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Wang M, Pan S, Sun L, Sun X, Ma Q. Development and testing of a questionnaire assessing knowledge, attitudes, and practices to prevent unplanned oral extubation. Nurs Crit Care 2024; 29:366-384. [PMID: 37592820 DOI: 10.1111/nicc.12953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/13/2023] [Accepted: 07/05/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND The prevention of unplanned endotracheal extubation (UEE) is significant for the critical care of intensive care unit (ICU) patients. AIM To develop a questionnaire to assess the knowledge, attitude, and practice (KAP) of the nurses regarding of the prevention of UEE in ICU patients with transoral endotracheal intubation (TEI) and to test the validity and reliability of the questionnaire. STUDY DESIGN Items relevant to KAP were prepared following a literature review, and then screened using a Delphi expert consultation, pre-test, and factor analysis. The nursing staffs in four tertiary hospitals in Qinghai, Jiangsu, Gansu, and Shandong provinces were surveyed to test the reliability and validity of the questionnaire. RESULTS The questionnaire contained 76 items, including 10, 37, and 29 in the dimensions of knowledge, attitude, and practice, respectively. The scale-level content validity index (S-CVI) of the questionnaire was 0.96. The results of exploratory factor analysis (EFA) showed that the Kaiser-Meyer-Olkin value was 0.956, indicating that the sample was adequate and suitable for factor analysis. The result of the Bartlett spherical test was significant (p < .001), indicating that the questionnaire was suitable for further EFA. A total of six common factors were extracted by EFA with a cumulative variance interpretation rate of 85.52%, indicating that the questionnaire had good structural validity. The Cronbach's alpha was 0.981 for the whole questionnaire; and was 0.966, 0.996, and 0.981 for the dimensions of knowledge, attitude, and practice, respectively. The test-retest reliability for the questionnaire was 0.843. CONCLUSIONS The developed questionnaire has good reliability and validity and can be used as a scientific tool for the nursing leaders to prevent UEE in ICU patients with TEI. RELEVANCE TO CLINICAL PRACTICE The instrument provides a theoretical reference for establishing preventive strategies and management programs in clinical practice.
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Affiliation(s)
- Meizhong Wang
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Shiqin Pan
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Lijuan Sun
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Xiaolin Sun
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Qin Ma
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
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Zhang J, Ma G, Peng S, Hou J, Xu R, Luo L, Hu J, Yao N, Wang J, Huang X. Risk Factors and Predictive Models for Peripherally Inserted Central Catheter Unplanned Extubation in Patients With Cancer: Prospective, Machine Learning Study. J Med Internet Res 2023; 25:e49016. [PMID: 37971792 PMCID: PMC10690529 DOI: 10.2196/49016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/24/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Cancer indeed represents a significant public health challenge, and unplanned extubation of peripherally inserted central catheter (PICC-UE) is a critical concern in patient safety. Identifying independent risk factors and implementing high-quality assessment tools for early detection in high-risk populations can play a crucial role in reducing the incidence of PICC-UE among patients with cancer. Precise prevention and treatment strategies are essential to improve patient outcomes and safety in clinical settings. OBJECTIVE This study aims to identify the independent risk factors associated with PICC-UE in patients with cancer and to construct a predictive model tailored to this group, offering a theoretical framework for anticipating and preventing PICC-UE in these patients. METHODS Prospective data were gathered from January to December 2022, encompassing patients with cancer with PICC at Xiangya Hospital, Central South University. Each patient underwent continuous monitoring until the catheter's removal. The patients were categorized into 2 groups: the UE group (n=3107) and the non-UE group (n=284). Independent risk factors were identified through univariate analysis, the least absolute shrinkage and selection operator (LASSO) algorithm, and multivariate analysis. Subsequently, the 3391 patients were classified into a train set and a test set in a 7:3 ratio. Utilizing the identified predictors, 3 predictive models were constructed using the logistic regression, support vector machine, and random forest algorithms. The ultimate model was selected based on the receiver operating characteristic (ROC) curve and TOPSIS (Technique for Order Preference by Similarity to Ideal Solution) synthesis analysis. To further validate the model, we gathered prospective data from 600 patients with cancer at the Affiliated Hospital of Qinghai University and Hainan Provincial People's Hospital from June to December 2022. We assessed the model's performance using the area under the curve of the ROC to evaluate differentiation, the calibration curve for calibration capability, and decision curve analysis (DCA) to gauge the model's clinical applicability. RESULTS Independent risk factors for PICC-UE in patients with cancer were identified, including impaired physical mobility (odds ratio [OR] 2.775, 95% CI 1.951-3.946), diabetes (OR 1.754, 95% CI 1.134-2.712), surgical history (OR 1.734, 95% CI 1.313-2.290), elevated D-dimer concentration (OR 2.376, 95% CI 1.778-3.176), targeted therapy (OR 1.441, 95% CI 1.104-1.881), surgical treatment (OR 1.543, 95% CI 1.152-2.066), and more than 1 catheter puncture (OR 1.715, 95% CI 1.121-2.624). Protective factors were normal BMI (OR 0.449, 95% CI 0.342-0.590), polyurethane catheter material (OR 0.305, 95% CI 0.228-0.408), and valved catheter (OR 0.639, 95% CI 0.480-0.851). The TOPSIS synthesis analysis results showed that in the train set, the composite index (Ci) values were 0.00 for the logistic model, 0.82 for the support vector machine model, and 0.85 for the random forest model. In the test set, the Ci values were 0.00 for the logistic model, 1.00 for the support vector machine model, and 0.81 for the random forest model. The optimal model, constructed based on the support vector machine, was obtained and validated externally. The ROC curve, calibration curve, and DCA curve demonstrated that the model exhibited excellent accuracy, stability, generalizability, and clinical applicability. CONCLUSIONS In summary, this study identified 10 independent risk factors for PICC-UE in patients with cancer. The predictive model developed using the support vector machine algorithm demonstrated excellent clinical applicability and was validated externally, providing valuable support for the early prediction of PICC-UE in patients with cancer.
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Affiliation(s)
- Jinghui Zhang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Diseases, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guiyuan Ma
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Sha Peng
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Jianmei Hou
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ran Xu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Lingxia Luo
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Jiaji Hu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Nian Yao
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, Hunan, China
- Xiangya School of Nursing, Central South University, Changsha, Hunan, China
| | - Jiaan Wang
- Vascular Access Department, Hainan Provincial People's Hospital, Hainan, China
| | - Xin Huang
- Department of Nursing, Affiliated Hospital of Qinghai University, Qinghai, China
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Mekonnen AS, Kebede Z, Demissie DB. Incidence, Outcome and Determinants of Unplanned Extubation Among Pediatric Intensive Care Unit Addis Ababa, Ethiopia, 2023: Nested, Unmatched Case-Control Study Design. Pediatric Health Med Ther 2023; 14:347-359. [PMID: 37908318 PMCID: PMC10614650 DOI: 10.2147/phmt.s429457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/21/2023] [Indexed: 11/02/2023] Open
Abstract
Background Unplanned extubating is the most common adverse event occurring in intensive care units (ICUs) and significantly increases morbidity and mortality in children, but there is limited current evidence on unplanned extubating in Ethiopia. Therefore, this study aimed to determine the incidence, outcome, and determinants of unplanned extubating among children in the pediatric intensive care unit in Addis Ababa, Ethiopia, in 2023. Methods A nested unmatched case-control design study was conducted at selected government hospitals in Addis Ababa from September 1, 2022, to April 30, 2023. A total of 198 intubated child patients (66 cases of unplanned extubating were nested with 132 controls of planned extubating) were followed up until they completed the full weaning process or based on hospital protocols. Data was collected through standardized data extraction, and the data was cleaned, entered into Epidata version 4.6, and exported to SPSS version 25.0 for further analysis. Binary and multiple logistic regression analyses were used to identify determinants of unplanned extubating, with an adjusted odds ratio (AOR) of 99% confidence interval (CI) at p value <0.01. Results The study revealed a high mortality rate of 15.65% among intubated children in pediatric intensive care units, and the incidence of unplanned extubating was 7.2 per 100 days. This study identified determinants of unplanned extubating among patients admitted to the pediatric intensive care unit: agitated patients (AOR = 3.708; 99% CI: 1.401-9.81), working in night shift hours (AOR: 8.789; 99% CI: 2.37-32.58), use of plaster or roll bandages separately (AOR = 4.12; 99% CI: 1.215-13.96), A nurse-to-patient ration 1:2 (AOR: 6.65, 99% CI: 1.87-23.69), intermittent sedation (AOR, 3.717; 99% CI, 1.017-10.816), physically restrained (AOR = 3.717; 99% CI: 1.02-13.54), and death outcome (AOR = 14.86, 99% CI: 3. 24-68.097), respectively. Conclusion and Recommendations This study found that the incidence and mortality rate of unplanned extubating were high, with identified determinants increasing the risk of unplanned extubating among patients admitted to pediatric intensive care unit. Therefore, policymakers and health planners should design further protocols and algorithms for the management of pediatric endotracheal intubation (ETT) quality of patient outcomes and to prevent unplanned extubating in a resource limited set up.
