/2015] [Indexed: 01/01/2023] Open
Abstract
Most reports regarding unplanned extubation (UE) are case-control studies with matching age and disease severity. To avoid diminishing differences in matched factors, this study with only matching duration of mechanical ventilation aimed to re-examine the risk factors and the factors governing outcomes of UE in intensive care units (ICUs). This case-control study was conducted on 1,775 subjects intubated for mechanical ventilation. Thirty-seven (2.1%) subjects with UE were identified, and 156 non-UE subjects were randomly selected as the control group. Demographic data, acute Physiological and Chronic Health Evaluation II (APACHE II) scores, and outcomes of UE were compared between the two groups. Logistic regression analysis was used to identify the risk factors of UE. Milder disease, younger age, and higher Glasgow Coma Scale (GCS) scores with more frequently being physically restrained (all p<0.05) were related to UE. Logistic regression revealed that APACHE II score (odds ratio (OR) 0.91, p<0.01), respiratory infection (OR 0.24, p<0.01), physical restraint (OR 5.36, p<0.001), and certain specific diseases (OR 3.79–5.62, p<0.05) were related to UE. The UE patients had a lower ICU mortality rate (p<0.01) and a trend of lower in-hospital mortality rate (p = 0.08). Cox regression analysis revealed that in-hospital mortality was associated with APACHE II score, age, shock, and oxygen used, all of which were co-linear, but not UE. The results showed that milder disease with higher GCS scores thereby requiring a higher use of physical restraints were related to UE. Disease severity but not UE was associated with in-hospital mortality.
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Affiliation(s)
- Ming-Lung Chuang
- Division of Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Critical Care Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- * E-mail: (MLC); (CYL)
| | - Chai-Yuan Lee
- Department of Nursing, Chung Shan Medical University, Taichung, Taiwan
- * E-mail: (MLC); (CYL)
| | - Yi-Fang Chen
- Division of Respiratory Care, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Shih-Feng Huang
- Division of Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Department of Critical Care Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - I-Feng Lin
- Institute and Department of Public Health, National Yang Ming University, Taipei, Taiwan
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Fontenot AM, Malizia RA, Chopko MS, Flynn WJ, Lukan JK, Wiles CE, Guo WA. Revisiting endotracheal self-extubation in the surgical and trauma intensive care unit: Are they all fine? J Crit Care 2015; 30:1222-6. [PMID: 26271687 DOI: 10.1016/j.jcrc.2015.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 07/13/2015] [Accepted: 07/17/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Endotracheal self-extubation (ESE) is a serious health care concern. We designed this study to test our hypothesis that not all patients with ESE are successful in spontaneous breathing and reintubation has negative impact on outcomes. METHODS Data on all 39 patients of ESE in our surgical and trauma intensive care unit (ICU) in 2012 were prospectively collected and retrospectively analyzed. RESULTS There were 42 episodes of ESE in 39 of 939 intubated patients (frequency, 4.0%), with 54% of events requiring reintubation. Pre-ESE positive end-expiratory pressure was higher and Pao2/fraction of inspired oxygen ratio was lower, and the post-ESE respiration rate was higher in the reintubated group. On univariate analysis, weaning and spontaneous breathing trial before ESE were favorable predictors for nonreintubation. Multivariate regression analysis demonstrated that agitation before ESE was an independent predictor of reintubation. The need for reintubation was associated with increased risk of pulmonary infectious complications, ventilator days, the need for tracheostomy, and ICU and hospital LOS. The financial costs for ventilator days and ICU rooms were significantly higher in patients with reintubation. CONCLUSION Not all patients were fine after ESE. We have not decreased the frequency of ESE or improved outcomes if the patients were reintubated. The need for reintubation was not only associated with a high pulmonary complication rate but also prolonged duration on mechanical ventilation and hospital/ICU stay and increased the hospital costs.
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Affiliation(s)
- Ashleigh M Fontenot
- Division of Acute Care Surgery, Department of Surgery, SUNY-Buffalo, Buffalo, NY
| | - Robert A Malizia
- Division of Acute Care Surgery, Department of Surgery, SUNY-Buffalo, Buffalo, NY
| | - Michael S Chopko
- Division of Acute Care Surgery, Department of Surgery, SUNY-Buffalo, Buffalo, NY
| | - William J Flynn
- Division of Acute Care Surgery, Department of Surgery, SUNY-Buffalo, Buffalo, NY
| | - James K Lukan
- Division of Acute Care Surgery, Department of Surgery, SUNY-Buffalo, Buffalo, NY
| | - Charles E Wiles
- Division of Acute Care Surgery, Department of Surgery, SUNY-Buffalo, Buffalo, NY
| | - Weidun Alan Guo
- Division of Acute Care Surgery, Department of Surgery, SUNY-Buffalo, Buffalo, NY.
