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Personal use only. For copyright permission information:Published online http://www.ajcconline.org 2011 American Association of Critical-Care Nurses
doi: 10.4037/ajcc20113342011;20:304-312Am J Crit CareMary Jarachovic, Maggie Mason, Kathleen Kerber and Molly McNettIntensive Care UnitThe Role of Standardized Protocols in Unplanned Extubations in a Medical
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By Mary Jarachovic, RN, BSN, Maggie Mason, RN, BSN, Kathleen Kerber, RN, MSN,ACNS, BC, and Molly McNett, RN, PhD
Background Many patients admitted to medical intensive care
units require mechanical ventilation to assist with respiratory
management. Unplanned extubations of these patients are
associated with poor outcomes for patients and organizations.
No previous research has investigated the role of standardized
protocols in unplanned extubations when examined in con-
junction with traditional risk factors.Objective To identify risk factors associated with unplanned
extubation among patients receiving mechanical ventilation
and determine degree of compliance with pain, sedation, and
weaning protocols.
Methods A prospective cohort study design was used. Data
on all patients admitted to the medical intensive care unit
who required mechanical ventilation were gathered daily.
Additional data were gathered on those patients who experi-
enced unplanned extubation. Descriptive, correlational, and
regression analyses were performed.
Results Weaning protocols were a significant predictor of
unplanned extubation: patients who had weaning protocols
ordered and followed were least likely to experience unplannedextubation. Only 10% of the 190 patients in the study required
reintubation, resulting in a significantly shorter ventilation time
and unit length of stay among the unplanned extubation group.
Conclusions Weaning protocols were associated with decreased
incidence of unplanned extubation. Use of standardized pro-
tocols was feasible, as compliance among health care providers
was high when protocols were medically prescribed. The
reintubation rate in this study was low and associated with a
significantly shorter ventilatory period and unit length of stay
in the unplanned extubation group. (American Journal of
Critical Care. 2011;20:304-312)
THE ROLE OFSTANDARDIZED PROTOCOLSIN UNPLANNEDEXTUBATIONS IN AMEDICAL
INTENSIVE CARE UNIT
Pulmonary Critical Care
C E 1.0 Hour
Notice to CE enrollees:A closed-book, multiple-choice examinationfollowing this article tests your understanding ofthe following objectives:
1. Identify weaning protocols used in assisting
planned extubations.2. Explore types and percentages of unplanned
extubations.3. Examine important implications of unplanned
extubations for patient care.
To read this article and take the CE test online,visit www.ajcconline.org and click CE Articlesin This Issue. No CE test fee for AACN members.
2011 American Association of Critical-Care Nurses
doi: 10.4037/ajcc2011334
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Within our institution, an ongoing quality
improvement project indicated that unplanned extu-
bation continued to occur despite implementation
of sedation, pain management, and weaning proto-
cols that addressed factors reported in the literatureto be associated with unplanned extubation. Addi-
tional investigation was needed to explore factors
associated with unplanned extubation. Therefore, a
research project was initiated with the following study
aims: (1) to identify factors associated with unplanned
extubation among patients admitted to the MICU
who are receiving mechanical ventilation and (2) to
determine the degree of compliance of physicians and
nurses with sedation, pain, and weaning protocols.
Background
The reported rates of unplanned extubationrange between 7% and 18% in most ICUs.1,3-6 Risks
associated with unplanned extubation include bron-
chospasms, arrhythmias, aspiration, pneumonia,
respiratory failure, and cardiopulmonary arrest.7,8
Although mortality rates have not consistently been
shown to increase with unplanned extubation,
unplanned extubation does result in prolonged
mechanical ventilation, longer ICU and hospital
stay, and an increased need for chronic care for
those patients who do not tolerate an unplanned
extubation.1,9 Despite research regarding risk factors
associated with unplanned extubation, it continues
to occur and remains a serious complication of
translaryngeal intubation.