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Affiliation(s)
| | - Zegeye Kebede
- Schools of Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Dereje Bayissa Demissie
- Department of Neonatal, School of Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Harbrecht BG, Miller KR, Egger ME, Nash NA, Doan R, Georgel J, Franklin GA, Smith JW, Bozeman MC, Benns MV. A Decade of Analysis of Unplanned Extubation Etiology in Trauma Patients Including the Impact of the COVID Pandemic. Respir Care 2023; 69:respcare.10868. [PMID: 37751930 PMCID: PMC10753617 DOI: 10.4187/respcare.10868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Unplanned extubations (UEs) in injured patients are potentially fatal, but etiology and patient characteristics are not well described. We have been prospectively characterizing the etiology of UEs after we identified a high rate of UEs and implemented an educational program to address it. This period of monitoring included the years of the COVID-19 pandemic that produced high rates of workforce turnover in many hospitals, dramatically affecting nursing and respiratory therapy services. We hypothesized that frequency of UEs would depend on the etiology and that the workforce changes produced by the COVID-19 pandemic would increase UEs. METHODS This study was a prospective tracking and retrospective review of trauma registry and performance improvement data from 2012-2021. RESULTS UE subjects were younger, were more frequently male, were diagnosed more frequently with pneumonia (38% vs 27%), and had longer hospital (19 d vs 15 d) and ICU length of stay (LOS) (12 d vs 10 d) (all P < .05). Most UEs were due to patient factors (self-extubation) that decreased after education, while UEs from other etiologies (mechanical, provider) were stable. Subjects with UEs from mechanical or provider etiologies had longer ICU LOS, higher mortality, and were less likely to be discharged home. The COVID-19 pandemic was associated with more total patient admissions and more days of ventilator use, but the rate of UEs was not changed. CONCLUSIONS UEs were decreased by education with ongoing tracking, and UEs from patient factors were associated with better outcome than other etiologies. Workforce changes produced by the COVID-19 pandemic did not change the rate of UEs.
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Affiliation(s)
- Brian G Harbrecht
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky.
| | - Keith R Miller
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Michael E Egger
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Nicholas A Nash
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Regina Doan
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Jiliene Georgel
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Glen A Franklin
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Jason W Smith
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Matthew C Bozeman
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
| | - Matthew V Benns
- The Hiram C. Polk Jr MD Department of Surgery, University of Louisville, Louisville Kentucky
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Anis A, Patel R, Tanios MA. Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches. J Intensive Care Med 2023:8850666231199055. [PMID: 37670719 DOI: 10.1177/08850666231199055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
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.
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Affiliation(s)
- Antonious Anis
- Internal Medicine Residency Program, St. Mary Medical Center, Long Beach, CA, USA
- Critical Care Medicine Fellowship, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Ravi Patel
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, CA, USA
| | - Maged A Tanios
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, CA, USA
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Harwayne-Gidansky I, Dominick C, Nishisaki A. Unplanned Extubations in the Cardiac ICU: Are We Missing the Beat? Pediatr Crit Care Med 2023; 24:617-619. [PMID: 37409898 PMCID: PMC10348451 DOI: 10.1097/pcc.0000000000003271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Ilana Harwayne-Gidansky
- Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical College, Albany, NY
| | - Cheryl Dominick
- Department of Respiratory Care, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Ma H, Pan H, Dong X, Li L. An Empirical Study of Feedforward Control in Unplanned Extubation of Nasogastric Tube. J Multidiscip Healthc 2023; 16:1465-1471. [PMID: 37255995 PMCID: PMC10226536 DOI: 10.2147/jmdh.s408676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/17/2023] [Indexed: 06/01/2023] Open
Abstract
Objective To explore the effect of feedforward control on reducing the incidence of unplanned extubation and improving the quality of catheter nursing. Methods A total of 186 patients with nasogastric tube after gastrointestinal surgery in the eastern region of our hospital from September 2020 to September 2021 were selected as the control group; 186 patients with nasogastric tube after gastrointestinal surgery in the western region of our hospital at the same period were selected as the experimental group. The influencing factors of unplanned extubation in patients with long-term postoperative nasogastric tube were analyzed, and effective preoperative and postoperative health education was conducted. The ratio of unplanned extubation of nasogastric tube and nursing satisfaction of patients in the two groups were compared. Results Patient constraint, perceived pressure score, anxiety score, nasal gastrointestinal canal health education feedback score and indwell tube comfort score were independent risk factors for unplanned extubation. The restraint rate and the incidence of unplanned extubation in the experimental group were lower than those in the control group after intervention, with statistical significance (P < 0.05). The nursing satisfaction of the experimental group was significantly higher than that of the control group after feedforward cognitive intervention. After intervention, serum albumin and gastric PH in the experimental group were significantly higher than those in the control group (P < 0.05). Conclusion The safe nursing management method of feed forward control can effectively reduce the incidence of unplanned extubation in inpatients, which is worth further promoting in nursing work.
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Affiliation(s)
- Hexing Ma
- Department of General Surgery, Affiliated Hospital of Yangzhou University, Yangzhou, 225007, People’s Republic of China
| | - Hailong Pan
- Department of Major Surgery, Affiliated Hospital of Yangzhou University, Yangzhou, 225007, People’s Republic of China
| | - Xiangxiang Dong
- Department of Major Surgery, Affiliated Hospital of Yangzhou University, Yangzhou, 225007, People’s Republic of China
| | - Lingyu Li
- Department of Major Surgery, Affiliated Hospital of Yangzhou University, Yangzhou, 225007, People’s Republic of China
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Wang X, Zhang T, He X, Ding J. Study on the effectiveness, safety and comprehensive evaluations of novel medical restraint gloves in patients with consciousness disorders. Am J Transl Res 2023; 15:3624-3630. [PMID: 37303630 PMCID: PMC10251008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/29/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To develop novel medical restraint gloves and investigate their application effect in patients with consciousness and cognitive disorders. METHODS The clinical data of 63 patients with consciousness or cognitive impairment admitted to The First People's Hospital of Lin'an District from June 2021 to January 2022 were retrospectively analyzed. According to the different type of restraint gloves used for treatment, patients were divided into a control group and an observation group. Thirty-one patients from the observation group were treated with the novel medical restraint gloves, and 32 patients in the control group underwent conventional restraint gloves. The effectiveness, safety as well as the comprehensive evaluations of the gloves were detected and compared between the two groups. RESULTS In the term of effectiveness of gloves, the outcomes of protective performances, treatment operations, the fixed gloves/rings, the flexible fingers and overturned gloves in the observation group were significantly better than those in the control group (all P<0.05). In the term of safety of gloves, there was significant difference regarding the local skin redness (P<0.05) between the control group and the observation group, while there was no remarkable difference regarding strangulation marks, local skin damage and local skin swelling. The results of comprehensive evaluation showed the qualified outcome in the observation group was 100%, which was significantly higher than that in the control group (50%) (P<0.05). CONCLUSION Compared with the traditional restraint gloves, the outcomes of effectiveness, safety and comprehensive evaluation results from the observation group were better, indicating that the novel medical restraint gloves better meet the requirements of clinical practices and thus have more clinical application value.
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Affiliation(s)
- Xiaoling Wang
- Department of General Medicine, The First People’s Hospital of Hangzhou Lin’an DistrictHangzhou, Zhejiang, China
| | - Ting Zhang
- Department of Intensive Care Unit, The First People’s Hospital of Hangzhou Lin’an DistrictHangzhou, Zhejiang, China
| | - Xiaofei He
- Department of Orthopedic, The First People’s Hospital of Hangzhou Lin’an DistrictHangzhou, Zhejiang, China
| | - Jia Ding
- Department of Radiology, The First People’s Hospital of Hangzhou Lin’an DistrictHangzhou, Zhejiang, China
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Niu F, Liu Q, Li X, Li X. Clinical application and evaluation of a new type of tracheal catheter fixation belt. Nurs Open 2023; 10:2593-2599. [PMID: 36480230 PMCID: PMC10006639 DOI: 10.1002/nop2.1519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022] Open
Abstract
AIM To evaluate a new fixation band for tracheal catheter in intensive care unit. DESIGN A cross-sectional study. METHODS A total of 90 patients admitted to the ICU between August 2018-February 2019 were enrolled in the study. Patients were randomly divided into experimental group and control group (N = 45/per each group). 3 M strong adhesive tape and a new tracheal catheter fixation band were applied to patients in two groups, respectively. The fixation effect, incidence of mucosal pressure injury and nursing cost were evaluated. RESULTS Forty-three patients from the experimental group and 42 patients from the control group participated in this study. Mild, moderate and severe catheter dislocation happened in 2, 0, 0 cases in the experimental group, and 6, 3 and 2 cases in the control group, respectively; the difference was statistically significant. The rates of mucosal pressure injury were 4.7% and 21.4%, which was significantly different, and the experiment group had a lower average daily nursing cost related to tracheal intubation. CONCLUSIONS The new tracheal catheter fixation band, which allows for accurate fixation, is simple to operate, may reduce the incidence of mucosal pressure injury, decrease the nursing cost and improve the patients' comfort in clinical practice.
