The relationship of sedation to deliberate self-extubation

STUDY OBJECTIVES

To evaluate the relationship between sedative therapy and self-extubation in a large medical-surgical intensive care unit (ICU).

DESIGN

Retrospective, case-controlled study.

SETTING

Large teaching hospital.

PATIENTS

All adult patients who underwent unplanned self-extubation during a 12-month period (n = 50). Each patient was matched to two control patients who did not self-extubate based on age, gender, dates in hospital and diagnosis.

INTERVENTIONS

none.

MEASUREMENTS

Data collected included time to self extubation, dosages and types of benzodiazepines, opioid analgesics, antipsychotics, and hypnotics. Data on the degree of agitation as assessed by nursing staff also were obtained.

MAIN RESULTS

When compared to controls, patients in the self-extubation group were more likely to have received benzodiazepines (59% vs. 35%; p < 0.05), but equally likely to have received opioids and/or paralytic drugs. Patients who self-extubated were twice as likely as controls to be agitated (54% vs. 22%; p < 0.05). Use of benzodiazepines was more common in agitated patients than in nonagitated patients (62% vs. 35%; p < 0.02). Among nonagitated patients who self-extubated, increased use of benzodiazepines (57% vs. 29%; p < 0.05) was noted when compared to nonagitated controls.

CONCLUSIONS

In intubated ICU patients, benzodiazepines may not consistently treat agitation effectively or prevent self-extubation. Such an effect may be due to paradoxical excitation, disorientation during long-term administration, or differences in drug administration between ICU and operating room (OR) environments.

Happy employees lead to loyal patients. Survey of nurses and patients shows a strong link between employee satisfaction and patient loyalty

A strong relationship exists between employee satisfaction and patients' perceptions of the quality of their care, measured in terms of their intent to return and to recommend the hospital to others. Employee dissatisfaction can negatively affect quality of care and have an adverse effect on patient loyalty and, thus hospital profitability. Therefore, health care marketers should regularly measure employee satisfaction as one way to monitor service quality. Health care marketers must work more closely with their human-resource departments to understand and influence employees' work environment and maintain a high level of job satisfaction. Marketers also should place an increased emphasis on both employee and patient perceptions of satisfaction when developing internal and external strategic marketing plans and formulating future research.

Characteristics and outcomes of patients who self-extubate from ventilatory support: a case-control study

OBJECTIVE

To identify factors associated with the occurrence of deliberate self-extubation and to describe associated patient outcomes.

DESIGN

Case-control study.

SETTING

ICUs of a national referral, tertiary medical center.

PARTICIPANTS

Fifty adult, intubated patients who had self-extubated from mechanical ventilatory support. Two control subjects who had not self-extubated were matched to each case based on age, gender, primary discharge diagnosis, and time hospitalized (within same quarter).

MEASUREMENTS

Standardized coding of medical record information, including demographic characteristics, clinical information, intubation and mechanical ventilation characteristics, medications, and selected laboratory indexes.

RESULTS

As compared to the control subjects, patients who self-extubated were more likely to be medical than surgical patients (p<0.001) and have a current history of smoking (p<0.05). Prior to the self-extubation, patients had a greater likelihood of hospital-acquired infections (p<0.001) or other hospital-acquired adverse events (p<0.001), abnormal (<10, >50 mg/dL) BUN (p<0.05), and abnormal (<20, >50 mm Hg) PaCO2 (p<0.05); they also were more likely to be restless or agitated (p<0.001), and more likely to be physically restrained (p<0.001). A logistic regression model demonstrated that presence of restlessness or agitation and presence of a hospital-acquired adverse event were independently associated with self-extubation from mechanical ventilatory support. In examining outcomes, as compared to the control subjects, those who self-extubated had longer lengths of stay in ICU and hospital, were more likely to need reintubation, and were more likely to suffer complications from intubation. However, none of the cases died within 48 h of self-extubation.

CONCLUSION

The results underscore the need for clinical guidelines for weaning and for monitoring patients at risk of self-extubation.

Reducing risks through quality improvement, infection control, and risk management

Health care organizations in America are undergoing major changes. As these changes are occurring, organizations are being asked to demonstrate how they monitor and improve their services to provide cost-effective, quality care. The integration of quality improvement methodologies, risk management programs, and infection-control systems provides the structure necessary for identifying organization risks and attempting to eliminate them. This integration is demonstrated by a case study for reducing needlestick injuries in the intensive care unit.