Multidisciplinary interventions and continuous quality improvement to reduce unplanned extubation in adult intensive care units: A 15-year experience

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

AIMS

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

REPORTING METHOD

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

PATIENT OR PUBLIC CONTRIBUTION

Nurses contributed to the study by participating in investigations.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches

Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE.

The intervention of artificial intelligence to improve the weaning outcomes of patients with mechanical ventilation: Practical applications in the medical intensive care unit and the COVID-19 intensive care unit: A retrospective study

Patients admitted to intensive care units (ICU) and receiving mechanical ventilation (MV) may experience ventilator-associated adverse events and have prolonged ICU length of stay (LOS). We conducted a survey on adult patients in the medical ICU requiring MV. Utilizing big data and artificial intelligence (AI)/machine learning, we developed a predictive model to determine the optimal timing for weaning success, defined as no reintubation within 48 hours. An interdisciplinary team integrated AI into our MV weaning protocol. The study was divided into 2 parts. The first part compared outcomes before AI (May 1 to Nov 30, 2019) and after AI (May 1 to Nov 30, 2020) implementation in the medical ICU. The second part took place during the COVID-19 pandemic, where patients were divided into control (without AI assistance) and intervention (with AI assistance) groups from Aug 1, 2022, to Apr 30, 2023, and we compared their short-term outcomes. In the first part of the study, the intervention group (with AI, n = 1107) showed a shorter mean MV time (144.3 hours vs 158.7 hours, P = .077), ICU LOS (8.3 days vs 8.8 days, P = .194), and hospital LOS (22.2 days vs 25.7 days, P = .001) compared to the pre-intervention group (without AI, n = 1298). In the second part of the study, the intervention group (with AI, n = 88) exhibited a shorter mean MV time (244.2 hours vs 426.0 hours, P = .011), ICU LOS (11.0 days vs 18.7 days, P = .001), and hospital LOS (23.5 days vs 40.4 days, P < .001) compared to the control group (without AI, n = 43). The integration of AI into the weaning protocol led to improvements in the quality and outcomes of MV patients.

Experience of patients with restraints in acute care hospitals and the view of their relatives: A qualitative study

AIM

To describe the experiences of patients and relatives with any form of restraints in somatic acute care hospitals.

DESIGN

Qualitative explorative design.

METHODS

Qualitative research methods were used. Participants were recruited through clinical nursing specialists in participating departments of a university hospital between June and August 2020. Individual interviews were conducted and analysed using content analysis.

RESULTS

Four interviews with patients and five interviews with relatives were conducted with a mean duration of 25 min. The following three topics emerged in the analysis as important: What was perceived as restraints, Assessing the experiences of restraint use on a continuum, and Lack of information about restrictive measures. Patients and relatives defined restraint very broadly and assessed the experiences of restraint on a continuum from positive to negative, with a more critical view from patients. Relatives clearly seemed to approve of the use of restraints in acute care hospitals because it provided them with a sense of security. In general, there seemed to be a lack of information about the use of restraint and its effects on patients and relatives alike.

CONCLUSION

The involvement of patients and relatives in the decision-making process about restraint use seems to be low. Healthcare professionals need to be better educated to be able to pass on adequate information and to involve patients and their relatives adequately in all processes of restraint use. However, when relatives are involved in decision-making as proxies for patients, it is important to consider that patients' and relatives' opinions on restraints may differ.

PATIENT OR PUBLIC CONTRIBUTION

Patients and relatives agreed to participate in the study and shared their experiences with us.

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

AIMS

This study was performed to identify and summarize systematic reviews focusing on the prevention of unplanned endotracheal extubation in the intensive care unit.

DESIGN

Overview of systematic reviews.

METHODS

This overview was conducted according to the Preferred Reporting Items for Overviews of Systematic Reviews, including the harms checklist. A literature search of PubMed, the Cochrane Library, CINAH, Embase, Web of Science, SINOMED and PROSPERO was performed from January 1, 2005-June 1, 2021. A systematic review focusing on unplanned extubation was included, resulting in an evidence summary.