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Affiliation(s)
- Fang Niu
- Department of Critical Care Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Qinghua Liu
- Department of Critical Care Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Xiaohui Li
- Department of Critical Care Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Xiang Li
- Department of Critical Care Medicine, Minhang Hospital, Fudan University, Shanghai, China
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10
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Malin SW, McCallister AE, Abu-Sultaneh SM, Valentine KM. A Quality Improvement Initiative to Reduce Unneeded Screening Chest Radiographs in a Pediatric Cardiovascular ICU. Respir Care 2023; 68:392-399. [PMID: 36191928 PMCID: PMC10027155 DOI: 10.4187/respcare.10375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/08/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adult critical care and radiographical societies have recommended changing practice from routine screening radiographs to on-demand chest radiographs (CXRs) for stable mechanically ventilated adult patients. There are no similar recommendations for patients in the pediatric ICU. Reducing the frequency with which unneeded CXRs are obtained can decrease radiation exposure and reduce waste, a substantial contributor to rising health care costs. We aimed to reduce unneeded daily screening CXRs in a pediatric cardiovascular ICU (CICU) by 20% in 6 months. METHODS Criteria delineating which subjects in the CICU required daily screening CXRs were created and added to the daily rounding sheet for discussion for each subject. The primary goal of this study was to reduce CXRs in mechanically ventilated subjects as our previous practice had been to order daily CXRs. Respiratory therapists increased the frequency of evaluating and documenting endotracheal tube positioning prior to the initiation of this project. The outcome measure was the percentage subjects who received a daily screening CXR. The ratio of daily screening CXRs to the number of total CXRs ordered and unplanned extubations were followed as balancing measures. RESULTS The number of subjects who received a daily screening CXR decreased from a baseline of 67% to 44% over the course of this project. There was no change in the ratio of daily screening CXRs to the number of total CXRs ordered or an increase in unplanned extubations. With an estimated cost of $268 per CXR, a reduction of 33% in routine screening CXRs saves an estimated $250,000 annually. CONCLUSIONS A decrease in daily screening CXRs can be sustained through the development of specific criteria to determine which patients need screening radiographs. This can be achieved without an increase in CXRs obtained at other times throughout the day or an increase in unplanned extubations. This eliminates unneeded health care expenditures, improves resource allocation for radiology technicians, and decreases disruptive interventions for patients.
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Affiliation(s)
- Stefan W Malin
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana.
| | - Anne E McCallister
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
| | - Samer M Abu-Sultaneh
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
| | - Kevin M Valentine
- Division of Pediatric Critical Care, Department of Pediatrics, Riley Hospital for Children at Indiana University Health and Indiana University School of Medicine, Indianapolis, Indiana
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Wu J, Liu Z, Shen D, Luo Z, Xiao Z, Liu Y, Huang H. Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews. Nurs Open 2023; 10:392-403. [PMID: 35971250 PMCID: PMC9834196 DOI: 10.1002/nop2.1317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/07/2022] [Accepted: 07/29/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Jinhua Wu
- Shantou University Medical College, Shantou, China
- Shantou University Medical College Affiliated First Hospital, Shantou, China
| | - Zhili Liu
- Shantou University Medical College Affiliated First HospitalShantouChina
| | - Danqiao Shen
- Shantou University Medical College Affiliated First HospitalShantouChina
| | - Zebing Luo
- Shantou University Medical CollegeShantouChina
- Cancer Hospital of Shantou University Medical CollegeShantouChina
| | - Zewei Xiao
- Shantou University Medical CollegeShantouChina
| | - Yeling Liu
- Shantou University Medical College Affiliated First HospitalShantouChina
| | - Haixing Huang
- Shantou University Medical College Affiliated First Hospital, No.57 Changping Road, Shantou, Guangdong 515041, China
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12
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Chang TC, Cheng AC, Hsing SC, Chan KS, Chou W, Chen CM. Risk factors for reintubation and mortality among patients who had unplanned extubation. Nurs Crit Care 2023; 28:56-62. [PMID: 35434930 DOI: 10.1111/nicc.12777] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/24/2022] [Accepted: 04/03/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Ting-Chia Chang
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ai-Chin Cheng
- Section of Respiratory Care, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Shu-Chen Hsing
- Section of Respiratory Care, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Khee-Siang Chan
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Willy Chou
- Department of Physical Medicine and Rehabilitation, Chi Mei Medical Center, Chiali, Taiwan.,Department of Physical Medicine and Rehabilitation, Chung Shan Medical University, Taichung, Taiwan
| | - Chin-Ming Chen
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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13
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Nair V, Loganathan PK, Smith H, Lal MK. Outcomes of Preterm Infants Who Experienced Unplanned Extubation. Respir Care 2022; 67:1320-1326. [PMID: 35790395 PMCID: PMC9994326 DOI: 10.4187/respcare.10005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unplanned extubation (UE) is associated with adverse outcomes. The aim of the study was to compare the clinical outcomes in preterm infants who experienced at least one UE to those who did not experience any UE. METHODS The matched cohort study compared ventilated preterm infants < 32 weeks who experienced UE to those who did not experience any UE. The main outcomes were duration of mechanical ventilation after matching, duration of hospital stay, retinopathy of prematurity (ROP) requiring intervention, and bronchopulmonary dysplasia (BPD). RESULTS Forty-seven infants were included in each group. The groups were matched for mechanical ventilation duration before UE, birth gestation, and birthweight. The duration of mechanical ventilation after matching (adjusted odds ratio [aOR] 14.8 [11.2-18.4], P = <.001), the total length of stay in the hospital (aOR 16.4 [3.7-29.2], P = .01), and severe ROP (aOR 6.7 [1.7-27.0], P = .007) were significantly higher in infants who experienced UE. After adjusting for mechanical ventilation duration, UE was not associated with ROP or BPD. However, infants who spent longer time on mechanical ventilation had higher odds of developing ROP (aOR 1.1 [1.0-1.2], P = .004) and BPD (aOR 1.5 [1.1-2.1], P = .01). Sensitivity analysis including infants who had UE and managed on noninvasive respiratory support showed significant association between UE and the outcomes of duration of mechanical ventilation, hospital length of stay, ROP, and BPD. CONCLUSIONS Infants who experienced UE had higher odds of spending longer time on mechanical ventilation and spent significantly more days in the hospital.
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Affiliation(s)
- Vrinda Nair
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom; and Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, England, United Kingdom.
| | - Prakash Kannan Loganathan
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom; Clinical Academic Office, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, England, United Kingdom; and Department of Physics, University of Durham, Durham, England, United Kingdom
| | - Helena Smith
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom
| | - Mithilesh Kumar Lal
- Neonatal Unit, James Cook University Hospital, Middlesbrough, England, United Kingdom
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14
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Le Blanc G, Jabbour E, Patel S, Kazantseva O, Zeid M, Olivier F, Shalish W, Beltempo M. Organizational Risk Factors and Clinical Impacts of Unplanned Extubation in the Neonatal Intensive Care Unit. J Pediatr 2022; 249:14-21.e5. [PMID: 35714965 DOI: 10.1016/j.jpeds.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/31/2022] [Accepted: 06/09/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To assess the association between organizational factors and unplanned extubation events in the neonatal intensive care unit (NICU) and to evaluate the association between unplanned extubation event and bronchopulmonary dysplasia (BPD) among infants born at <29 weeks of gestational age. STUDY DESIGN This is a retrospective cohort study of infants admitted to a tertiary care NICU between 2016 and 2019. Nursing provision ratios, daily nursing overtime hours/total nursing hours ratio, and unit occupancy were compared between days with and days without unplanned extubation events. The association between unplanned extubation events (with and without reintubation) and the risk of BPD was evaluated in infants born at <29 weeks who required mechanical ventilation using a propensity score-matched cohort. Multivariable logistic regression analysis was used to assess the association between exposures and outcomes while adjusting for confounders. RESULTS On 108 of 1370 days there was ≥1 unplanned extubation event for a total of 116 unplanned extubation event events. Higher median nursing overtime hours (20 hours vs 16 hours) and overtime ratios (3.3% vs 2.5%) were observed on days with an unplanned extubation event compared with days without an unplanned extubation event (P = .01). Overtime ratio was associated with higher adjusted odds of a unplanned extubation event (aOR, 1.09; 95% CI, 1.01-1.18). In the subgroup of infants born at <29 weeks, those with an unplanned extubation event who were reintubated had a longer postmatching duration of mechanical ventilation (aOR, 13.06; 95% CI, 4.88-37.69) and odds of BPD (aOR, 2.86; 95% CI, 1.01-8.58) compared with those without an unplanned extubation event. CONCLUSIONS Nursing overtime ratio is associated with an increased number of unplanned extubation events in the NICU. In infants born at <29 weeks of gestational age, reintubation after an unplanned extubation event is associated with a longer duration of mechanical ventilation and increased risk of BPD.
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Affiliation(s)
| | - Elias Jabbour
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Sharina Patel
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Olga Kazantseva
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Marco Zeid
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Francois Olivier
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Wissam Shalish
- Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Marc Beltempo
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada; McGill University Health Center Research Institute, Montreal, Quebec, Canada; Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada.