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Wagner JL, Shandas R, Lanning CJ. Extubation force depends upon angle of force application and fixation technique: a study of 7 methods. BMC Anesthesiol 2014; 14:74. [PMID: 25214815 PMCID: PMC4161264 DOI: 10.1186/1471-2253-14-74] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 08/13/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer L Wagner
- Department of Bioengineering, University of Colorado Denver, Aurora, CO, USA
| | - Robin Shandas
- Department of Bioengineering, University of Colorado Denver, Aurora, CO, USA
| | - Craig J Lanning
- Department of Bioengineering, University of Colorado Denver, Aurora, CO, USA
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Luk E, Sneyers B, Rose L, Perreault MM, Williamson DR, Mehta S, Cook DJ, Lapinsky SC, Burry L. Predictors of physical restraint use in Canadian intensive care units. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R46. [PMID: 24661688 PMCID: PMC4075126 DOI: 10.1186/cc13789] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/07/2014] [Indexed: 12/14/2022]
Abstract
Introduction Physical restraint (PR) use in the intensive care unit (ICU) has been associated with higher rates of self-extubation and prolonged ICU length of stay. Our objectives were to describe patterns and predictors of PR use. Methods We conducted a secondary analysis of a prospective observational study of analgosedation, antipsychotic, neuromuscular blocker, and PR practices in 51 Canadian ICUs. Data were collected prospectively for all mechanically ventilated adults admitted during a two-week period. We tested for patient, treatment, and hospital characteristics that were associated with PR use and number of days of use, using logistic and Poisson regression respectively. Results PR was used on 374 out of 711 (53%) patients, for a mean number of 4.1 (standard deviation (SD) 4.0) days. Treatment characteristics associated with PR were higher daily benzodiazepine dose (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00 to 1.11), higher daily opioid dose (OR 1.04, 95% CI 1.01 to 1.06), antipsychotic drugs (OR 3.09, 95% CI 1.74 to 5.48), agitation (Sedation-Agitation Scale (SAS) >4) (OR 3.73, 95% CI 1.50 to 9.29), and sedation administration method (continuous and bolus versus bolus only) (OR 3.09, 95% CI 1.74 to 5.48). Hospital characteristics associated with PR indicated patients were less likely to be restrained in ICUs from university-affiliated hospitals (OR 0.32, 95% CI 0.17 to 0.61). Mainly treatment characteristics were associated with more days of PR, including: higher daily benzodiazepine dose (incidence rate ratio (IRR) 1.07, 95% CI 1.01 to 1.13), daily sedation interruption (IRR 3.44, 95% CI 1.48 to 8.10), antipsychotic drugs (IRR 15.67, 95% CI 6.62 to 37.12), SAS <3 (IRR 2.62, 95% CI 1.08 to 6.35), and any adverse event including accidental device removal (IRR 8.27, 95% CI 2.07 to 33.08). Patient characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, admission category, prior substance abuse, prior psychotropic medication, pre-existing psychiatric condition or dementia) were not associated with PR use or number of days used. Conclusions PR was used in half of the patients in these 51 ICUs. Treatment characteristics predominantly predicted PR use, as opposed to patient or hospital/ICU characteristics. Use of sedative, analgesic, and antipsychotic drugs, agitation, heavy sedation, and occurrence of an adverse event predicted PR use or number of days used.
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Kiekkas P, Aretha D, Panteli E, Baltopoulos GI, Filos KS. Unplanned extubation in critically ill adults: clinical review. Nurs Crit Care 2012; 18:123-34. [PMID: 23577947 DOI: 10.1111/j.1478-5153.2012.00542.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Panagiotis Kiekkas
- Nursing Department, Highest Technological Educational Institute of Patras, Patras 263-31, Greece.
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King JN, Elliott VA. Self/unplanned extubation: safety, surveillance, and monitoring of the mechanically ventilated patient. Crit Care Nurs Clin North Am 2012; 24:469-79. [PMID: 22920470 DOI: 10.1016/j.ccell.2012.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Julie N King
- Weinberg Intensive Care Unit, Johns Hopkins Hospital, 401 North Broadway: Wbg 3A, Baltimore, MD 21231, USA.
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da Silva PSL, Fonseca MCM. Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg 2012; 114:1003-14. [PMID: 22366845 DOI: 10.1213/ane.0b013e31824b0296] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In this study, we updated the state of knowledge on unplanned tracheal extubations in the intensive care unit. We focused on the following topics: incidence, risk factors, reintubation after unplanned extubation, outcomes, and prevention. Based on this review, recommendations were made for preventing unplanned extubations. METHODS Electronic databases were searched for relevant publications from January 1, 1950 through June 30, 2011 on the MEDLINE, EMBASE, CINAHL, SciELO, LILACS, and Cochrane systems. Fifty articles were eligible for data abstraction. Study quality was assessed using the Newcastle-Ottawa Scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine. RESULTS Unplanned extubations occur at a rate of 0.1 to 3.6 events per 100 intubation days. Risk factors associated with unplanned extubations included male gender (odds ratio [OR] 4.8), APACHE score ≥17 (OR 9.0), chronic obstructive pulmonary disease, restlessness/agitation (OR 3.3-30.6), lower sedation level (OR 2.0-5.4), higher consciousness level (OR 1.4-2.0), and use of physical restraints (OR 3.1). Reintubation rates ranged from 1.8% to 88% of unplanned extubations. Thirteen studies assessed preventive measures for avoiding unplanned extubations. These studies focused on data collection tools, standardization of procedures, staff education, staff surveillance, and identification and management of high-risk patients. These studies reported reductions in unplanned extubation rate from 22% to 53%. The best methods of securing the endotracheal tube and use of physical restraints remain controversial issues. CONCLUSIONS Despite numerous publications on unplanned extubation, few studies assess preventive strategies for adverse events, and few clinical trials have assessed unplanned extubations. Recommendations are proposed based on the currently available literature.