Traditional Risk Factors for UnplannedExtubation
Several risk factors contribute to unplanned
extubation among patients receiving mechanical
ventilation in intensive care units. These factors
include patient level variables such as agitation,
altered level of consciousness, and inadequate
sedation, as well as structure/environmental vari-
ables, which include oral intubation,
method of securing tube, and the
use of physical restraints.5,10,11
A case-control study of
unplanned extubation amongpatients in medical and surgical
ICUs indicated that patients who
experience unplanned extubation
were more likely to be medical
patients, to have a current history of
smoking, a nosocomial infection, or
metabolic disorder, and to be agi-
tated or restless and restrained.7 In
a second study,9 researchers reported that all
patients who experienced unplanned extubation
were orally intubated, and 56% of those patients
had to be emergently reintubated. Unplanned extu-bation is associated with prolonged duration of
mechanical ventilation, and longer stays in the ICU
and hospital. Other factors associated with unplanned
extubation include anxiety, routine care interventions,
and a history of previous unplanned extubations.12
Sedation/Agitation: The Role of Pain and
Sedation Protocols
A key factor that contributes to unplanned self-
extubation is inadequate level of sedation, resulting
A
number of patients admitted to medical intensive care units (MICUs) require
mechanical ventilation to assist with short- or long-term respiratory management
and stabilization. Unplanned extubation (defined as an endotracheal tube being
removed by the patient or accidentally) of MICU patients is a potentially life-
threatening situation that continues to occur despite research and educational
efforts. Unplanned extubation, whether deliberate or accidental, is associated with a numberof medical complications and increased length of stay in the hospital and unit.1,2 Deliberate
unplanned extubation occurs when a patient intentionally pulls out an endotracheal tube,
whereas accidental unplanned extubation is the unintentional removal of the endotracheal
tube by either patient or staff, which can occur with repositioning, procedures, or coughing.
About the AuthorsMary Jarachovic is a clinical nurse, Maggie Mason is anurse manager, and Kathleen Kerber is a clinical nursespecialist in the medical intensive care unit and MollyMcNett is director of nursing research in the Depart-ment of Nursing at MetroHealth Medical Center inCleveland, Ohio.
Corresponding author: Molly McNett, 2500 MetroHealthDrive, Nursing Business Office, MetroHealth MedicalCenter, Cleveland, OH 44109 (e-mail: mmcnett@metrohealth.org).
Unplanned extu-
bation, whether
deliberate or acci-
dental, increases
length of intensive
care unit and
hospital stay.
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of stay in the hospital and ICU.16,17 Protocol adher-
ence by all members of the health care team is equally
important, as such adherence has contributed to
decreased use of restraints and shorter stays.18 It is
evident that use of pain and sedation protocols
with patients receiving mechanical ventilation can
improve patients outcomes. By decreasing the levelof agitation among patients receiving mechanical
ventilation, protocol use addresses a key factor
associated with unplanned extubation. However,
no studies were found that explored the impact of
these protocols on rates of unplanned extubation
when combined with traditional risk factors.
The Role of Weaning Protocols
The use of standardized protocols for weaning
from mechanical ventilation has been widely stud-
ied.19-26The use of computerized protocols or proto-
cols directed by the nurse or respiratory therapist iseffective in improving outcomes associated with
mechanical ventilation, for example, reducing the
number of ventilator days, reintubation rates, and
rates of ventilator-associated pneumonia.19-24,27 How-
ever, additional research is needed to investigate
the degree to which these weaning protocols influ-
ence unplanned extubation, which is a key ventila-
tory outcome not considered in previous studies.
On the basis of the factors identified in the lit-
erature as contributing to unplanned extubation in
patients receiving mechanical ventilation, a concep-
tual framework was created (see Figure). Taggart and
Lind8 suggest that variables influencing unplanned
extubations can be categorized according to whether
they are related to the patient, the structure/environ-
ment, or the process. The specific variables used in
the present study were therefore categorized as such
and are depicted in the Figure. The traditional risk
factors identified in previous research studies encom-
pass the patient variables and structure/environmental
variables that were included in the present study. To
examine how much standardized protocols for pain,
sedation, and weaning affected unplanned extuba-
tion, we classified these variables as MICU process
variables (see Figure).
