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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: [email protected]).

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.



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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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Unplanned extubation in orally intubated medical patientsin the intensive care unit: a prospective cohort study. HeartLung. 2007;36(4):270-276.

3. Mion LC, Minnick AF, Leipzig RM, Catrambone CD, JohnsonME. Patient-initiated device removal in intensive care units:a national prevalence study. Crit Care Med. 2007;35(12):2714-2720.

4. Boulain T. Unplanned extubations in the adult intensive careunit: a prospective multi-center study. Am J Respir CritCare Med. 1998;157:1131-1137.

5. Chang LY, Wang KK, Chao, YF. Influence of physical restraint

on unplanned extubation of adult intensive care patients: acase-control study. Am J Crit Care. 2008;17:408-415.6. Coppolo DP, May JJ. Self-extubations: a 12-month experi-

ence. Chest. 1990;98:165-169.7. Atkins PM, Mion LC, Mendelson W, et al. Characteristics

and outcomes of patients who self-extubate from ventilatorysupport: a case control study. Chest. 1997;112:1317-1323.

8. Taggart J, Lind, M. Evaluating unplanned endotrachealextubations. Dimens Crit Care Nurs. 1994;13:114-120.

9. Epstein SK, Nevins ML, Chung J. Effect of unplanned extu-bation on outcome of mechanical ventilation. Am J RespirCrit Care Med. 2000;161:1912-1916.

10. Chevron VM, Menard JF, Richard JC, et al. Unplanned extu-bation: risk factors of development and predictive criteriafor reintubation. Crit Care Med. 1998;26:1049-1053.

11. Tindol GA, Dibenedetto RJ, Kosciuk L. Unplanned extuba-tions. Chest. 1994;105:1804-1807.

12. Maguire GP DeLorenzo LJ, Moggio RA. Unplanned extubationin the intensive care unit: a quality of care concern. Crit CareNurs Q. 1994;17:40-47.

13. Jaber S, Chanques G, Altairac C, et al. A prospective study ofagitation in a medical-surgical ICU: incidence, risk factors, andoutcomes. Chest. 2005;128:2749-2757.

14. Curry K, Cobb S, Kutash M, Diggs C. Characteristics associ-ated with unplanned extubations in a surgical intensive careunit. Am J Crit Care. 2008;17(1):45-51.

15. Balon J. Common factors of spontaneous self-extubation in acritical care setting. Int J Trauma Nurs. 2001;7:93-99.

16. MacLaren R, Plamondon JM, Ramsay KB, Rocker GM, Ward DP,Hall RJ. A prospective evaluation of empiric versus protocol-based sedation and analgesia. Pharmacotherapy. 2000;20(6):662-672.

17. Brook AD, Ahrens RS, Schaiff R, Prenice D, Sherman G, Shan-non W, Kollef MH. Effect of a nursing-implemented sedationprotocol on the duration of mechanical ventilation. Crit CareMed. 1999;27(12):2609-2615.

18. Bair N, Bobek M, Hoffman-Hogg L, Mion LC, Slomka J,Arroliga A. Introduction of sedative, analgesic, and neuro-muscular blocking agent guidelines in a medical intensivecare unit: physician and nurse adherence. Crit Care Med.2000;28(3):707-713.

19. Grap MJ, Strickland D, Tormey L, et al. Collaborative Practice:Development, implementation, and evaluation of a weaningprotocol for patients receiving mechanical ventilation. Am JCrit Care. 2003;12:454-460.

20. Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M.Protocol weaning of mechanical ventilation in medical andsurgical patients by respiratory care practitioners and nurses:effect on weaning time and incidence of ventilator-associatedpneumonia. Chest. 2001;118:459-467.

21. Ely EW, Baker AM, Dunagan DP, et al. Effect on the durationof mechanical ventilation of identifying patients capable ofbreathing spontaneously. N Engl J Med. 1996;335:1864-1869.

22. Kollef MH, Shapiro SD, Silver P, et al. A randomized controlledtrial of protocol-directed versus physician-directed weaningfrom mechanical ventilation. Crit Care Med. 1997;25:567-574.

23. Strickland JH, Hasson JH. A computer-controlled ventilatorweaning system. Chest. 1993;103:1220-1226.

24. Duane TM, Riblet JL, Golay D, Cole FJ, Weireter LJ, Britt LD.Protocol-driven ventilator management in a trauma intensivecare unit population. Arch Surg. 2002;137:1223-1227.

25. Krishnan JA, Moore D, Robeson C, et al. A prospective, con-trolled trial of a protocol-based strategy to discontinue mechan-

ical ventilation. Am J Respir Crit Care Med. 2004;169:673-678.

26. Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM,Haponik EF. Large scale implementation of a respiratory ther-apist-driven protocol for ventilator weaning. Am J Respir CritCare Med. 1999;159:439-446.

27. McLean SE, Jensen LA, Schroeder DG, Gibney NR, SkjodtNM. Improving adherence to a mechanical ventilation wean-ing protocol for critically ill adults: outcomes after an imple-mentation program. Am J Crit Care. 2006;15:299-309.

28. Whelan J, Simpson SQ, Levy H. Unplanned extubation: pre-dictors of successful termination of mechanical ventilatorysupport. Chest. 1994;105:1808-1812.

29. Happ MB. Treatment interference in acutely and critically illadults. Am J Crit Care. 1998;7:224-235.

30. Slomka J, Hoffman-Hogg L, Mion LC, Bair N, Bobek M,Arroliga AC. Influence of clinicians values and perceptions onuse of clinical practice guidelines for sedation and neuromus-

cular blockade in patients receiving mechanical ventilation.Am J Crit Care. 2000;9:412-418.31. Tanios MA, Wit M, Epstein SK, Devlin JW. Perceived barriers to

use of sedation protocols and daily sedation interruption: amultidisciplinary survey. J Crit Care. 2009;24:66-73.

32. Mehta S, Burry L, Fischer S, et al. Canadian survey of the use ofsedatives, analgesics, and neuromuscular blocking agents incritically ill patients. Crit Care Med. 2006;34:374-380.

33. Patel RP, Gambrell M, Speroff T, et al. Delirium and sedation inthe intensive care unit: survey of behaviors and attitudes of1384 healthcare professionals. Crit Care Med. 2009;37:825-832.

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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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it took me hours/minutes.

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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Fee: AACN members, $0; nonmembers, $10 Passing score: 8 Correct (73%) Synergy CERP Category: A Test writer: Jane Baron, RN, CS, ACNP

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACNprogramming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

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