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Affiliation(s)
- Paulo Sergio Lucas da Silva
- Department of Intensive Care Medicine, Hospital do Servidor Público Municipal, Rua Castro Alves, 60, São Paulo, Brazil, 01532-900.
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MESHULACH-NETZER I, BAHARAV A, SIVAN Y. Prevention of accidental extubation in ventilated infants and children. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.9.2.58.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Endotracheal tube fixation methods for optimal stability: a comparison of adhesive tape, suture, and tape-suture fixation. J Craniofac Surg 2011; 21:1250-1. [PMID: 20613600 DOI: 10.1097/scs.0b013e3181e20860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Accidental extubation of an intubated patient is a serious consideration in the surgical patient. Adequate fixation in the intubated patient is essential to prevent potentially life-threatening complications. Several methods of endotracheal tube fixation have been described in the literature. In this study, we examine 3 common methods of fixation: adhesive tape alone, suture, and tape-suture. Testing occurred in a laboratory setting with 2 fresh cadavers. Endotracheal tubes were inserted, using the methods of fixation in question. We subjected each fixation technique to progressively increasing weight to determine which technique is most resistant to accidental removal. We found that fixation of the tube by combining tape around the tube with a suture through the tape is the best noninvasive technique of the 3 methods evaluated in cases where movement of the head is anticipated.
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Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations. Pediatr Crit Care Med 2010; 11:287-94. [PMID: 19794322 DOI: 10.1097/pcc.0b013e3181b80951] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Owen R, Castle N, Hann H, Reeves D, Naidoo R, Naidoo S. Extubation force: A comparison of adhesive tape, non-adhesive tape and a commercial endotracheal tube holder. Resuscitation 2009; 80:1296-300. [DOI: 10.1016/j.resuscitation.2009.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 07/03/2009] [Accepted: 08/02/2009] [Indexed: 10/20/2022]
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Calvino Günther S, Schwebel C, Vésin A, Remy J, Dessertaine G, Timsit JF. Interventions to decrease tube, line, and drain removals in intensive care units: the FRATER study. Intensive Care Med 2009; 35:1772-6. [PMID: 19557388 DOI: 10.1007/s00134-009-1555-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 06/04/2009] [Indexed: 11/30/2022]
Abstract
PURPOSES To evaluate the incidence of unintended tube, line, and drain removals (UTRs) in our ICU, to identify system factors associated with UTRs, and to evaluate interventions designed to decrease UTR occurrence. METHODS Interventional study in the 18-bed medical ICU of a French general university hospital. We prospectively determined the incidence and circumstances of UTRs in our ICU over a 2-year period. Demographic and clinical data were collected for consecutively admitted patients, and additional information was recorded about patients experiencing UTRs. Investigators analyzed UTR data twice a month to identify possible causes and developed interventions to decrease UTRs (mainly securing tubes and sedation protocol). Conditional logistic regression stratified on length of stay was used to identify risk factors for UTRs and segmented linear regression analysis to test the effects of interventions. RESULTS Of 2,007 admitted patients (12,256 patient days), 193 (9.6%) experienced 270 UTRs (22/1,000 patient days). Clinical or therapeutic consequences occurred for 17% of UTRs. Three factors were independently associated with UTR; two were risk factors, namely, admission for coma [OR, 2.68; 95% CI (1.87; 3.84); P < 0.0001] and mechanical ventilation in over 65% of all ICU patients [OR = 1.65 (1.19; 2.29); P = 0.003], and one was protective, namely, mean SAPS II >45 in all ICU patients [OR, 0.54; 95% CI (0.39; 0.75); P = 0.0003]. Segmented regression analysis showed a 67.4% drop [95% CI (17.2%; 117.3%); P = 0.009] in the UTR rate after the first intervention was introduced. System factors played a major role in UTR occurrence. CONCLUSION UTRs are common. A continuous quality-improvement program can reduce UTR rates in the ICU.