MethodsDesign
A prospective cohort study design was used to
determine risk factors associated with unplanned
extubation among all patients in the MICU who
were receiving mechanical ventilation and to docu-
ment the degree of compliance with the units seda-
tion, pain management, and weaning protocols.
Data on the presence of risk factors for unplanned
in increased agitation.10A prospective, multicenter
observational study4 showed that a major predis-
posing factor to unplanned extubation was the lack
of intravenous sedation, along with the orotracheal
route for intubation, and a lack of strong tube fixa-
tion. In a separate prospective study,13 researchers
found agitation, common in intensive care units, to
be associated with adverse outcomes including
prolonged ICU stay, nosocomial infections, and
unplanned extubations. Agitation and lack of suffi-cient sedation have repeatedly been identified as
factors contributing to unplanned extubation.3,4,14,15
To address agitation and standardize sedation
management practices among patients receiving
mechanical ventilation, many institutions have
adopted protocols or guidelines for administration
of pain and sedation medications. Implementation
of these protocols has decreased the variability of
the types of medications used, shortened the dura-
tion of mechanical ventilation, and decreased length
Figure Conceptual framework for the study.Abbreviation: MICU, medical intensive care unit.
Unplannedextubation
Variables related to the environment
Type of physical restraintsType of device used to secure tube
Route of intubation
Activities being performed whenunplanned extubation occurs
Variables related to MICU processesand protocols
Compliance with sedation protocolCompliance with pain protocol
Compliance with weaning protocol
Variables related to patients
AgePrimary diagnosis
Secondary diagnosisMedical history
Level of consciousnessRiker score
Results of arterial blood gas analysisLength of stay in the MICUNo. of days intubated
Pain scoreVentilator settings
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extubation were prospectively collected on all patients
consecutively admitted to the MICU who required
mechanical ventilation.
Sample and Setting
The study took place in the MICU at MetroHealth
Medical Center, a large urban teaching hospital inCleveland, Ohio. The MICU is a 13-bed unit that
admits a mean of 1200 patients per year. The sam-
ple comprised all adult patients receiving mechani-
cal ventilation who were admitted to the MICU
from September 1, 2007 to September 1, 2008. A
power analysis indicated that a sample size of 156
would be sufficient for detecting a medium effect
size at 0.80 power.
Procedures
This study was reviewed and approved by the
hospitals institutional review board. All MICUpatients receiving mechanical ventilation were
screened to verify that the inclusion criteria (adult,
cared for under MICU service) were met. Daily data
were gathered on all eligible patients. Data on patient,
environmental, and MICU process/protocol vari-
ables were collected. Patient variables included the
patients age, number of days intubated, primary
and secondary diagnosis, medical history, scores on
Glasgow Coma Scale (GCS), Riker scores (agitation
scale of 1-7, where 1= unarousable and 7 = danger-
ous agitation), results of arterial blood gas analysis,
pain score (recorded once for each 24-hour period,
using the mean score from the preceding 24 hours),
ventilator settings, and MICU length of stay. Envi-
ronmental variables were use of restraints, device
used to secure the endotracheal tube, route of intuba-
tion, and nursing activities. Finally, MICU process/
protocol variables included presence and compli-
ance with sedation, pain, and weaning protocols.
If a patient experienced an unplanned extubation,
additional data were gathered on specific circum-
stances at the time of the unplanned extubation:
time of unplanned extubation, results of arterial
blood gas analysis, ventilator settings, restraints,
device used to secure the endotracheal tube, Rikerscore, presence of protocols for pain, sedation, or
weaning, and whether reintubation was necessary.
The use of protocols for sedation, pain, and
weaning was documented daily. Data were first gath-
ered to determine whether the protocol was ordered
by the physician and were coded as yes/no. To exam-
ine compliance with each protocol, data were then
gathered on the degree to which the protocol was
followed by the nursing staff. Response options were
yes, no, or moderately. If a protocol were ordered
and each step of the protocol followed and docu-
mented within the previous 24 hours, then a yes
answer was recorded. If the protocol were ordered,
but had not been followed by the staff for the preced-
ing 24 hours, a no response was recorded. Finally, if
the protocol were ordered and had
been followed to some degree withinthe preceding 24 hours, but not every
component of the protocol had been
implemented and documented, then
a response of moderately was
recorded by the data collectors.