RESULTS

Thirteen systematic reviews were included. A summary of evidence on unplanned endotracheal extubation was developed, and the main contents were risk factors, preventive measures and prognosis. The most important nursing measures were restraint, fixation of the tracheal tube, continuous quality improvement, psychological care and use of a root cause analysis for the occurrence of unplanned endotracheal extubation.

CONCLUSIONS

This overview re-evaluated risk factors and preventive measures for unplanned endotracheal extubation in the intensive care unit, resulting in a summary of evidence for preventing unplanned endotracheal extubation and providing direction for future research.

TRIAL REGISTRATION DETAILS

The study was registered on the PROSPERO website.

Risk factors for reintubation and mortality among patients who had unplanned extubation

BACKGROUND

Unplanned extubation (UE) occurs among 2%-16% of patients with mechanical ventilation (MV). Failed UE requiring reintubation could be associated with several adverse events.

AIMS

The aim of this study was to investigate the outcomes and prognostic factors of patients with UE in intensive care units (ICUs).

METHODS

We prospectively registered the patients who had UE and retrospectively reviewed the electronic medical records for 96-bed ICUs between 1 January 2009, and 31 December 2020.

RESULTS

A total of 392 patients had UE, and 234 patients (59.7%) were ≥65 years (older adult group). The median Acute Physiology and Chronic Health Evaluation (APACHE) II score were 17 and the median Glasgow Coma Scale score was 10. In total, 205 patients (52.3%) were reintubated within 48 h (due to failed UE) and 75 patients (19.1%) died during hospitalization. Multivariate analyses were performed to evaluate those factors predicting failed UE and mortality. These analyses demonstrated that higher positive end-expiratory pressure (PEEP) and the admission APACHE II scores predicted failed UE. A higher fraction of inspiration O₂ (FiO₂ ) and minute ventilation; lower haemoglobin (Hb); and higher instances of liver cirrhosis, cancer, and failed UE were independently associated with hospital mortality.

CONCLUSION

We concluded that among patients who had UE, higher FiO₂ or minute ventilation, or under MV or with lower Hb, liver cirrhosis, cancer, and failed UE tended to have higher mortality.

RELEVANCE TO CLINICAL PRACTICE

Patients with high disease severity indices who have an increased risk of UE required special attention to techniques to prevent endotracheal tubes from accidental removal.

Risk factors of self-extubation in intensive care. Retrospective cohort study

Introduction: Acute respiratory failure remains one of the three leading causes of admission to the intensive care unit (ICU). Self-extubation is an adverse outcome requiring reintubation in 50% of cases. Objective: To assess for determinants (risk factors) of self-extubation and mortality in the ICU by using a generalized estimation equation model (GEE). Methods: The data was collected from a retrospective cohort study from 2017-2020 including all patients admitted to the ICU with mechanical ventilation. Univariate and bivariate analyses were performed. Then, a GEE model was conducted to predict the risk of self-extubation and mortality. Results: A total of 857 subjects were included, with a mean age of 60.5 +/- 17 years-old. Most of the subjects were males (55.2%). An 8.99-fold risk (95%CI 3.83-21.1, p<0.01) of self-extubation was identified in patients with agitation. Exposure to infusion of neuromuscular blockade was also found to increase the risk of self-extubation 3.37 times (95%CI 1.31-8.68, p=0.01). No associations were identified between immobilization and self-extubation (OR 1.38 95%CI 0.76-2.51, p=0.29). Finally, light sedation according to the Richmond Sedation Scale (RASS) between 0 to -2 rather than moderate (RASS-3) reduces the risk of mortality (OR 0.57, 95%CI 0.38-0.83, p<0.01). Conclusions: The main factors resulting in self-extubation were: agitation, delirium, and infusion of neuromuscular blocking agents. An association was found between light sedation and a lower risk of mortality. No association was found between the use of physical restraint and the desired outcome.