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Chang LY, Wang KWK, Chao YF. Influence of Physical Restraint on Unplanned Extubation of Adult Intensive Care Patients: A Case-Control Study. Am J Crit Care 2008. [DOI: 10.4037/ajcc2008.17.5.408] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Li-Yin Chang
- Li-Yin Chang is supervisor of the nursing department at Taichung Veterans General Hospital and is a doctoral student in the School of Nursing, National Yang-Ming University, Taipei, Taiwan. Kai-Wei Katherine Wang is an assistant professor in the School of Nursing at National Yang-Ming University, Taipei, Taiwan. Yann-Fen Chao is a professor in the College of Nursing at Taipei Medical University, Taipei, Taiwan
| | - Kai-Wei Katherine Wang
- Li-Yin Chang is supervisor of the nursing department at Taichung Veterans General Hospital and is a doctoral student in the School of Nursing, National Yang-Ming University, Taipei, Taiwan. Kai-Wei Katherine Wang is an assistant professor in the School of Nursing at National Yang-Ming University, Taipei, Taiwan. Yann-Fen Chao is a professor in the College of Nursing at Taipei Medical University, Taipei, Taiwan
| | - Yann-Fen Chao
- Li-Yin Chang is supervisor of the nursing department at Taichung Veterans General Hospital and is a doctoral student in the School of Nursing, National Yang-Ming University, Taipei, Taiwan. Kai-Wei Katherine Wang is an assistant professor in the School of Nursing at National Yang-Ming University, Taipei, Taiwan. Yann-Fen Chao is a professor in the College of Nursing at Taipei Medical University, Taipei, Taiwan
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Gardner A, Hughes D, Cook R, Henson R, Osborne S, Gardner G. Best practice in stabilisation of oral endotracheal tubes: a systematic review. Aust Crit Care 2008; 18:158, 160-5. [PMID: 18038537 DOI: 10.1016/s1036-7314(05)80029-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Mechanical ventilation of patients in intensive care units is common practice. Artificial airways are utilised to facilitate ventilation and the endotracheal tube (ETT) is most commonly used for this purpose. The ETT must be stabilised to optimise ventilation and avoid displacement or unplanned extubation. Tube movement is a major factor in causing airway trauma. A destabilised tube can cause fatal complications. A systematic review was conducted to identify and analyse the best available evidence on ETT stabilisation to determine which stabilisation method resulted in reduced tube displacement and the least amount of unplanned or accidental extubations. The types of stabilisations included one or a combination of the following methods: twill or cotton tape, adhesive tape, gauze, or a manufactured device. All relevant randomised controlled and quasi-experimental studies of ETT stabilisation practices, identified through electronic and hand searching, were assessed for inclusion in the study. One published randomised controlled trial and six published quasi-experimental studies met the inclusion and exclusion criteria and were retrieved. Data were extracted independently by two reviewers. Results of the systematic review showed that no single method of ETT stabilisation could be identified as superior for minimising tube displacement and unplanned or accidental extubations. Rigorous randomised controlled trials with clearly identified and described ETT stabilisation methods are required to establish best practice. In addition, comparative research to evaluate cost effectiveness and nursing time requirements would also be of significant benefit to critical care nursing practice.
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Affiliation(s)
- Anne Gardner
- Cabrini Deakin Centre for Nursing Research, Deakin University, Melbourne, VIC
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Patient-initiated device removal in intensive care units: A national prevalence study*. Crit Care Med 2007; 35:2714-20; quiz 2725. [DOI: 10.1097/01.ccm.0000291651.12767.52] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Patient-initiated device removal in intensive care units: A national prevalence study *. Crit Care Med 2007. [DOI: 10.1097/00003246-200712000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Happ MB. The trouble with tubes *. Crit Care Med 2007. [DOI: 10.1097/00003246-200712000-00030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
STUDY OBJECTIVES To assess the consequences of unplanned extubation (UE) in the ICU. DESIGN Case-control study. SETTING Fourteen-bed, medical-surgical ICU of a university-affiliated community teaching hospital. PATIENTS One hundred patients who underwent UE compared to 200 control patients who underwent mechanical ventilation (MV) without UE between January 1, 1999, and June 30, 2004. INTERVENTIONS None. MEASUREMENTS AND RESULTS Patients with UE had longer ICU and hospital length of stay (LOS) and longer duration of MV than did control subjects. Hospital mortality was 20% among UE and 35% among control patients (p = 0.011). Of the 100 patients with UE, reintubation within 48 h (UE R+) was required in 44 patients and no reintubation within 48 h (UE R-) was required in 56 patients. ICU and hospital LOS; duration of MV; rate of ICU-acquired infections; ICU pharmacy, laboratory and diagnostic imaging charges; and mortality were all much higher among UE R+ patients than among UE R- patients. Multiple logistic regression analysis revealed that age was the only predictor of the need for reintubation after UE and that age and the need for reintubation were the only predictors of mortality after UE. CONCLUSIONS UE was associated with increased hospital and ICU LOS but decreased mortality in this heterogeneous population of critically ill adult patients. These findings were entirely explained by the divergent outcomes of the UE R+ and UE R- groups. Patients with UE who did not require reintubation had remarkably good outcomes. It remains incumbent on ICU teams to institute protocols for regular identification of patients ready to be liberated from MV.