Data Analysis
All data were analyzed by using
the Statistical Package for the Social
Sciences (SPSS) software, version
15.0 (SPSS Inc, Chicago, Illinois).
Descriptive statistics, includingmeans, frequencies, and standard deviations, were
first calculated. Correlational and logistic regression
analyses were then conducted to identify relation-
ships among study variables and to determine which
factors were predictive of unplanned extubation.
ResultsData were gathered on 190 patients who met
the inclusion criteria. Twenty-nine patients (15%)
experienced unplanned extubation. Most patients
(n = 110, 57.9%) were between the ages of 46 and
75 years and had a diagnosis of respiratory failure
(n = 76, 40%). Table 1 displays the characteristics of
the patients who experienced an
unplanned extubation and those
who did not. Most patients
(72.4%) who experienced an
unplanned extubation were male.
No significant differences were found
between the 2 groups for sex, GCS
or pain scores, use of restraints, or
for the presence of weaning, seda-
tion, and pain protocols. Patients
who had an unplanned extubation
had slightly higher Riker scores(mean [SD], 3.64 [1.136] vs 3.05
[1.142], P= .009), fewer ventilator
days (2.86 [2.371] vs 5.59 [4.508], P< .001), and a
shorter MICU length of stay (5.07 [5.464] vs 9.27
[6.666], P< .001) than did the patients who did not
experience an unplanned extubation.
Risk Factors at the Time of Unplanned Extubation
Additional data were gathered from the 29
patients who experienced unplanned extubation.
The study docu-mented degree
of compliance
with the units
sedation, pain
management,
and weaning
protocols.
Patients who
had an unplanned
extubation had
higher Riker
scores and
shorter intensive
care unit lengthsof stay.
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followed were least likely to experience unplanned
extubation (test statistic = 5.875 [1 degree of free-
dom], P= .02).
Compliance with Protocols
A secondary aim of this study was to examine
the degree of physicians and nurses compliance
with sedation, pain, and weaning protocols for ven-
tilator patients. Physicians compliance with proto-
cols was measured by documenting whether the
protocol was ordered for the patient. Response
options were either yes (protocol was ordered) or
no (protocol was not ordered) for this variable.
Nurses compliance was determined by examining
the degree to which the protocol was followed once
it was ordered, as measured by yes (fully compli-ant), no (not compliant at all), or moderately (fol-
lowed some aspects of the protocol, but not in its
entirety). Physician compliance with ordering the
protocols was fairly high for pain protocols (72%),
but less so for weaning (59%) and sedation (57%).
Full nursing compliance when the protocols were
ordered (ie, protocol was followed in its entirety
when it was ordered by the physician) was highest
for weaning protocols (96%) and moderately high
for pain (80%) and sedation (80%).
Table 2 displays a summary of the risk factors that
were present among these patients at the time of
unplanned extubation. Of the 29 patients who
experienced an unplanned extubation, 26 (89.7%)did not require reintubation. The mean Riker score
at the time of unplanned extubation was 4.04 (range,
3-6; SD, 0.744), which was slightly increased from
the mean Riker score that had been documented
before the unplanned extubation (mean, 3.56; range,
2-6; SD, 0.847).
Results of Regression Analyses: Predictors of
Unplanned Extubation
A series of logistic regression models were cre-
ated to explore the degree to which daily data were
predictive of unplanned extubation. Daily clinicaland ventilator variables were gathered on all patients
and entered into the regression analyses. These vari-
ables included the presence of protocols (weaning,
sedation, and pain), ventilator settings, GCS and
Riker scores, pain scores, and the presence of restraints.
A summary of the regression coefficients for each
variable is provided in Table 3. The only variable
that was significant in predicting unplanned extu-
bation was the presence of weaning protocols.