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15
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Hur S, Min JY, Yoo J, Kim K, Chung CR, Dykes PC, Cha WC. Development and Validation of Unplanned Extubation Prediction Models Using Intensive Care Unit Data: Retrospective, Comparative, Machine Learning Study. J Med Internet Res 2021; 23:e23508. [PMID: 34382940 PMCID: PMC8387891 DOI: 10.2196/23508] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/19/2020] [Accepted: 07/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background Patient safety in the intensive care unit (ICU) is one of the most critical issues, and unplanned extubation (UE) is considered the most adverse event for patient safety. Prevention and early detection of such an event is an essential but difficult component of quality care. Objective This study aimed to develop and validate prediction models for UE in ICU patients using machine learning. Methods This study was conducted in an academic tertiary hospital in Seoul, Republic of Korea. The hospital had approximately 2000 inpatient beds and 120 ICU beds. As of January 2019, the hospital had approximately 9000 outpatients on a daily basis. The number of annual ICU admissions was approximately 10,000. We conducted a retrospective study between January 1, 2010, and December 31, 2018. A total of 6914 extubation cases were included. We developed a UE prediction model using machine learning algorithms, which included random forest (RF), logistic regression (LR), artificial neural network (ANN), and support vector machine (SVM). For evaluating the model’s performance, we used the area under the receiver operating characteristic curve (AUROC). The sensitivity, specificity, positive predictive value, negative predictive value, and F1 score were also determined for each model. For performance evaluation, we also used a calibration curve, the Brier score, and the integrated calibration index (ICI) to compare different models. The potential clinical usefulness of the best model at the best threshold was assessed through a net benefit approach using a decision curve. Results Among the 6914 extubation cases, 248 underwent UE. In the UE group, there were more males than females, higher use of physical restraints, and fewer surgeries. The incidence of UE was higher during the night shift as compared to the planned extubation group. The rate of reintubation within 24 hours and hospital mortality were higher in the UE group. The UE prediction algorithm was developed, and the AUROC for RF was 0.787, for LR was 0.762, for ANN was 0.763, and for SVM was 0.740. Conclusions We successfully developed and validated machine learning–based prediction models to predict UE in ICU patients using electronic health record data. The best AUROC was 0.787 and the sensitivity was 0.949, which was obtained using the RF algorithm. The RF model was well-calibrated, and the Brier score and ICI were 0.129 and 0.048, respectively. The proposed prediction model uses widely available variables to limit the additional workload on the clinician. Further, this evaluation suggests that the model holds potential for clinical usefulness.
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Affiliation(s)
- Sujeong Hur
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea.,Department of Patient Experience Management, Samsung Medical Center, Seoul, Republic of Korea
| | - Ji Young Min
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Junsang Yoo
- Department of Nursing, College of Nursing, Sahmyook University, Seoul, Republic of Korea
| | - Kyunga Kim
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea.,Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Patricia C Dykes
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea.,Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Digital Innovation Center, Samsung Medical Center, Seoul, Republic of Korea
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16
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Abstract
BACKGROUND Unplanned extubation (UE) is a preventable adverse event and may lead to additional complications such as cardiovascular resuscitation or respiratory compromise in a critically ill neonate during an emergent re-intubation. A quality improvement project to reduce unplanned endotracheal tube dislodgement would reduce these morbidities. We aimed to reduce UEs in the NICU to 1 UE/100 ventilator days by October 2018. METHODS As of the baseline period (March 2017 to November 2017), our level 4 NICU had 950 annual admissions and a baseline rate of 9.9 UEs/100 ventilator days. We formed an inter-professional task force consisting of a neonatologist, 2 respiratory therapists, and the NICU nurse educator. We tracked all of our UE events and required the staff involved to file an electronic safety report. PDSA (plan-do-study-act) cycles consisted of staff attitude survey, development of a data collection tool, protocol of 2 staff members for all transfers of intubated patients, staff education around securement device, and daily retaping of endotracheal tubes to securement device. UE events and ventilator days were extracted from a respiratory database and the electornic medical record. RESULTS A special cause variation was noted via control chart rules for the mean UE rate from a baseline of 9.9 UEs/100 ventilator days in the baseline period compared to a post-intervention mean of 1.6 UEs/100 ventilator days for the period of August 2018 to March 2019). During the intervention phase of the project (December 2017 to July 2018), a special cause variation was noted with a UE rate of 5/100 ventilator days. CONCLUSIONS Development of a quality improvement project by a multidisciplinary taskforce, along with several PDSA cycles including education and staff awareness, reduced the UE rate by 84% in a level 4 NICU. Ongoing surveillance, education, and review of UE cases will be key to maintaining UE events at a goal of 1 UE/100 ventilator days.
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Affiliation(s)
- Deborah A Igo
- Department of Respiratory Therapy, Maine Medical Center, Portland, Maine
| | | | | | - Alan P Picarillo
- Division of Neonatology, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine.
- Tufts University School of Medicine, Boston, Massachusetts
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17
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Liu D, Zhao D, Luo Z, Jin L, Ding L. The application of standardized nursing assessment and intervention in reducing the incidence of unplanned extubation of gastric tube. Am J Transl Res 2021; 13:5374-5379. [PMID: 34150133 PMCID: PMC8205823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The goal of this study was to explore the application of standardized nursing assessment and intervention in reducing the incidence of unplanned extubation of gastric tube. METHODS 100 patients with indwelling gastric tube admitted to our hospital from November 2018 to November 2019 were recruited, and according to the order of admission, they were divided into an experimental group and a control group, with 50 patients in each group. Patients in the control group received routine care, while patients in the experimental group received standardized care. The clinical indicators, incidence of slipping of the catheter, nursing disputes, complications, pain relief time and swelling relief time, unplanned extubation of the gastric tube, nursing and patient satisfaction rate, and extubation time were compared between the two groups. RESULTS The rates of success intubation and indwelling compliance in experimental group were higher than those in the control group (P<0.05). The experimental group exhibited smaller probability of catheter blockage compared with the control group (P<0.05). The incidence of complications was observed to be lower in the experimental group compared with the control group (P<0.05). We identified no statistical difference in catheter slippage and nursing disputes in the two groups (P>0.05). Regarding the 'nursing and patient satisfaction, the experimental group displayed significantly higher score in comparison with the control group (P<0.05). Furthermore, the extubation time, the pain relief time and swelling relief time in experimental group were found to be shorter (P<0.05). The unplanned gastric tube extubation rate of the experimental group was obviously lower than that of the control group's (P<0.05). CONCLUSION The incidence of unplanned gastric extubation tube and occurrence of complications and unexpected situations of patients can be reduced significantly through standardized nursing evaluation and intervention, which should be widely promoted and adopted in clinical practice.
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Affiliation(s)
- Dandan Liu
- Neurosurgery Department, Jingmen No. 2 People’s HospitalJingmen, Hubei Province, China
| | - Dan Zhao
- Nursing Department, Jingmen No. 2 People’s HospitalJingmen, Hubei Province, China
| | - Zaiping Luo
- Operating Room, Jingmen No. 2 People’s HospitalJingmen, Hubei Province, China
| | - Ling Jin
- Neurosurgery Department, Jingmen No. 2 People’s HospitalJingmen, Hubei Province, China
| | - Li Ding
- People’s Hospital of Lanling CountyLinyi, Shandong Province, China
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18
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Zhang P, Liu LP. Design of assessment tool for unplanned endotracheal extubation of artificial airway patients. Nurs Open 2021; 8:1696-1703. [PMID: 33616306 PMCID: PMC8186713 DOI: 10.1002/nop2.807] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/24/2020] [Accepted: 01/29/2021] [Indexed: 12/27/2022] Open
Abstract
Aim Unplanned endotracheal extubation (UEE) is one of the most common adverse events reported in patients with artificial airway. Current research in UEE is mostly limited to the summary of risk factors and analysis of prevention strategies. The aim of the study was to develop an assessment tool for medical staff to assess the risk of unplanned extubation in endotracheal intubation patients. Design The design was a qualitative study. Methods Based on literature review, group discussion, pre‐investigation, the initial risk assessment scale on unplanned extubation for endotracheal intubation patients was established. Fifteen experts from thirteen tertiary‐A hospitals across eight provinces participated in two rounds of Delphi panel. Results The risk assessment tool on unplanned extubation for endotracheal intubation patients was established by the Delphi method. It was composed of 11 indicators, which got agreement among two rounds panel.