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Birkett KM, Southerland KA, Leslie GD. Reporting unplanned extubation. Intensive Crit Care Nurs 2005; 21:65-75. [PMID: 15778070 DOI: 10.1016/j.iccn.2004.07.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2004] [Indexed: 12/29/2022]
Abstract
Between 1995 and 2002 seven clinical audits were undertaken in consecutive periods over twelve months to determine the frequency and risk factors associated with reported unplanned extubation (UE) within a 22-bed general and surgical Intensive Care Unit (ICU). Nursing and medical staff provided information on the patient's age, diagnosis, mental status, precipitating causes and investigations/treatment ordered. Following the first audit, modifications were made to include anonymous reporting. Additional information was also obtained on the patient's position, sedation regimen, method of endotracheal tube (ETT) placement and the use of physical restraints. A clinical indicator was established to monitor the UE incidence based as a rate of UE per 100 patients. Audit results were between 1.06% and 4.86% with an aggregate rate from 1995 to 2002 of 2.6%. This rate compares favourably with the range of 2.8-22.5% reported in the literature. Over the survey periods, 28-60% of patients were assessed as being confused or agitated, 47-67% restrained and 53-70% sedated. The UE reported rate initially increased when anonymous reporting was introduced from 1.06% to 4.86%. Unplanned extubation incidence subsequently decreased in Surgical ICU following the introduction of clinical pathways, early weaning and nurse led extubation. Monitoring UE in ICU provides important information on the quality of care. We would recommend a system of anonymous reporting to more freely reflect incidence.
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Yeh SH, Lee LN, Ho TH, Chiang MC, Lin LW. Implications of nursing care in the occurrence and consequences of unplanned extubation in adult intensive care units. Int J Nurs Stud 2004; 41:255-62. [PMID: 14967182 DOI: 10.1016/s0020-7489(03)00136-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2002] [Revised: 07/19/2003] [Accepted: 07/25/2003] [Indexed: 11/28/2022]
Abstract
This 18-month study used a structured questionnaire to explore the roles of nursing care on the occurrence and consequences of unplanned endotracheal extubation (UEE) in intensive care units in Taiwan. Experiencing UEE were 225/1176 (22.5%) intubated patients: 91.7% were self-extubations and 8.3% were accidental. Self-extubations occurred most frequently during night shifts and in the care of nurses with less working experience. Accidental extubations occurred most frequently in patients undergoing routine nursing procedures, usually required immediate re-intubation and were associated with more complications. An appropriate nurse-to-patient ratio, better working procedures and continual nursing education programs might help reduce occurrence and complications of UEE.
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Affiliation(s)
- Shu-Hui Yeh
- Chang Gung Institute of Technology, Chang Gung Hospital at Kaohsiung, Niao-Sung, Kaohsiung Hsiang 833, Taiwan.
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Affiliation(s)
- Amy L. Richmond
- Amy L. Richmond is a critical care nurse in the surgical intensive care unit at St. Joseph’s Hospital in Marshfield, Wis. She chairs the Endotracheal Tube Committee and has been instrumental in practice changes in critical care at St. Joseph’s Hospital
| | - Dena L. Jarog
- Dena Jarog is the pediatric critical care clinical nurse specialist in the pediatric intensive care unit at St. Joseph’s Hospital in Marshfield, Wis
| | - Vicki M. Hanson
- Vicki Hanson is a respiratory therapist in the surgical and pediatric intensive care units at St. Joseph’s Hospital in Marshfield, Wis
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Maccioli GA, Dorman T, Brown BR, Mazuski JE, McLean BA, Kuszaj JM, Rosenbaum SH, Frankel LR, Devlin JW, Govert JA, Smith B, Peruzzi WT. Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies--American College of Critical Care Medicine Task Force 2001-2002. Crit Care Med 2003; 31:2665-76. [PMID: 14605540 DOI: 10.1097/01.ccm.0000095463.72353.ad] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop clinical practice guidelines for the use of restraining therapies to maintain physical and psychological safety of adult and pediatric patients in the intensive care unit. PARTICIPANTS A multidisciplinary, multispecialty task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM), the Society of Critical Care Medicine (SCCM), and the American Association of Critical Care Nurses (AACN). EVIDENCE The task force members reviewed the published literature (MEDLINE articles, textbooks, etc.) and provided expert opinion from which consensus was derived. Relevant published articles were reviewed individually for validity using the Cochrane methodology (http://hiru.mcmaster.ca/cochrane/ or www.cochrane.org). CONSENSUS PROCESS The task force met as a group and by teleconference to identify the pertinent literature and derive consensus recommendations. Consideration was given to both the weight of scientific information within the literature and expert opinion. Draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft then was reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. CONCLUSIONS The task force developed nine recommendations with regard to the use of physical restraints and pharmacologic therapies to maintain patient safety in the intensive care unit.
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Abstract
After a stay in intensive care, patients may suffer physiological after effects, such as muscle wasting, polyneuropathies, disturbed sleep, itching and poor mobility. The care that patients receive whilst on intensive care may contribute to the severity of some of these physical problems. Raising awareness amongst critical care nurses may help reduce the severity of some of the physiological after effects. Increased awareness amongst nurses on the wards about the physical impact of intensive care may lead to a greater understanding of the needs of this group of patients and may improve discharge planning.
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Affiliation(s)
- Wayne P Robson
- Intensive Care Unit, Chesterfield & North Derbyshire Royal NHS Trust, Derbyshire.
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Vance DL. Effect of a treatment interference protocol on clinical decision making for restraint use in the intensive care unit: a pilot study. AACN CLINICAL ISSUES 2003; 14:82-91. [PMID: 12574706 DOI: 10.1097/00044067-200302000-00010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The literature is replete with articles describing restraint reduction strategies used in long-term care settings, geriatric specialty units, and medical/surgical units in the acute care setting. The feasibility, effectiveness, and appropriateness of such strategies cannot be capriciously applied to the intensive care setting. This article provides an overview of the implementation and outcomes of a pilot study using an algorithmic approach that is clinically appropriate and justifiable for restraint use in the intensive care environment. It provides the critical care nurse with a standardized method for decision analysis when managing patients at risk for treatment interference.