Restraining patients in acute care hospitals-A qualitative study on the experiences of healthcare staff

AIM

The focus was to explore the perceptions and experiences of healthcare workers with respect to the use of restraints in acute care hospitals.

DESIGN

The study followed a qualitative design.

METHODS

Three topic-based focus group interviews were conducted, involving 19 participants from the fields of nursing, physical therapy and medicine. For data collection and analysis, the method of mapping techniques for rapid qualitative data analysis was used. After discussing and validating the individual mind maps, all data were condensed to identify the key findings.

RESULTS

Participants described restraints as safety measures for the patients. The implementation of most restraints was led by nurses. The use of restraints differed significantly, even in the interprofessional team. Attitudes and experiences were the main determinants for restraint use. Nurses asked for more discussion about restraints in the team, for more support at an interprofessional level and for better guidelines to help with the decision-making process.

Superficial placement of endotracheal tubes associated with unplanned extubation: A case-control study

INTRODUCTION

Unplanned extubations (UEs) refer to the inadvertent removal of endotracheal tubes (ETTs). Superficially placed ETTs anecdotally increases the risk of UEs. This study aims to assess the impact of ETT position as well as other factors that could be associated with risk of UEs.

METHOD

A retrospective case-control study was conducted at NewYork-Presbyterian Queens Hospital from January 2017 to February 2020. All adults admitted to intensive care units (ICUs) who received mechanical ventilation (MV) through ETTs were screened to identify UEs. For each case with UE, two controls with planned extubation were identified. A multivariate logistic regression was conducted to identify risk factors associated with UEs.

RESULTS

1100 patients received MV through ETTs during the time period. The incidence of UE was 4.9%. 53 patients with UEs and 106 patients with planned extubation were included for statistical analysis. Overall, patients with UE had higher in-hospital mortality rates (26.4% versus 11.3%, P = 0.02) and reintubation rates (28.3% versus 6.6%, P < 0.001). Within the UE group, patients who required reintubation had significantly higher in-hospital mortality rates than those who did not require reintubation (53.3% versus 15.8%, P = 0.005). Multivariate logistic regression showed higher APACHE II scores (Odds ratios (OR) 1.07; 95% Confidence interval (CI), 1 to 1.13), distance of ETT tips to carina ≥6 cm (OR 6.41; 95% CI, 1.1 to 37.3), physical restraint use (OR 2.98; 95% CI, 1.28 to 6.95) and continuous infusions of sedatives and/or analgesics (OR 10.72, 95% CI, 4.19 to 27.43) were associated with UE.

CONCLUSION

UE and the need for reintubation is associated with worse outcomes. Distance of ETT tips to carina ≥6 cm may be associated with higher risks of UE. Further prospective studies are needed to establish the optimal position of ETT to prevent UE.

A Scoping Review of Implementation Science in Adult Critical Care Settings

OBJECTIVES

The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation.

DATA SOURCES

A librarian-assisted search was performed using three electronic databases.

STUDY SELECTION

Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included.

DATA EXTRACTION

Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system.

DATA SYNTHESIS

Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes.

CONCLUSIONS

The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.

Unplanned Removal of Medical Devices in Critical Care Units in North West England Between 2011 and 2016

BACKGROUND

The unplanned removal of medical devices poses a risk of harm to critically ill patients.

OBJECTIVE

To determine rates, causes, and consequences of unplanned medical device removal, as well as factors mitigating harm to patients, in critical care units in the United Kingdom by reviewing patient safety incident reports.

METHODS

Incidents of unplanned medical device removal in critical care units in North West England between 2011 and 2016 were retrospectively reviewed and classified. The incidents were classified by type of device displaced, staff and patient factors, causes and consequences of removal, and staff actions following removal. Displacement rates were calculated per 1000 patient days per unit.

