Unplanned extubation of patients in ICU 

Eunok Kwon, RN, PhD Nursing Director of Operating room, Seoul national University Hospital, South Korea

10th International Congress of World Federation of Critical Care Nurses, Antalya, Turkey , November 12~ 15th 2014.

Safety Issues in ICU• More than 5 million patients are admitted to intensive

care units each year in the United States.• Mortality rates in patients admitted to the ICU average

10% to 20% in most hospitals.• Overall, approximately 200,000 patients die in U.S.ICU

each year.

Safety issues in ICUClassification of incidents used in the Australian AIMS

• Airway and ventilation: e.g. unplanned extubation and disconnections.

• Drugs and medications: e.g. allergic reactions and drug errors.

• Procedures, equipment and catheters: e.g. inadvertent carotid artery cannulation.

• Patient environment: e.g. a lack of appropriate beds causing pressure sores.

• ICU management: e.g. incidents caused by an over reliance on agency staff.

Patient’s outcome indicators in ICU( European Society of Intensive Care Medicine)

Domain Description Consensus (%)

Structure Intensive Care Unit (ICU) fulfills national requirements to provide Intensive Care.

100

24-h availability of a consultant level Intensivist 94

Adverse event reporting system 100

Process Presence of routine multi-disciplinary clinical ward rounds 100

Standardized Handover procedure for discharging patients 100

The maintenance of continuing medical education according to national standards

77

The maintenance of bed occupancy rates below a threshold level. 82

Outcome Reporting and analysis of standardized mortality ratio (SMR) 100

ICU re-admission rate within 48 h of ICU discharge  94

The rate of central venous catheter-related blood stream infection

100

The rate of unplanned endotracheal extubations 100

The endotracheal re-intubation rate within 48 h of a planned  extubation

77

The rate of ventilator-associated pneumonia 77

Factors related to safety issues in ICU

INTENSIVE CARE SOCIETY STANDARDS © 2005

Therapeutic catheters in ICU

• Types of catheters;

Foley catheter(75%), Central venous

catheter(64%), Endotracheal catheter (62%),

Arterial line(44%) Chest tibe(14%)

• 1995,European Prevalence of Infection in

Intensive Care (EPIC) study; Catheter related

infection & hospital acquired infection,

Unplanned extubation results in fetal patient’s

outcome.

Accidental removal of catheter threatens patient’s safety

Importance of management catheters

• Complication of accidental removal of catheters

• Intraventricular brain drainage ; hydrocephalus

• Cardiac surgical drainage; cardiac tamponade

• Subclavian or jugular venous catheter reinsertion;

pneumothorax and/or hemothorax.

• Endotracheal reintubation ; nosocomial pneumonia,

• New drains reinsertion; hemorrhage or nosocomial

infection.

Prevention of Unplanned extubation in ICU

Unplanned endotracheal extubations in ICU

Unplanned extubation rate; 0.1~3.6/100 intubation days. Risk factors; male gender, APACHE score≥ 17(OR9.0), COPD,

restlessness/agitation(OR3.3-30.6), lower sedation level(OR2.0-5.4), Higher consciousness level(OR 1.4-2.0), Use of physical restrains (OR3.1). Reintubation rates 1.8-88% of unplanned extubation. Preventive measures; Standardization of procedures, staff education, staff surveillance & identification &

management of high risk patients - decreasing rate; 22~53%

Best methods; securing E tube & use of Physical restraints ??

Anesth Analg.2012 may;114(5);1003-14,Epub 2012 feb 24. Silva PS Analysis 1950 yr~2011yr 50articles

Nurse staffing factors related patient outcomes in ICU

• 28 research RN-to patient ratio vs patient outcome odds ratio

• RN staffing ratio vs ICU mortality OR 0.91(95%Cl)0.86-0.96 surgical 0.84 medical 0.94

• Increase by 1RN per patient day decreased VAP OR 0.7(95%Cl 0.56-0.88) unplanned extubation (OR,0.49;95%Cl),respiratory failure(0.40;95%Cl), cardiac arrest in ICU(OR 0.72;95%Cl),lower risk of failure to rescue in surgical patients(OR0.84;95%Cl), Length of stay was shorter by 24% in ICUs(OR 0.76;95Cl)& 31% in surgical patients(OR,0.69;95%Cl)

• The association of registered nurse staffing levels and patient oucomes;Med care.2007 Dec;45(12)1195-204 Kane RL et al

Safety model related to unplanned extubation in ICU ; SEIPS model(Carayon et al.2006)

Introduction- Critical care unit in SNUH

MICU22 bed

SICU1 18bed

CPICU8 bed

CCU8 bed

SICU2 14bed

EICU12 bed

Adult ICU; 70 bed

NICU40bed

PICU20bed

1821 total hospital beds, 154 ICU Beds

Emergency center

Children’s Hospital

Nurse Staffing

Nurse to patient ratio= 1:2Nurse to patient ratio= 1:2

Case; SNUH adult ICU• A case-control study over 3 years period from

January 1,2010 through December 31,2012.• A 62-beds medical & surgical intensive care unit

of 1800 beds tertiary hospital

Unplanned VS planned extubation Patients

• Data were retrospectively collected from electronic medical records.