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Affiliation(s)
- Diana L Vance
- Summa Health System Hospitals, Akron, Ohio 44309-2090, USA.
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Stratmann G, Benumof JL. Near tracheal extubation because of edema of the face and tongue. Anesth Analg 2002; 95:1809-11, table of contents. [PMID: 12456463 DOI: 10.1097/00000539-200212000-00063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
IMPLICATIONS Edema of the face and tongue can cause migration of the endotracheal tube out of the trachea. The present case illustrates the importance of preventing this potentially disastrous complication because reintubation might be impossible when the edema is severe.
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Affiliation(s)
- Greg Stratmann
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 94143, USA.
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María Peñalta Sánchez R, Álvarez Plaza G, Pérez Serna Y, García Arias M, Gordo Vidal F. Desarrollo de un sistema de garantía de calidad en ventilación mecánica (registro en una UCC polivalente). ENFERMERIA INTENSIVA 2002. [DOI: 10.1016/s1130-2399(02)78082-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mion LC, Fogel J, Sandhu S, Palmer RM, Minnick AF, Cranston T, Bethoux F, Merkel C, Berkman CS, Leipzig R. Outcomes following physical restraint reduction programs in two acute care hospitals. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2001; 27:605-18. [PMID: 11708040 DOI: 10.1016/s1070-3241(01)27052-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities. METHODS The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists. RESULTS Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event. DISCUSSION Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns. SUMMARY Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.
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Affiliation(s)
- L C Mion
- Geriatric Nursing Program, Division of Nursing, Cleveland Clinic Foundation, Cleveland, USA.
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Balon JA. Common factors of spontaneous self-extubation in a critical care setting. INTERNATIONAL JOURNAL OF TRAUMA NURSING 2001; 7:93-9. [PMID: 11477388 DOI: 10.1067/mtn.2001.117769] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A prospective, concurrent study was conducted of all patients who self-extubated in a mixed critical care setting during a 14-month period. The purpose of the study was to identify the incidence and common factors associated with spontaneous self-extubation (SSE). A total of 75 cases of SSE occurred in 68 patients who had an incidence of 38.5 SSEs per 100 intubated days. The analysis of common factors of the total population found the following: 60 cases (80%) were restrained; 44 cases (59%) required reintubation; 66 cases (88%) followed commands or localized painful stimuli at the time of SSE; and 67 cases (89%) elicited spontaneous eye opening or opened eyes to verbal command at the time of SSE. Only 18 cases (24%) had analgesia administered within 1 to 2 hours of SSE. Twenty-four cases (32%) had anxiolytics administered within 4 hours of SSE. Of the 56 cases of SSE that were witnessed, 43 cases (73% of those observed) were considered deliberate rather than accidental. The practice of using intravenous boluses on an "as needed" dosing frequency for administering sedation and analgesia was a common factor in SSE. Adequate doses of sedation and analgesia delivered by continuous infusion may prevent SSE in alert, intubated patients.
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Affiliation(s)
- J A Balon
- Conemaugh's Memorial Medical Center, Department of Surgery, Johnstown, Pennsylvania 15905, USA
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Tung A, Tadimeti L, Caruana-Montaldo B, Atkins PM, Mion LC, Palmer RM, Slomka J, Mendelson W. The relationship of sedation to deliberate self-extubation. J Clin Anesth 2001; 13:24-9. [PMID: 11259891 DOI: 10.1016/s0952-8180(00)00237-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVES To evaluate the relationship between sedative therapy and self-extubation in a large medical-surgical intensive care unit (ICU). DESIGN Retrospective, case-controlled study. SETTING Large teaching hospital. PATIENTS All adult patients who underwent unplanned self-extubation during a 12-month period (n = 50). Each patient was matched to two control patients who did not self-extubate based on age, gender, dates in hospital and diagnosis. INTERVENTIONS none. MEASUREMENTS Data collected included time to self extubation, dosages and types of benzodiazepines, opioid analgesics, antipsychotics, and hypnotics. Data on the degree of agitation as assessed by nursing staff also were obtained. MAIN RESULTS When compared to controls, patients in the self-extubation group were more likely to have received benzodiazepines (59% vs. 35%; p < 0.05), but equally likely to have received opioids and/or paralytic drugs. Patients who self-extubated were twice as likely as controls to be agitated (54% vs. 22%; p < 0.05). Use of benzodiazepines was more common in agitated patients than in nonagitated patients (62% vs. 35%; p < 0.02). Among nonagitated patients who self-extubated, increased use of benzodiazepines (57% vs. 29%; p < 0.05) was noted when compared to nonagitated controls. CONCLUSIONS In intubated ICU patients, benzodiazepines may not consistently treat agitation effectively or prevent self-extubation. Such an effect may be due to paradoxical excitation, disorientation during long-term administration, or differences in drug administration between ICU and operating room (OR) environments.