Patients who had weaning protocols ordered and
.06
.97
.39
.009
.38
.68
.91
.55
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DiscussionFindings from this study contribute information
about risk factors associated with unplanned extuba-
tion and the role of standardized protocols in reduc-
ing rates of unplanned extubation. Our rate of
unplanned extubation (15%) was consistent with
rates reported in the literature, which range from 7%to 18%.1,3-6The percentage of patients in our study
who required reintubation (10.3%), however, was
low; researchers in other studies1-7,11,14,15,28 have
reported reintubation rates of 31% to 78%. This
finding, in conjunction with the fact that those
patients in our study who experienced unplanned
extubation had significantly shorter stays in the
MICU and fewer ventilator days suggests that most
patients who had unplanned extubation were essen-
tially ready to be extubated.
The need for tracheostomy and its effect on
unplanned extubation were not evaluated in thisstudy, as the mean ventilation time for both patients
who did and patients who did not experience
unplanned extubation was less than 5 days, and no
studies were found that linked early tracheostomy
with a lower incidence of unplanned extubation.
In our study, the use of bilateral soft wrist
restraints was common, as evidenced by an 83%
restraint rate in both the patients who experienced
an unplanned extubation and those who did not.
This rate falls within the wide range reported in the
literature (41%-91%) related to unplanned extuba-
tion.29 Per hospital policy, all patients in our study
were on an established restraint protocol, which is
in compliance with regulations from federal and pri-
vate accrediting agencies. These restraint protocols
included the need for a physicians order for restraint
every 24 hours, use of the least restrictive type of
restraint, documentation of restraint alternatives, and
monitoring of restraint use every 2 hours by a regis-
tered nurse. Despite the use of restraints in our study,
unplanned extubations continued to occur, which
is consistent with findings from other studies.5,7,10,11
Quality improvement efforts are currently under way
to examine additional alternatives to use of restraints
in this critical care setting. However, in our study,
the variable of physical restraint use was not a signif-
icant risk factor for unplanned extubation.
Findings from previous studies on the effects of
unplanned extubation yield mixed results. Several
groups have reported that unplanned extubation is
associated with longer stays and duration of mechani-
cal ventilation.1,2,5,7,9 In one study,10 however, researchers
found that patients who had unplanned extubations
had shorter durations of mechanical ventilation and
hospital stays, whereas researchers in another study4
reported no significant differences in duration of
mechanical ventilation when patients who had an
unplanned extubation were compared with patients
who did not. Chevron et al10 concluded, however, that
patients who required reintubation had longer peri-
ods of mechanical ventilation and longer ICU stays.
Table 2
Risk factors at time of unplanned extubation
Risk factor No. (%)
Method of securing tubeCommercial tube holderCloth tapeEndotracheal tube ties
Mechanism of unplanned extubationNot witnessedPatient pulledNursing procedure being performedPatient coughed out tube
Patient tongued out tube
On weaning protocol at unplanned extubationNoYes
On sedation protocol at unplanned extubationNoYes
Pain protocolNoYes
Restrained at unplanned extubationNo restraintsYes, bilateral wrist restraintsYes, wrist and ankle restraints
Require reintubationNoYes
24 (82.8)2 (6.9)3 (10.3)
6 (20.7)17 (58.6)
1 (3.4)4 (13.8)
1 (3.4)
24 (82.8)5 (17.2)
6 (20.7)23 (79.3)
27 (93.1)2 (6.9)
2 (6.9)25 (86.2)
2 (6.9)
26 (89.7)3 (10.3)
Table 3
Logistic regression models: risk factors for unplannedextubation, adjusted for ventilator days
Variable Pt
Weaning protocol ordered and followed
Sedation protocol ordered and followed
Pain protocol ordered and followed
On nonprotocol sedation/pain medications
Score on Glasgow Coma Scale
Riker score
Pain score
Patient restrained
0.661
-0.0809
-0.226
0.123
0.049
0.218
-0.142
0.491
5.875
0.070
0.587
0.109
0.520
1.112
0.252
1.116
.02
.79
.44
.74
.47
.29
.62
.29
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factors, lack of familiarity of resident physicians with
the protocols, physicians personal preference, lack
of nursing support, and fear of oversedation have
been cited as reasons associated with noncompliance
with protocols.18,30,31When examining use of proto-
cols, it has been reported that practitioners working
in larger or university-affiliated ICUs are more likelyto use sedation or pain protocols,32 and protocol use
ranges from 20% to 90%.18,30-33Actual adherence,
however, ranges from 20% to 58%.18The percentage
of the time that protocols were ordered in our study
was consistent with the percentages reported in the
literature; however, our adherence rates were much
higher than those reported in other studies.