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Affiliation(s)
- Ping Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li-Ping Liu
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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19
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Chhina AK, Loyd GE, Szymanski TJ, Nowak KA, Peruzzi WT, Yeldo NS, Han X, Kerzabi LS, Galusca DM, Cazacu S, Brodie C, Penning DH. Frequency and Analysis of Unplanned Extubation in Coronavirus Disease 2019 Patients. Crit Care Explor 2020; 2:e0291. [PMID: 33251520 DOI: 10.1097/CCE.0000000000000291] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objectives: To determine if patients with coronavirus disease 2019 had a greater number of unplanned extubations resulting in reintubations than in patients without coronavirus disease 2019. Design: Retrospective cohort study comparing the frequency of unplanned extubations resulting in reintubations in a group of coronavirus disease 2019 patients to a historical (noncoronavirus disease 2019) control group. Setting: This study was conducted at Henry Ford Hospital, an academic medical center in Detroit, MI. The historical noncoronavirus disease 2019 patients were treated in the 68 bed medical ICU. The coronavirus disease 2019 patients were treated in the coronavirus disease ICU, which included the 68 medical ICU beds, 18 neuro-ICU beds, 32 surgical ICU beds, and 40 cardiovascular ICU beds, as the medical ICU was expanded to these units at the peak of the pandemic in Detroit, MI. Patients: The coronavirus disease 2019 cohort included patients diagnosed with coronavirus disease 2019 who were intubated for respiratory failure from March 12, 2020, to April 13, 2020. The historic control (noncoronavirus disease 2019) group consisted of patients who were admitted to the medical ICU in the year spanning from November 1, 2018 to October 31, 2019, with a need for mechanical ventilation that was not related to surgery or a neurologic reason. Interventions: None. Measurements and Main Results: To identify how many patients in each cohort had unplanned extubations, an electronic medical records query for patients with two intubations within 30 days was performed, in addition to a review of our institutional quality and safety database of reported self-extubations. Medical charts were manually reviewed by board-certified anesthesiologists to confirm each event was an unplanned extubation followed by a reintubation within 24 hours. There was a significantly greater incidence of unplanned extubations resulting in reintubation events in the coronavirus disease 2019 cohort than in the noncoronavirus disease 2019 cohort (coronavirus disease 2019 cohort: 167 total admissions with 22 events—13.2%; noncoronavirus disease 2019 cohort: 326 total admissions with 14 events—4.3%; p < 0.001). When the rate of unplanned extubations was expressed per 100 intubated days, there was not a significant difference between the groups (0.88 and 0.57, respectively; p = 0.269). Conclusions: Coronavirus disease 2019 patients have a higher incidence of unplanned extubation that requires reintubation than noncoronavirus disease 2019 patients. Further study is necessary to evaluate the variables that contribute to this higher incidence and clinical strategies that can reduce it.
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20
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Abstract
BACKGROUND Unplanned extubation (UE) is a common adverse event and is an important measure of quality and patient safety in the neonatal ICU. It is well recognized that UEs occur more frequently in neonates than in any other group of ventilated patients. The objective of this study was to evaluate the effectiveness of the quality improvement interventions in reducing the rates of UE in a tertiary neonatal ICU. METHODS A retrospective audit performed on ventilated infants showed a rate of 7.2 unplanned extubations per 100 ventilation days in a 12-month period (April 2016 to March 2017). We evaluated the common factors associated with UEs, with the primary reasons being loose fixation and providing care without assistance. We introduced sequential interventions focusing on better practices. Standardizing endotracheal tube fixation, continuous scrutiny of fixation through checks, 2-person technique for providing care, and adverse event reporting were a few of the important interventions. Rates of UE for each month were collected and analyzed. RESULTS With interventions, UE rates reduced by 80% (from 7.2 per 100 ventilated days in the pre-implementation period to 1.4 per 100 ventilated days in the post-implementation period) in 12-18 months. CONCLUSIONS Significant reductions in UE rates were achieved by implementing quality improvement interventions. It is important to analyze critical event rates continuously and for longer periods of time to determine the true change.
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Affiliation(s)
- Vrinda Nair
- South Tees National Health Service Trust, Middlesbrough, United Kingdom. .,Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helena Smith
- South Tees National Health Service Trust, Middlesbrough, United Kingdom
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21
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Kambestad KK, Huack A, Nair S, Chapman R, Chin S, Langga L, Mounger E, Guerrero E, Iyer NP. The Adverse Impact of Unplanned Extubation in a Cohort of Critically Ill Neonates. Respir Care 2019; 64:1500-1507. [PMID: 31138734 DOI: 10.4187/respcare.06721] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We sought to describe adverse events associated with unplanned extubation (UE) and to explore risk factors for serious adverse events post-UE among infants who experienced UE. METHODS Data were prospectively collected on all infants who had a UE event at a single institution over a 4-y period. Demographic information and information on outcomes were obtained retrospectively. We described the frequency of post-UE adverse events: success or failure of extubation trial if offered, rate of re-intubation, post-UE changes in ventilator settings, and serious adverse events post-UE (eg, need for cardiopulmonary resuscitation, clinical sepsis, and death or tracheostomy prior to discharge). We used a multivariate logistic regression model to identify the risk factors associated with serious adverse events. RESULTS There were 134 documented UE events. Agitation was the most common known cause. After UE, 49% of the subjects were given a trial of extubation, and 65% of the trials were successful at 48 h. Cardiopulmonary resuscitation (CPR) was performed in 13% of cases. In subjects requiring immediate re-intubation, mean airway pressure (̄Paw) and oxygen requirement increased in 33% and 55% of the subjects, respectively. Post-UE clinical sepsis occurred in 17% of subjects. Higher pre-UE ̄Paw and difficult re-intubation were associated with a need for CPR. Subjects who received CPR had increased odds (3.7×) of developing clinical sepsis. CONCLUSION UE can result in serious adverse events, including hemodynamic instability and possibly an increased risk for clinical sepsis. Difficult re-intubation was associated with a higher risk of needing CPR and, later, tracheostomy and death.
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Affiliation(s)
- Kristi Kuhn Kambestad
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.,Division of Neonatal-Perinatal Medicine, Department of Pediatrics, LAC + USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Aaron Huack
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Srikumar Nair
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.,The Steven & Alexandra Cohen Foundation Newborn and Infant Critical Care Unit, Children's Hospital Los Angeles, Los Angeles, California
| | - Rachel Chapman
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.,The Steven & Alexandra Cohen Foundation Newborn and Infant Critical Care Unit, Children's Hospital Los Angeles, Los Angeles, California
| | - Steven Chin
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.,The Steven & Alexandra Cohen Foundation Newborn and Infant Critical Care Unit, Children's Hospital Los Angeles, Los Angeles, California
| | - Leo Langga
- Respiratory Care Services, Children's Hospital Los Angeles, Los Angeles, California
| | - Erin Mounger
- The Steven & Alexandra Cohen Foundation Newborn and Infant Critical Care Unit, Children's Hospital Los Angeles, Los Angeles, California
| | - Edward Guerrero
- Respiratory Care Services, Children's Hospital Los Angeles, Los Angeles, California
| | - Narayan P Iyer
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California. .,The Steven & Alexandra Cohen Foundation Newborn and Infant Critical Care Unit, Children's Hospital Los Angeles, Los Angeles, California
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22
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Lin PH, Chen CF, Chiu HW, Tai HP, Lee DL, Lai RS. Outcomes of unplanned extubation in ordinary ward are similar to those in intensive care unit: A STROBE-compliant case-control study. Medicine (Baltimore) 2019; 98:e14841. [PMID: 30882675 PMCID: PMC6426589 DOI: 10.1097/md.0000000000014841] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
| | - Chiu-Fan Chen
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Department of Internal Medicine, Taipei Veterans General Hospital, Taitung Branch, Taitung
| | - Hsin-Wei Chiu
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Hsueh-Ping Tai
- Sub-acute Respiratory care ward, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung
| | - David Lin Lee
- Division of Respiratory Therapy
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ruay-Sheng Lai
- Division of Respiratory Therapy
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
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Deshpande GG, Sanford JE, Tripathi S. Comparison of Flow Resistance Characteristics and Placement of Two Endotracheal Tubes. Respir Care 2019; 63:1118-1124. [PMID: 30166410 DOI: 10.4187/respcare.05813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In a traditional endotracheal tube (ETT), there is a linear outward pull through its attachment to the ventilator tubing that leads to risk of accidental dislodgement. This study was conducted to assess the ETT flow characteristics and to evaluate providers' intubation experience using two ETT's in a simulated setting. METHODS Respiratory pressure-volume dynamics for the 2 ETTs were studied in a simulation laboratory by using 3 different flow settings and 2 different test lungs. The time taken for successful intubation on a mannikin was compared by direct observation of 33 separate intubation attempts by 11 different providers. Comfort with intubation by using both tubes was assessed with a Likert scale-based survey. The potential increase in physical and cognitive work load of nurses and respiratory therapists was assessed by the NASA task load index. RESULTS There were slightly lower average tidal volumes delivered with SecureTube compared with the standard tube at different peak inspiratory pressures. Similarly, the same tidal volume delivered with a different flow and bag compliance required slightly higher peak inspiratory pressure compared with the standard ETT. Among providers, there was no difference in the average time to intubate when using either tube. All survey respondents (N = 11) rated intubation attempts with the SecureTube to be very easy compared with the standard tube. The NASA task load index (N = 26) showed very low task loads on all the tasks. CONCLUSIONS There was minimal impact on flow resistance on pressure or volume with the SecureTube compared with the standard tube. Most providers felt comfortable intubating with the SecureTube and took a comparable amount of time to intubate in a simulated setting. We observed low task load scores for securement, maintenance, and manipulation per nurses and respiratory therapists.