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Affiliation(s)
- A Tung
- Department of Anesthesia and Critical Care and Sleep Research Laboratory, University of Chicago, Chicago, IL 60637, USA.
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Fraser GL, Riker RR, Prato BS, Wilkins ML. The frequency and cost of patient-initiated device removal in the ICU. Pharmacotherapy 2001; 21:1-6. [PMID: 11191727 DOI: 10.1592/phco.21.1.1.34444] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the frequency and pattern with which patients in the intensive care unit (ICU) remove medical devices on their own, and the costs associated with this problem. DESIGN Prospective observational study. SETTING Two 10-bed sections of a multidisciplinary ICU in a tertiary care teaching hospital. PATIENTS Adults admitted to the ICU for longer than 24 hours during October 1998. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Medical records were reviewed prospectively for the occurrence of patient-initiated device removal and the responses to those events by health care providers. Associated costs were estimated using hospital databases and Medicare physician reimbursement schedules. Annual cost estimates were calculated using 1997 admission statistics for 1211 adults in an ICU for more than 24 hours. Thirty-six patients were studied for 199 patient-days. Ten patients (28%) removed 42 devices: 88% of these events involved gastrointestinal tubes and vascular catheters. Significant agitation was documented within 2 hours before 74% of the events. Estimated cost associated with device removal was $7606, or $181/event. The estimated annual cost in this 42-bed ICU was more than $250,000. CONCLUSIONS Patients commonly remove medical devices on their own, and this represents significant consumption of health care resources.
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Affiliation(s)
- G L Fraser
- Department of Critical Care, Maine Medical Center, Portland 04102, USA
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Frezza EE, Carleton GL, Valenziano CP. A quality improvement and risk management initiative for surgical ICU patients: a study of the effects of physical restraints and sedation on the incidence of self-extubation. Am J Med Qual 2000; 15:221-5. [PMID: 11022369 DOI: 10.1177/106286060001500507] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- E E Frezza
- Department of Critical Care, Morristown Memorial Hospital, NJ, USA
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Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000; 161:1912-6. [PMID: 10852766 DOI: 10.1164/ajrccm.161.6.9908068] [Citation(s) in RCA: 116] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Unplanned extubation is a major complication of translaryngeal intubation, but its impact on mortality, duration of mechanical ventilation (MV), length of intensive care unit (ICU) and hospital stay, and need for ongoing hospital care has not been adequately defined. We performed a case-control study in a tertiary-care medical ICU, comparing 75 patients with unplanned extubation and 150 controls matched for Acute Physiology and Chronic Health Evaluation II score, presence of comorbid conditions, age, indication for MV, and sex. Forty-two (56%) patients required reintubation after unplanned extubation (74% immediately, 86% within 12 h). Thirty-three (44%) unplanned extubations occurred during weaning trials, and 30% of these patients needed reintubation (failed unplanned extubation). In contrast, 76% of patients with unplanned extubation occurring during ventilatory support required reintubation. Although mortality was similar to that of controls (failed unplanned extubation 40%, versus control 31%, p > 0.2), patients with failed unplanned extubation had a significantly longer duration of MV (19 versus 11 d, p < 0.01), longer stay in the ICU (21 versus 14 d, p < 0.05), and longer hospital stay (30 versus 21 d, p < 0.01), and survivors were more likely to require chronic care (64% versus 24%, p < 0.001). Successfully tolerated unplanned extubation was associated with a reduction in time from beginning of weaning to extubation (0.9 versus 2.0 d, p = 0.06), but with no difference in overall duration of MV, mortality, discharge location, ICU, or hospital stay as compared with these measures for controls. We conclude that unplanned extubation is not associated with increased mortality when compared with that of matched controls, although it does result in prolonged MV, longer ICU and hospital stay, and increased need for chronic care. These effects are due exclusively to patients who fail to tolerate unplanned extubation. Although successfully tolerated unplanned extubation decreased the duration of weaning trials, it had no other measurable beneficial impact on outcome.