The protocols for pain, weaning, and sedation
that were investigated in our study were created col-
laboratively by the nursing, respiratory, and medical
staff and have been in place for several years. The
protocols are to be routinely ordered on all ventila-tor patients; however, findings from this study indi-
cate that physicians compliance with routinely
ordering protocols was low. Protocols are validated
annually by the attending physicians, clinical nurse
specialist, and nurse manager on the basis of current
evidence-based respiratory recommendations for
medical and nursing critical care. Work is currently
underway collaboratively in our MICU with the
attending physician team and nursing staff to ensure
that all physicians (ie, residents, fellows, attendings)
are educated about the importance of these proto-
cols and that quality initiatives are in place to moni-
tor compliance with protocol ordering and use.
Findings from these quality projects will be used to
determine whether future refinement of protocols is
needed, particularly before annual review.
Limitations of this study include the fact that it
was conducted in the MICU of only 1 medical cen-
ter. Thus, findings cannot be widely generalized. In
addition, although this study explored a number of
risk factors for unplanned extubation, several other
variables that were not included in this study may
influence unplanned extubation, such as delirium,
hypoxia, nurse staffing levels, and the method of
endotracheal tube fixation in both groups. Future
studies incorporating these variables may yield addi-
tional information on risk factors. Despite these limi-
tations, findings from this study do contribute to what
is known about factors associated with unplanned
extubation, and the study is one of the first to investi-
gate the role of standardized protocols on unplanned
extubation. Weaning protocols specifically in this
study were feasible and decreased patients risk of
unplanned extubation. Additional research is neces-
sary to substantiate this finding further.
Results of previous studies of unplanned extu-
bation indicate that sedation, agitation, use of phys-
ical restraints, altered level of consciousness, oral
intubation, and method for securing the tube are
linked with the occurrence of unplanned extuba-
tion.5,10,11 However, no studies had
investigated the role of these vari-ables in conjunction with the pres-
ence of standardized protocols (ie,
weaning, sedation, and pain proto-
cols) on unplanned extubation. In
this study, we found that the pres-
ence of weaning protocols was the
strongest predictor of unplanned
extubation: those who had weaning
protocols ordered were least likely to
experience unplanned extubation.
This finding is supported by the fact
that 82.8% of patients who experienced unplannedextubation were not on weaning protocols at the
time of the unplanned extubation.
Results of other studies indicate that the presence
of weaning protocols is associated with positive
outcomes, including a reduction in duration of
mechanical ventilation, rates of ventilator-associated
pneumonia, rates of reintubation, and hospital
costs.19-24,27 Use of these protocols is feasible, as reports
on user compliance are typically high.19,26,27 In our
study, weaning protocols were ordered by a member
of the physician team 59% of the time. However,
nursing compliance with this protocol, once it was
ordered, was very high (96%). Thus, compliance
with protocols was high when the protocols were
medically prescribed.
Compliance of the nursing staff with pain
protocols tended to be high as well (80%). These
protocols were ordered 72% of the time by physi-
cian staff. Although many of the
patients (93%) were not on the pain
protocol at the time of the unplanned
extubation, pain scores recorded at
the time of and before the unplanned
extubation suggest that pain was not
a reason for the unplanned extubation(mean at time of unplanned extuba-
tion, 0.00; SD, 0.000; mean before
unplanned extubation, 0.29; SD,
1.512). In addition, the variable of pain did not prove
to be statistically significant in the bivariate or
regression analyses, which supports this conclusion.
Several studies have investigated reasons why
health care practitioners do not order or comply
with established guidelines for weaning, pain, or
sedation within the ICU setting. Patient-specific
The restraint ratewas the same in
patients who
experienced an
nplanned extuba-
tion and those
who did not.