RESULTS

A total of 34 705 incident reports were reviewed, of which 1090 described unplanned device removal. The median rate of device removal was 0.7 (interquartile range, 0.4-2.2) per 1000 patient days per unit. Devices displaced most commonly included nasogastric tubes (317), central catheters (245), tracheostomy tubes (174), and endotracheal tubes (140). A total of 11 cardiac arrests were reported (8 associated with airway devices and 3 with central catheters). Factors contributing to displacement included initial placement (188), patient factors (563), and manual handling (238). Manual handling was cited in 49% of central catheter incidents and only 9% of nasogastric tube incidents. Patients' organic confusion was a factor in 16% of endotracheal tube and 80% of nasogastric tube removals.

CONCLUSIONS

Unplanned device removal may cause patient harm and is often preventable. The causes and consequences depend on the type of device removed.

Incidence, risk factors, and outcomes of unplanned extubation in adult patients in a resource-limited teaching hospital in the Philippines: a cohort study

OBJECTIVE

We aimed to determine the incidence, risk factors, and outcomes of unplanned extubation among adult patients.

METHODS

We conducted a prospective cohort study of adult intubated patients admitted to the charity wards of a government tertiary teaching hospital in the Philippines. Patients managed in both intensive care and nonintensive care settings were included. Patients were followed-up until discharge or until seven days postextubation.

RESULTS

The outcomes of the 191 included patients were planned extubation (35%), unplanned extubation (19%), death (39%), and discharge against advice (7%). Competing risk regression showed that male sex (Crude OR: 2.25, 95%CI: 1.10 - 4.63) and age (Crude OR 0.976, 95%CI: 0.957 - 0.996) were significant baseline factors. The night shift (Crude OR: 24.6, 95%CI: 2.87 - 211) was also consistently associated with more unplanned extubations. Among postextubation outcomes, reintubation (unplanned extubation: 61.1% versus planned extubation: 25.4%), acute respiratory failure (unplanned extubation: 38.9% versus planned extubation: 17.5%), and cardiovascular events (unplanned extubation: 8.33% versus planned extubation: 1.49%) occurred significantly more often among the unplanned extubation patients. Admission in an intensive care unit was not associated with a lower risk of unplanned extubation (Crude OR 1.15, 95%CI: 0.594 - 2.21).

CONCLUSION

Many intubated patients had unplanned extubation. Patients admitted in nonintensive care unit settings did not have significantly higher odds of unplanned extubation.

Outcomes of unplanned extubation in ordinary ward are similar to those in intensive care unit: A STROBE-compliant case-control study

Unplanned extubation (UE) may cause considerable adverse effects in patients receiving mechanical ventilation (MV). Previous literature showed inconsistent prognosis in patients with UE. This study aimed to evaluate the clinical implications and outcomes of UE.The intubated adult patients with MV support in our hospital were enrolled, and they were divided into the UE and non-UE groups. Demographic data, admission unit, MV duration, overall weaning rate, and mortality rates were compared. The outcomes of UE in ordinary ward and intensive care unit (ICU) were also assessed.Totally 9245 intubated adult patients were included. UE occurred in 303 (3.5%) patients, and the UE events were 0.27 times/100 MV days. Old age, nonoperation related MV cause, and admission out of the ICU were significant factors associated with UE events. UE patients showed a trend of better overall weaning rate (71.9% vs 66.7%, P = .054) than non-UE. However, the in-hospital mortality rate (25.7% vs 24.8%, P = .713) were similar between the UE and non-UE patients. The reintubation rate of UE patients was 44.1% (142/322). Successful UEs were associated with patients in weaning process (52.8% vs 38.7%, P = .012), and patients received non-invasive positive pressure ventilation (NIPPV) support after UE (19.4% vs 3.5%, P < .001). Patients with successful UE had significantly shorter MV days, higher overall weaning rate, and lower mortality than those with unsuccessful UE. Outcomes of UE in ordinary ward and in ICU had similar MV duration, reintubation rate, overall weaning rate, and in-hospital mortality rate.The overall weaning rate and in-hospital mortality rates of the UE and non-UE patients were similar. UE occurred in ordinary ward had similar outcomes to those in ICU. Patients receiving MV should be assessed daily for weaning indications to reduce delayed extubation, and therefore, may decrease UE occurrence. Once the UE happened, NIPPV support may reduce the reintubation rate.