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Affiliation(s)
- Girish G Deshpande
- Division of Pediatric Critical Care, Department of Pediatrics, University of Illinois College of Medicine, Peoria, Illinois.
| | - John E Sanford
- Department of Respiratory Therapy, OSF St Francis Medical Center, Peoria, Illinois
| | - Sandeep Tripathi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Illinois College of Medicine, Peoria, Illinois
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Kudela A, Millereux M, Gouezel C, Prat D, Jacobs F, Hamzaoui O, Demars N, Moneger G, Dumenil AS, Trouiller P, Sztrymf B. Effect of Noninvasive Ventilation After Unplanned Extubation. Respir Care 2018; 64:248-254. [PMID: 30401754 DOI: 10.4187/respcare.06328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Our study set out to test the effect of noninvasive ventilation (NIV) performed after unplanned extubation. METHODS Retrospective analysis of prospectively collected data in a university-affiliated mixed ICU of 12 beds during a 5-y period (January 2013 to December 2017). Unplanned extubation was defined as the occurrence of an unplanned removal of the endotracheal tube, whether deliberate or accidental. NIV after an unplanned extubation was not protocolized and was decided by the physician in charge on an individual basis. RESULTS A total of 121 subjects (median [25th-75th percentile] age, 62.1 [43.3-73.6] y; median [25th-75th percentile] Simplified Acute Physiology Score II, 45 [36-54]) experienced 131 unplanned extubation episodes. Re-intubation was deemed necessary in 35 subjects (28.9%). NIV was used in 24 subjects (19.8%) (prophylactic NIV, n = 10; rescue NIV, n = 14). The re-intubation rates were 25.8%, 10%, and 64.3% in the no NIV, prophylactic, and rescue NIV subgroups, respectively. The median (25th-75th percentile) time to re-intubation was longer for subjects on NIV (9.1 [3.5-49.2] vs 0.46 [0.25-1] h, P = .001). The median (25th-75th percentile) ICU length of stay and duration of mechanical ventilation were longer in the subjects who underwent NIV (14.5 [7-24.5] vs 6 [3-14] d, respectively, P = .004; and 9 [3-22] vs 3 [1-7.3] d, respectively, P = .003). CONCLUSIONS NIV after unplanned extubation had uncertain efficacy, especially when provided as rescue management of postextubation respiratory failure.
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Affiliation(s)
- Agathe Kudela
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Maude Millereux
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Corentin Gouezel
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Dominique Prat
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Frédéric Jacobs
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Olfa Hamzaoui
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Nadège Demars
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Guy Moneger
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Anne Sylvie Dumenil
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Pierre Trouiller
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France
| | - Benjamin Sztrymf
- Réanimation polyvalente et surveillance continue, Hôpital Antoine Béclère, Assistance Publique - Hôpitaux de Paris, Hôpitaux universitaires Paris Sud, Clamart, France. .,Institut National de la Santé et de la Recherche Médicale U999, Centre Chirurgical Marie Lannelongue, Université Paris Sud, Le Plessis Robinson, France
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25
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Aydon L, Zimmer M, Sharp M. Reporting the incidence of unplanned extubation in the neonatal intensive care unit. J Paediatr Child Health 2018; 54:784-787. [PMID: 29476579 DOI: 10.1111/jpc.13850] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/07/2017] [Accepted: 01/05/2018] [Indexed: 12/27/2022]
Abstract
AIM The aim of this study was to highlight the incidence of unplanned extubation (UE) and identify associated factors in our neonatal population. METHODS This study was a prospective audit. RESULTS A specifically designed audit tool was used to capture UE events; 182 neonates required mechanical ventilation for 863 days. There were 41 episodes of UE. The UE rate was 4.75 per 100 days of ventilation. At the time of UE, median gestational age of patients was 27.3 weeks (23.4-37.6), with a corrected age median of 29.2 weeks (23.4-37.6). Re-intubation was required in two thirds of the patients for increasing apnoea and increased work of breathing. Endotracheal tubes are secured in a standardised way either using Neobar or brown tape. UE events occurred with both methods. The two most common factors associated with UE included active handling of the baby and the time of day (0700-1000 h). CONCLUSIONS This audit has provided our neonatal intensive care unit with a benchmark for improvement. It has also created staff awareness of the risk of UE and promoted staff engagement to reduce UE. A bundle approach to reduce UE has been introduced. Future audits are planned to monitor the impact of these initiatives.
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Affiliation(s)
- Laurene Aydon
- Neonatal Directorate, King Edward Memorial Hospital and Princess Margaret Hospitals, Women and Newborn Health Service, Perth, Western Australia, Australia.,Department of Nursing and Midwifery Education and Research, Women and Newborn Health Service, Perth, Western Australia, Australia.,Centre for Research and Neonatal Education, School of Child and Paediatric Health, University of Western Australia, Perth, Western Australia, Australia
| | - Margo Zimmer
- Neonatal Directorate, King Edward Memorial Hospital and Princess Margaret Hospitals, Women and Newborn Health Service, Perth, Western Australia, Australia.,Department of Nursing and Midwifery Education and Research, Women and Newborn Health Service, Perth, Western Australia, Australia
| | - Mary Sharp
- Neonatal Directorate, King Edward Memorial Hospital and Princess Margaret Hospitals, Women and Newborn Health Service, Perth, Western Australia, Australia.,Centre for Research and Neonatal Education, School of Child and Paediatric Health, University of Western Australia, Perth, Western Australia, Australia
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26
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Curran MWT, Tredget EE. Ivy Loop Wiring: A Useful Form of Endotracheal Tube Stabilization in Burn Patients. Plast Surg (Oakv) 2017; 25:175-178. [PMID: 29026823 DOI: 10.1177/2292550317716123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The stabilization of endotracheal tubes in the burn population presents many problems. Access to the face for dressings, debridements, and the use of topical antimicrobials prevent adequate stabilization of the endotracheal tube with commonly used methods. Conventional methods have an increased risk of shifting, which can lead to injury to the friable burned tissue or unplanned extubation. To prevent these complications, alternative methods using the dentition to stabilize the endotracheal tube have been described. Here, we present our technique of using Ivy loops to secure the endotracheal tube. It is a simple method with low complications that provides a strong stabilization of the tube while giving access to the face.
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Affiliation(s)
- Matthew W T Curran
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Edward E Tredget
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
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27
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Hatch LD, Grubb PH, Markham MH, Scott TA, Walsh WF, Slaughter JC, Stark AR, Ely EW. Effect of Anatomical and Developmental Factors on the Risk of Unplanned Extubation in Critically Ill Newborns. Am J Perinatol 2017; 34:1234-1240. [PMID: 28494497 PMCID: PMC5705226 DOI: 10.1055/s-0037-1603341] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To quantify the daily risk of unplanned extubation (UE) in newborns based on developmental and anatomical factors. METHODS Prospective cohort of ventilated newborns over an 18-month period in a level IV neonatal intensive care unit (NICU). We captured UEs through four data streams. We generated multivariable logistic regression models to assess the association of UE with chronological age, birth weight, and postmenstrual age. RESULTS During the study, 718 infants were ventilated for 5,611 patient days with 117 UEs in 81 infants. The daily risk of UE had a significant, nonlinear relationship (p < 0.01) with chronological age, decreasing until day 7 (odds ratio [OR]: 0.5; 95% confidence interval [CI]: 0.17–1.47) and increasing after day 7 (day 7–28, OR: 1.36, 95% CI: 1.06–1.75; and >28 days, OR: 1.06, 95% CI: 1.0–1.14). Birth weight and postmenstrual age were not associated with UE. Adverse events occurred in 83/117 (71%) UE events. Iatrogenic causes of UE were more common in younger, smaller infants, whereas older, larger infants were more likely to self-extubate. CONCLUSION The daily risk and causes of UE change over the course of an infant’s NICU hospitalization. These data can be used to identify infants at the highest risk of UE for whom targeted proactive interventions can be developed.
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Affiliation(s)
- L. Dupree Hatch
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Peter H. Grubb
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melinda H. Markham
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Theresa A. Scott
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William F. Walsh
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C. Slaughter
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ann R. Stark
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine and the Center for Health Services Research, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee,Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center, Nashville, Tennessee
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28
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Lin LC, Chao YFC, Lin PC. [The Effect of Family Member Reminders on Reducing Anxiety and Unplanned Extubation in ICU Patients]. Hu Li Za Zhi 2017; 64:41-49. [PMID: 28948590 DOI: 10.6224/jn.000067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with endotracheal intubation often experience anxiety because they are unable to express their needs freely. However, the family members of these patients are able to provide encouragement, comfort, and substantive support. PURPOSE The aims of the present study were: (1) to compare the anxiety scores, vital signs, and incidence of unplanned extubation (UE) between the two comparison groups; (2) to compare the differences in vital signs before and after the intervention in the experimental group; and (3) to explore the satisfaction of patients in the experimental group with the intervention. METHODS A quasi-experimental, pretest-posttest design was carried out. A convenience sampling was adopted to recruit patients with endotracheal intubation in intensive care units (ICUs). The experimental group listened to the UE-prevention reminders of their family members for three times a day for 4 days. The control group was provided with usual care. RESULTS (1) No significant difference was observed in the anxiety scores between the two groups (t = -1.282, p = .205). (2) A repeated-measures analysis found no significant difference in vital signs, taken nightly at 10 p.m., between the experimental and control groups (p > .05). (3) The experimental group registered significantly lower heart rates, systolic blood pressure, diastolic blood pressure, and mean arterial pressure after the conclusion of the intervention (p < .05). However, no significant pre-test / posttest difference in breathing rate was observed for this group. (4) A large majority (89%) of the experimental group expressed satisfaction with the intervention treatment program. CONCLUSIONS / IMPLICATIONS FOR PRACTICE The present study, which used a DVD of family reminders encouraging and reminding patients about intubation safety, achieved a very high level of patient satisfaction and reduced their anxiety-related vital signs. The results may serve as a reference for providing intervention treatment to patients with endotracheal intubation in ICUs.