Weaning proto-
cols decreased
the incidence
of unplannedextubation.
310 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2011, Volume 20, No. 4 www.ajcconline.org by guest on February 2, 2012ajcc.aacnjournals.orgDownloaded from
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ConclusionIn this study, we explored risk factors associated
with unplanned extubation and the role of stan-
dardized protocols among patients in a MICU who
were receiving mechanical ventilation. The sedation,
pain, and weaning protocols in this study were fea-
sible, because compliance was high among healthcare practitioners where protocols were medically
prescribed. Weaning protocols in particular were
associated with a decreased incidence of unplanned
extubation. Only 10.3% of patients who experienced
unplanned extubation in this study required reintu-
bation, which highlights the need to ensure that unit
processes are in place to ensure timely extubation
of patients who indicate readiness. Future quality
improvement initiatives may be effective at explor-
ing the effectiveness of protocol-driven extubations.
Implementation of unit processes in addition to
standardized protocols can have potential impacton patients outcomes and hospital costs.
ACKNOWLEDGMENTSThe authors gratefully acknowledge the nursing staff ofthe medical intensive care unit, who routinely care for intu-bated patients and strive to prevent unplanned extubation.
FINANCIAL DISCLOSURESNone reported.
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CE Test Test ID A1120042: The Role of Standard ized Protocols i n Unplanned Ext ubations in a Medical Intensive Care Unit.Learning objectives: 1. Identify weaning protocols used in assisting planned extubations. 2. Explore types and percentages of unplanned extubations.3. Examine important implications of unplanned extubations for patient care.
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1. Which of the following is a n example of deliberateunplanned extubation?a. Occurs with repositioningb. Occurs during a procedurec. Occurs with coughing
d. Occurs when the patient pulls the tube out
2. The reported rates of unplanned extubations i n most inten-sive care units (ICUs) are which of the followi ng ?a. 2% to 12% c. 9% to 24%b. 7% to 18% d. 13% to 33%
3. Which of the following risks are associated with unplannedextubations?a. Laryngeal collapse, acute respiratory distress syndrome, heart blockb. Bronchospasms, arrhythmias, cardiopulmonary arrestc. Laryngitis, aspiration, septic shockd. Epiglotitis, sick sinus syndrome, pneumonia
4. Which of the following statements is true?a. Postoperative surgical patients are more likely to extubate themselves.b. Nonsmokers are more likely to extubate themselves.c. Patients with agitation are more likely to extubate themselves.d. Patients with pain are more likely to extubate themselves.
5. Which of the following levels of arousal do you expect froma patient with a Riker score of 7?a. Comatoseb. Sedated, rouses to deep painc. Lightly sedated, responds to commandsd. Dangerous agitation
6. Which of the following variables was significant in predictingthe minimal amount of unplanned extubations?a. Sedation protocolb. Pain management protocolc. Nutritional protocold. Weaning protocol
7. Which of the follow ing proto cols was ordered most byphysicians in this study?a. Sedationb. Pain managementc. Nutritional
d. Weaning
8. Which of the following protocols was followed in fullcompliance by nursing staf f ?a. Sedationb. Pain managementc. Nutritionald. Weaning
9. Which of the following statements is tr ue?a. The percentage of required reintubations for this study was 10.3%.b. Findings in this study can be generalized to other medical centers.c. Variables such as delirium and hypoxia play no role in unplanned
extubations.d. Most health care professionals do not order and do not complywith pain protocols.
10. Which of the following statements is true?a. The variable of physical restraint was a significant risk factor for
unplanned extubations in this study.b. The variable of pain control protocol was a significant risk factor
for reducing unplanned extubations in this study.c. The variable of weaning protocol was a significant risk factor for
reducing unplanned extubations in this study.d. The variable of sedation protocol was a significant risk factor for
reducing unplanned extubations in this study.
11. Which of the following patients is most likely to extubate?a. Diabetic smoker with a Riker score of 5b. Nonsmoking cardiac patient with a Riker score 2c. Postoperative cardiac valve patient with a Glasgow score of 6d. Patient with a closed head injury and a Glasgow score of 3
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