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Affiliation(s)
- S K Epstein
- Pulmonary and Critical Care Division, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
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Carrión MI, Ayuso D, Marcos M, Paz Robles M, de la Cal MA, Alía I, Esteban A. Accidental removal of endotracheal and nasogastric tubes and intravascular catheters. Crit Care Med 2000; 28:63-6. [PMID: 10667500 DOI: 10.1097/00003246-200001000-00010] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize the rates of accidental removal of endotracheal tubes, nasogastric tubes, central venous catheters, and arterial catheters. To assess the efficacy of corrective measures aimed at reducing the accidental removal of these devices. DESIGN Prospective, observational, and interventional study. SETTING Eighteen-bed medical-surgical intensive care unit of a 650-bed tertiary care hospital. PATIENTS Patients admitted to the intensive care unit who had any of the following devices in place for more than 24 hrs: endotracheal tube, nasogastric tube, central venous catheter, arterial catheter. MEASUREMENTS AND INTERVENTIONS Data were collected on the date of placement of tubes and catheters, position of vascular catheters, date of removal, and reason for removal. The study involved three consecutive 6-month periods. At the end of the first and the second periods, information about rates of accidental removal was provided to the physicians and nurses. In addition, the personnel were instructed to be more vigilant and specific measures aimed at reducing the accidental removal were introduced. MAIN RESULTS In the first period, 289 endotracheal tubes were placed and 13.1% (24.7 per 1000 days) were removed accidentally. In the second and third periods, 17.1% (25.5 per 1000 days) and 11.4% (15.1 per 1000 days) were removed accidentally, respectively. In the first period, 368 nasogastric tubes were placed and 41% (73.9 per 1000 days) were removed accidentally. In both the second and the third period, a significant reduction in the rate of accidental removal was observed (32.4% or 41.2 per 1000 days and 25.8% or 29.8 per 1000 days, respectively). A significant decrease was observed in the rates of accidental removal of central venous catheters from 7.5% (12.4 per 1000 days) in the first period to 3.6% (5.4 per 1000 days) in the second period. The rate of arterial catheters accidentally removed expressed according to the time at risk significantly decreased from 46.5 per 1000 days in the first period to 19.1 per 1000 days in the second period and 25.3 per 1000 days in the third period. CONCLUSIONS The information provided by the rates of accidental removal expressed by patient-days is helpful to compare results obtained in populations with different times of follow-up. Education of medical personnel and limiting upper-extremity access to within 20 cm from any catheter or tube resulted in a significant reduction of patient-related removal of tubes and catheters.
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Affiliation(s)
- M I Carrión
- Servicio de Cuidados Intensivos, Hospital Universitario de Getafe, Madrid, Spain
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Clarke T, Evans S, Way P, Wulff M, Church J. A comparison of two methods of securing an endotracheal tube. Aust Crit Care 1998; 11:45-50. [PMID: 9830891 DOI: 10.1016/s1036-7314(98)70436-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
While a variety of methods exist for securing an endotracheal tube (ETT), there has been little research on their safety and efficacy. This study aimed to test the equivalence of two methods in three critical care settings by randomly assigning patients to receive either the knot, which requires scissors or blade to remove the ETT tape, or the bow, which can be removed manually. These methods were evaluated by comparing ETT movement, malposition, dislodgement, inadvertent extubation, reduced skin integrity, the cutting of the pilot tube and nurse satisfaction. The 5-month study was conducted in three critical care settings in a large tertiary hospital. Of the 230 patients enrolled, 222 completed the trial. Results, based on a randomised, active control equivalence design, demonstrated the two methods to be equally effective with regard to ETT movement > 2 cm (knot = 21 per cent, bow = 19 per cent; 95 per cent confidence interval for the [2 per cent] difference-8 to 12.5 per cent). The incidence of ETT-related complications was similar for both methods. No pilot tubes were cut using either method. Nurses found that patient mouth care was easier and patient comfort and skin integrity enhanced with the bow method. On the other hand, nurses perceived the knot-tying method to be more secure and easier to apply. Given the equivalence of the two methods, the bow would seem preferable for reasons of safety and comfort.
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Affiliation(s)
- T Clarke
- Royal Prince Alfred Hospital, Sydney, New South Wales
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Atkins PM, Mion LC, Mendelson W, Palmer RM, Slomka J, Franko T. Characteristics and outcomes of patients who self-extubate from ventilatory support: a case-control study. Chest 1997; 112:1317-23. [PMID: 9367475 DOI: 10.1378/chest.112.5.1317] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To identify factors associated with the occurrence of deliberate self-extubation and to describe associated patient outcomes. DESIGN Case-control study. SETTING ICUs of a national referral, tertiary medical center. PARTICIPANTS Fifty adult, intubated patients who had self-extubated from mechanical ventilatory support. Two control subjects who had not self-extubated were matched to each case based on age, gender, primary discharge diagnosis, and time hospitalized (within same quarter). MEASUREMENTS Standardized coding of medical record information, including demographic characteristics, clinical information, intubation and mechanical ventilation characteristics, medications, and selected laboratory indexes. RESULTS As compared to the control subjects, patients who self-extubated were more likely to be medical than surgical patients (p<0.001) and have a current history of smoking (p<0.05). Prior to the self-extubation, patients had a greater likelihood of hospital-acquired infections (p<0.001) or other hospital-acquired adverse events (p<0.001), abnormal (<10, >50 mg/dL) BUN (p<0.05), and abnormal (<20, >50 mm Hg) PaCO2 (p<0.05); they also were more likely to be restless or agitated (p<0.001), and more likely to be physically restrained (p<0.001). A logistic regression model demonstrated that presence of restlessness or agitation and presence of a hospital-acquired adverse event were independently associated with self-extubation from mechanical ventilatory support. In examining outcomes, as compared to the control subjects, those who self-extubated had longer lengths of stay in ICU and hospital, were more likely to need reintubation, and were more likely to suffer complications from intubation. However, none of the cases died within 48 h of self-extubation. CONCLUSION The results underscore the need for clinical guidelines for weaning and for monitoring patients at risk of self-extubation.
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Affiliation(s)
- P M Atkins
- Department of Patient Care Operations Management and Infection Control, Cleveland Clinic Foundation, OH 44195, USA
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