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Affiliation(s)
- Li-Ching Lin
- MSN, RN, Head Nurse, Department of Nursing, Taipei Medical University Hospital, Taiwan, ROC
| | - Yann-Fen C Chao
- PhD, RN, Professor, School of Nursing, Mackay Medical College, Taiwan, ROC
| | - Pi-Chu Lin
- EdD, RN, Professor, Master Program of Long-Term Care, College of Nursing, Taipei Medical University, Taiwan, ROC.
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29
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Zhao CM, Qian JB, Zhang CM, Lin G. Open-label randomised controlled trial about application of bundle care in prevention of unplanned extubation of nasobiliary drainage catheter after endoscopic retrograde cholangiopancreatography. J Clin Nurs 2017; 27:2590-2597. [PMID: 28618046 DOI: 10.1111/jocn.13927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2017] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To observe the effects of bundle care on preventing unplanned extubation of nasobiliary drainage catheter after endoscopic retrograde cholangiopancreatography. BACKGROUND Preventing unplanned extubation has become a difficult problem for nursing staff because the catheter is stiff, fine and long. DESIGN A total of 114 cases that experienced nasobiliary drainage after endoscopic retrograde cholangiopancreatography for the first time in our hospital from April 2015-July 2016 were enrolled in this study. According to receiving routine nurse or bundle nurse, these cases were randomly divided into control (n = 56) and intervention (n = 58) group. METHOD The unplanned extubation incidence, contact area between tape and catheter and tensile resistance were compared between the two groups. RESULTS The contact area was one square centimetre in the control group and 5 cm2 in the intervention group. Tensile resistance was significantly higher in the intervention group than in the control (all p < .05). Unplanned extubation incidence was significantly lower in the intervention group (1.72%, 1/58) than in the control (12.5%, 7/56) (p = .0305). CONCLUSION Bundle care can effectively decrease unplanned extubation incidence after endoscopic retrograde cholangiopancreatography. RELEVANCE TO CLINICAL PRACTICE This study provides a basis for decreasing unplanned extubation incidence.
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Affiliation(s)
- Chun-Mei Zhao
- Department of Gastroenterology, The First People's Hospital of Nantong, Nantong, China
| | - Jun-Bo Qian
- Department of Gastroenterology, The First People's Hospital of Nantong, Nantong, China
| | - Chun-Mei Zhang
- Department of Gastroenterology, The First People's Hospital of Nantong, Nantong, China
| | - Gang Lin
- Department of Cardiovascular, The First People's Hospital of Nantong, Nantong, China
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Chao CM, Lai CC, Chan KS, Cheng KC, Ho CH, Chen CM, Chou W. Multidisciplinary interventions and continuous quality improvement to reduce unplanned extubation in adult intensive care units: A 15-year experience. Medicine (Baltimore) 2017; 96:e6877. [PMID: 28682859 PMCID: PMC5502132 DOI: 10.1097/md.0000000000006877] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
We conduct a retrospective study of patients with unplanned extubation (UE) in adult intensive care units (ICU) at a medical center. In 2001, a multidisciplinary team of intensivists, senior residents, nurses, and respiratory therapists was established at Chi Mei Medical Center. The improvement interventions, implemented between 2001 and 2015, were organized around 8 key areas: standardizing procedures, improving communication skills, revising sedation and weaning protocols, changing strategies for restraints, establishing a task force for identifying and managing high-risk patients, using new quality-improvement models as breakthrough series and team resource management, using the strategy of accountability without assigning blame, and changing a new method to secure endotracheal tube. We measured the outcome as the annual event and the rate of UE. During this 15-year period, there were 1404 episodes of UE, with 44,015 episodes of mechanical ventilation (MV) (319,158 ventilator-days). The overall rate of UE was 3.19/100 ventilated patients (4.40/1000 ventilator-days). In 2001, there were 188 episodes of UE and the rate of UE was 6.82/100 ventilated patients or 9.0/1000 ventilator-days. After this continue quality improvement project had been implemented, the annual number of episodes of UE declined to 27, and the rate fell to 0.95/100 ventilated patients or 1.36/1000 ventilator-days in 2015. Overall, the trend analysis showed the change was significant with P < .0001. In conclusion, UE in adult ICU can be continuously and effectively reduced using multidisciplinary and sequential quality improvement interventions.
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Affiliation(s)
- Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying
| | | | - Kuo-Chen Cheng
- Department of Internal Medicine, Chi Mei Medical Center
- Department of Safety, Health and Environment, Chung Hwa University of Medical Technology
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center
- Department of Pharmacy, Chia Nan University of Pharmacy and Science
| | - Chin-Ming Chen
- Department of Intensive Care Medicine
- Department of Recreation and Health-Care Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Willy Chou
- Department of Recreation and Health-Care Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
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31
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Crezeé KL, DiGeronimo RJ, Rigby MJ, Carter RC, Patel S. Reducing Unplanned Extubations in the NICU Following Implementation of a Standardized Approach. Respir Care 2017; 62:1030-1035. [PMID: 28559465 DOI: 10.4187/respcare.04598] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unplanned extubations (UEs) have been associated with increased ventilator days, risk of infection, cardiopulmonary resuscitation, and resuscitation medication usage. The UE rate in our level 4 NICU is lower than the national average. Efforts to further reduce UE events at our institution led an interdisciplinary group to define steps to eliminate UEs. Steps included: (1) requiring at least 2 care providers at the bedside for movement of an intubated subject; (2) standardizing head and endotracheal tube (ETT) position; (3) defining a set methodology for ETT securing; (4) introducing a postoperative handoff to improve communication; and (5) implementing a post-UE assessment tool. METHODS A quality improvement initiative reviewed subjects and compared UE rates before (January 2013 to December 2013) and after (January 2014 to December 2014) implementation of UE prevention guidelines. A de-identified data set was used for analysis. RESULTS 67 UE events were identified with 46 UE events at baseline in 2013 compared with 21 in 2014 post-implementation. This amounted to a 64% decrease in total UE events (from 46 to 21) (P < .001). Additionally, monthly UE rates decreased 50% (from 3.8 to 1.9), and UE events per 100 ventilator days decreased 53% (from 1.15 to 0.54). CONCLUSIONS The development of standard guidelines to prevent UE and a quality review process to track UE provided important information for education and practice change. In our NICU, these changes have significantly improved the UE rate through improved teamwork, accountability, and communication.
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Affiliation(s)
- Kevin L Crezeé
- Respiratory Care Services, Primary Children's Hospital, Salt Lake City, Utah.
| | | | - Marilyn J Rigby
- Neonatal Critical Care Services, Primary Children's Hospital, Salt Lake City, Utah
| | - Rick C Carter
- Respiratory Care Services, Primary Children's Hospital, Salt Lake City, Utah
| | - Shrena Patel
- Division of Neonatology, University of Utah, Salt Lake City, Utah
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Abstract
BACKGROUND Unplanned extubations can lead to iatrogenic injury and have the potential to contribute to serious safety events. We adopted lean methodology to reduce the unplanned extubation rate in a Level 3b NICU. We hypothesized that the use of a rapid-cycle PDSA (plan, do, study, act) initiative would reduce the unplanned extubation rate. METHODS Baseline unplanned extubation data were collected from November 1, 2012 to June 6, 2014. A voice of the customer survey ascertained perceptions regarding unplanned extubation causes and impact on care. The confidential survey contained 2 open-ended and 4 closed-ended questions and was distributed to a random sample of nurses and respiratory therapists. A fishbone diagram helped to identify opportunities. Six improvements were identified and rolled out in 2 phases using didactic and kinesthetic techniques. Phase 1 standardized the process for turning intubated infants, assessing endotracheal tube (ETT) placement with growth, and communicating tube position with caregivers. Phase 2 addressed respiratory plans of care, correcting ETT migration, establishing ETT re-securement methods, and standardizing position during radiography. The Fisher exact test was used to determine differences in the number of unplanned extubations per 100 intubated days. Descriptive statistics were used to report survey results. Statistical significance was established at P < .05. RESULTS A 68% (17 of 25) survey response rate was realized. Baseline data revealed 3.8 unplanned extubations/100 intubated days, and 2.7 unplanned extubations/100 intubated days occurred in the post-improvement phase (P = .01). We noted a statistically significant decrease in the number of intubated days between the pre- and post-improvement groups (P < .001). CONCLUSIONS Staff underestimated the prevalence of unplanned extubations but recognized the need for improvement. Rapid cycle PDSA significantly reduced the unplanned extubation rate. The decrease in intubated days may have been a by-product of the post-improvement phase improvements, which encouraged practice changes.