Reducing Unplanned Extubations Across a Children's Hospital Using Quality Improvement Methods

Supplemental Digital Content is available in the text.

Introduction:

Children who require an endotracheal (ET) tube for care during critical illness are at risk of unplanned extubations (UE), or the unintended dislodgement or removal of an ET tube that can lead to significant patient harm. A proposed national benchmark is 1 UE per 100 ventilator days. We aimed to reduce the rate of UEs in our intensive care units (ICUs) from 1.20 per 100 ventilator days to below the national benchmark within 2 years.

Methods:

We identified several key drivers including ET securement standardization, safety culture, and strategies for high-risk situations. We employed quality improvement methodologies including apparent cause analysis and plan-do-study-act cycles to improve our processes and outcomes.

Results:

Over 2 years, we reduced the rate of UEs hospital-wide by 75% from 1.2 to 0.3 per 100 ventilator days. We eliminated UEs in the pediatric ICU during the study period, while the UE rate in the neonatal ICU also decreased from 1.2 to 0.3 per 100 ventilator days.

Conclusion:

We demonstrated that by using quality improvement methodology, we successfully reduced our rate of UE by 75% to a level well below the proposed national benchmark.

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.

Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis

OBJECTIVES

To explore factors associated with unplanned extubation in Intensive Care Unit for adult patients.

RESEARCH METHODOLOGY

A systematic review and meta-analysis were performed of studies identified through Pubmed, CINAHL, Cochrane Library, PsycINFO and Web of Science published from initiation to September 2017. Only articles in English were included. The Newcastle-Ottawa Scale was used to evaluate the quality of the included articles.

RESULTS

Ten eligible studies were identified, encompassing a total of 2092 patients (457 in the unplanned extubation group; 1635 in the control group). The subsequent meta-analysis identified significant risk factors for unplanned extubation are male [odds ratio (OR) 1.54, 95% CI 1.12-2.12; P = 0.008], confusion [OR 0.10, 95% CI 0.05-0.17; P < 0.00001], physical restraint [OR 3.10, 95% CI 2.21-4.34; P < 0.00001], higher GCS scores [mean difference (MD) 1.06, 95% CI 0.59-1.52; P < 0.00001] and lower APACHE II scores [MD -2.26, 95% CI -3.35- -1.16; P < 0.0001]. Renal disease is a protective factor for unplanned extubation [OR 0.32, 95% CI 0.15-0.70; P = 0.004].

CONCLUSION

Patients were male, confused, having physical restraint, with higher GCS and lower APACHE II scores are significant risk factors for unplanned extubation in Intensive Care Unit adult patients.

Unplanned Extubations in Intensive Care Unit: evidences for risk factors. A literature review

Background and aim: Unplanned extubations (UE) are getting more and more relevant in Critical Care, becoming a quality and care safeness outcome. This happens because after an UE the patient can face some complications concerning the airway management, respiratory and hemodynamic problems, lengthen in the hospital stay and in the mechanical ventilation time. The aim of this review is identify and classify the factors that could increase UE risk. Methodology: A systematic review of scientific articles was performed consulting the databases PubMed, Cinahl, Medline, EBSCOhost and Google Scholar. Articles from 2006 to 2011 were included. Pediatric Care settings were excluded. Results: 21 articles were selected. From the results emerged that risk factors associated to the patient are widely controversial. Yet restlessness, a low level of sedation and a high level of consciousness seem to be highly related to UE. Organizational risk factors, as workload, nurse:patient ratio, and the use of interdisciplinary protocols seem to play an important role in UE. Conclusion: According the current literature, the research on UE still has to handle a wide uncertainty. There is the need for more studies developing conclusive evidences on the role of different risk factors. Anyway, literature highlights the importance of the nurse and of the healthcare system organization in reducing UE incidence.