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Affiliation(s)
- Bonnie M Powell
- Department of Respiratory Care, Akron Children's Hospital of the Mahoning Valley, Boardman, Ohio.
| | | | - Teresa A Volsko
- Department of Nursing Administration, Akron Children's Hospital, Akron, Ohio
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Abstract
PURPOSE Reintubation following unplanned extubation (UE) is often required and associated with increased morbidity; however, knowledge of risk factors leading to reintubation and subsequent outcomes in children is still lacking. We sought to determine the incidence, risk factors, and outcomes related to reintubation after UEs. METHODS All mechanically ventilated children were prospectively tracked for UEs over a 7-year period in a pediatric intensive care unit. For each UE event, data associated with reintubation within 24 hours and outcomes were collected. RESULTS Of 757 intubated patients, 87 UE occurred out of 11 335 intubation days (0.76 UE/100 intubation days), with 57 (65%) requiring reintubation. Most of the UEs that did not require reintubation were already weaning ventilator settings prior to UE (73%). Univariate analysis showed that younger children (<1 year) required reintubation more frequently after an UE. Patients experiencing UE during weaning experienced significantly fewer reintubations, whereas 90% of patients with full mechanical ventilation support required reintubation. Logistic regression revealed that requirement of full ventilator support (odds ratio: 37.5) and a COMFORT score <26 (odds ratio: 5.5) were associated with UE failure. There were no differences between reintubated and nonreintubated patients regarding the length of hospital stay, ventilator-associated pneumonia rate, need for tracheostomy, and mortality. Cardiovascular and respiratory complications were seen in 33% of the reintubations. CONCLUSION The rate of reintubation is high in children experiencing UE. Requirement of full ventilator support and a COMFORT score <26 are associated with reintubation. Prospective research is required to better understand the reintubation decisions and needs.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- 1 Department of Pediatrics, Pediatric Intensive Care Unit, Hospital do Servidor Público Municipal, São Paulo, Brazil
| | - Maria Eunice Reis
- 2 Division of Neonatology, Hospital e Maternidade Santa Joana, São Paulo, Brazil
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Kapadia FN, Tekawade PC, Nath SS, Pachpute SS, Saverkar SS, Bhise RA, Chavan AC, Varghese SJ, Kantak VU, Kshirsagar RV, Neve VA, D'souza SO. A prolonged observational study of tracheal tube displacements: Benchmarking an incidence <0.5-1% in a medical-surgical adult intensive care unit. Indian J Crit Care Med 2014; 18:273-7. [PMID: 24914254 PMCID: PMC4047687 DOI: 10.4103/0972-5229.132466] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background and Aims: Tracheal tubes are commonly used in intensive care unit (ICU) and lead to complications like displacements. The primary aim of the study was to evaluate if the rate of tracheal tube displacement benchmarked at <1% per patient and <0.5% per tracheal tube day, could be sustained over a prolonged period. The secondary aim was to document the patterns of all forms airway accident and to evaluate their consequences. Subjects and Methods: This was a prospective observational study of Intubated and ventilated patients in a General Medical-Surgical Adult ICU. The incidence of accidental extubation, self extubation, partial displacement and blockages of tracheal tubes were recorded. Results: The overall tracheal tube displacement rate was 61/10,112 (0.6%) per patient and 61/28,464 (0.22%) per tracheal tube day. There were 30 additional incidents of blockage, kinking or biting of the tracheal tube. Physiological consequences-69 were mild, 10 moderate, 12 major and one death. Of the 91 accidents, 30 were partly and 30 were completely preventable. 76 incidents involved an endotracheal tube (54 displaced, 12 blocked and 10 bitten-kinked) and 15 a tracheostomy tube (seven displaced and eight blocked). Accidents were more common in medical than surgical patients (medical = 48, cardiac surgical = 17 and other surgical/trauma = 26). Conclusion: Tracheal tube displacement rate in a mixed medical-surgical adult ICU was maintained below the pre-set benchmark of <1% per patient and <0.5% per intubated day over nearly a decade.
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Affiliation(s)
- Farhad N Kapadia
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Pandurang C Tekawade
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Shruti S Nath
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Sharad S Pachpute
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Sanjay S Saverkar
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Rupali A Bhise
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Aarti C Chavan
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Sholly J Varghese
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Vidya U Kantak
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Rohini V Kshirsagar
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Vaishali A Neve
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
| | - Samona O D'souza
- Department of Intensive Care, Hinduja Hospital, Mahim, Mumbai, Maharashtra, India
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35
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Abstract
BACKGROUND AND OBJECTIVES Unplanned extubation can be a significant event that places the patient at risk for adverse events. Our goal was to reduce unplanned extubations to <1 unplanned extubation per 100 patient-intubated days. METHODS All unplanned extubations in the NICU beginning in October 2009 were audited. Data collected included time of day, patient weight, and patient care activity at the time of the event. Bundles of potentially better practices were implemented in sequential Plan-Do-Study-Act cycles. Rates of unplanned extubation (number per patient-intubated day) for each month were analyzed by using control charts, and causes of unplanned extubation were analyzed by using Pareto charts. RESULTS We found a significant decrease in the unplanned extubation rate after implementation of the first bundle of potentially better practices in May 2010 (2.38 to 0.41 per 100 patient-intubated days). Several more Plan-Do-Study-Act cycles were conducted to sustain this improvement. A persistent reduction in the unplanned extubation rate (0.58 per 100 patient-intubated days) began in February 2013. Causes included dislodgement during care and procedures and variation in the fixation of the endotracheal tube. The majority of events occurred in very low birth weight infants during the daytime shift. CONCLUSIONS Unplanned extubations in the NICU can be reduced by education of staff and by implementing standard practices of care. Sustainability of any practice change to improve quality is critically dependent on culture change within the NICU. We suggest that the benchmark for unplanned extubation should be a rate <1 per 100 patient-intubated days.
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Affiliation(s)
- Lori Merkel
- Division of Newborn Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Kimberly Beers
- Division of Newborn Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Mary M Lewis
- Division of Newborn Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Joy Stauffer
- Division of Newborn Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Dennis J Mujsce
- Division of Newborn Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Mitchell J Kresch
- Division of Newborn Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
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36
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Silva PSLD, Reis ME, Aguiar VE, Fonseca MCM. Unplanned extubation in the neonatal ICU: a systematic review, critical appraisal, and evidence-based recommendations. Respir Care 2012; 58:1237-45. [PMID: 23271815 DOI: 10.4187/respcare.02164] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To update the state of knowledge on unplanned extubations (UEs) in neonatal ICUs. This review focuses on the following topics: incidence, risk factors, reintubation after UE, outcomes, and prevention. METHODS The MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for relevant publications from January 1, 1950, through January 30, 2012. Fifteen articles were selected for data abstraction. The search strategy included the following key words: "unplanned extubation," "accidental extubation," "self extubation," "unintentional extubation," "unexpected extubation," "inadvertent extubation," "unintended extubation," "spontaneous extubation," "treatment interference," and "airway accident." Study quality was assessed using the Newcastle-Ottawa scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine's levels of evidence system. Studies with Newcastle-Ottawa scale score ≥ 5 that included appropriate statistical analysis were deemed of high methodological quality. RESULTS The overall mean Newcastle-Ottawa scale score was 3.5. UE rates ranged from 0.14 to 5.3 UEs/100 intubation days, or 1% to 80.8%. Risk factors included restlessness/agitation (13-89%), poor fixation of endotracheal tube (8.5-31%), tube manipulation at the time of UE (17-30%), and performance of a patient procedure at bedside (27.5-51%). One study showed that every day on mechanical ventilation increased the UE risk 3% (relative risk 1.03, P < .001). The association between birth weight/gestational age and UE is controversial. Reintubation rates ranged from 8.3% to 100%. There is still a gap of information about strategies addressed to reduce the incidence of UE. The best method of endotracheal tube securement remains a controversial issue. CONCLUSIONS Despite numerous publications on UE, there are few studies assessing preventive strategies for adverse events and there is a lack of randomized clinical trials. Recommendations are proposed based on the current available literature.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sevidor Público Municipal, São Paulo, Brazil.
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37
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Abstract
BACKGROUND: Unplanned extubation is quite common in intensive care unit (ICU) patients receiving mechanical ventilatory support. The present study aimed to investigate the effectiveness of noninvasive positive pressure ventilation (NPPV) in patients with unplanned extubation. MATERIALS AND METHODS: A total of 15 patients (12 male, age: 57 ± 24 years, APACHE II score: 19 ± 7) monitored at the medical ICU during the year 2004 who developed unplanned extubation were included in the study. NPPV was tried in all of them following unplanned extubation. Indications for admission to the ICU were as follows: nine patients with pneumonia, three with status epilepticus, one with gastrointestinal bleeding, one with cardiogenic pulmonary edema and one with diffuse alveolar bleeding. RESULTS: Eleven of the patients (74%) were at the weaning period at the time of unplanned extubation. Among these 11 patients, NPPV was successful in 10 (91%) and only one (9%) was reintubated due to the failure of NPPV. The remaining four patients (26%) had pneumonia and none of them were at the weaning period at the time of extubation, but their requirement for mechanical ventilation was gradually decreasing. Unfortunately, an NPPV attempt for 6–8 h failed and these patients were reintubated. CONCLUSIONS: Patients with unplanned extubation before the weaning criteria are met should be intubated immediately. On the other hand, when extubation develops during the weaning period, NPPV may be an alternative. The present study was conducted with a small number of patients, and larger studies on the effectiveness of NPPV in unplanned extubation are warranted for firm conclusions.
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Affiliation(s)
- Emel Eryüksel
- Department of Pulmonary and Critical Care, Marmara University Hospital, Turkey.
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