• A total 230 episodes of deliberate unplanned extubation in 242 patients from 41,207 mechanically ventilated patients for 3 years(frequency 0.53%).

• 460 episodes in 460 patients with planned extubation age, gender & diagnosis-matched controls were analyzed in this case-control study.

Predictors related to unplanned extubation in SNUH cases

Predictors associated with unplanned extubation include •Better motor response (OR 1.3),•Admission route via ER(OR 1.8),•Higher APACHE Ⅱscore(1.061),•Mode of mechanical ventilation (CPAP, PSV: OR4.1, SIMV:3.0), •Peripheral O2 saturation(OR:0.9), heart rate(OR: 1.0), respiration rate(OR:1.0)

Predictors related to unplanned extubation in SNUH cases

• Pain (OR:0.3), • Agitation(OR:9.0),• Delirium(OR:11.6), • Night shift(OR:6.0) &morning care

time(OR:0.5).

Predictors related to unplanned extubation in SNUH cases

The patients’ & organizational outcomes of unplanned extubation were •Reintubation(OR;85.66)•Poor discharge result(OR:0.2)•Longer length of stay in the ICU (adj R-square:7%)and a longer length of stay in the hospital(adj R-square:4.3%).

High predictive factors of unplanned extubation in SNUH cases

• Delirium, agitation, ventilation mode and night shift are high predictive factors of unplanned extubation.

• The outcomes of unplanned extubation were  increasing reintubation, a poor patient outcome at the time of discharge and poor organizational outcome including longer length of stay in the ICU and hospital.

SICU

Safety issues of Adult ICU patients in SNUH

PAD concept of SNUH ICU

DeliriumDelirium

Failure of Failure of weaning weaning ventilatorventilator

Increased Increased mortality & mortality &

medical medical costcost

Low Low satisfaction satisfaction of caregiverof caregiver

Increased Increased length of length of

staystay

Delirium management in SNUH ICU

PAD management in SNUH ICU

Delirium management Delirium management protocol for high risk protocol for high risk

group of deliriumgroup of delirium

Delirium management Delirium management protocol for high risk protocol for high risk

group of deliriumgroup of delirium

High risk group?High risk group?Age>65

Visual acuity defect, hearing

disturbanceCognitive function

impairmentRestraint

High risk group?High risk group?Age>65

Visual acuity defect, hearing

disturbanceCognitive function

impairmentRestraint

Delirium Delirium management management

protocol protocol

Delirium Delirium management management

protocol protocol

2012 ICU QA outcome indicator

Accidental catheter removal

rate,Delirium incidence.

Establishing monitoring system of Delirium in Adult ICU; CAM ICU

ACR, Delirium occurrence ACR, Delirium occurrence rate 2012yrrate 2012yr

(1.4%)(1.4%)

(1.2%)(1.2%)

2013 PAD care bundle of ICU in SNUH

iPAD(ICU Pain, Agitation, Delirium) Care Bundle

PAIN AGITATION DELIRIUM

ASSESS

Assess pain ≥ 2/shiftPatient able to self-report → NRS (0-10)Unable to self-report → CNPS (0-9)

Assess agitation, sedation ≥ 2/shiftRASS (-5 to +4)

Assess delirium Q shiftCAM-ICU (+ or -)Delirium present if CAM-ICU is positive

TREAT

Treat pain with analgesia therapy

Targeted sedation: RASS -2 to 0(light sedation)Treat with sedatives for light sedation

Treat patients with nursing intervention: •Reorient patients•Use patient`s eyeglasses, hearing aids•Familiarize surroundings

Crit ical Care Nonverbal Pain Scale 

i tem tip scoreday

time

1

Facial

expressio

n

Natural expression 0

tears 1  

Painful expression 2  

Biting endotracheal tube 3  

2Physical

response

No movement, relax 0  

Slow motion 1  

Nodding, try to touch painful site 2  

Severe movement 3  

3

Synchrony with

ventilator(intubate

d patients)

No alarm sound,no cough 0  

Intermittent alarm, cough, 1  

Frequent alarm, hyperventilation 2  

Asynchrony with ventilator, consistent cough 3  

Voice

sound

(extubate

d

patients)

normal 0  

moaning 1  

Express about pain 2  

Loud voice, Cry, aggressive 3  

sum  

Indication: The patient can’t report by self due to consciousness change, sedation, artificial airway,

mechanical ventilation

Assess: 2 fr ≥ duty, ASSESS

intervention: 3 score ≥ CNPS, give pain killer.

reevaluation:

Pain scale in SNUH ICU

Pain scale in SNUH ICU

Education based on simulation about unplanned extubation

Simulation training related to unplanned extubation

I see you in ICUSafety based nursing

A nurse will always give us hope, an angel with a stethoscope.~Terri Guillemets

References• A. Rhodes, R. P. Moreno, E. Azoulay, M. Capuzzo, J. D. Chiche, J. Eddleston. et

al(2012). Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM), Intensive Care Med 38, 598–605.

• Atkins, P. M., Mion, L. C., Mendelson, W., Palmer, R. M., Slomka, J., & Franko, T.(1997). Characteristics and outcomes of patients who selfextubate from ventilatory support: A case- control study. Chest, 112(5),1317–1323.

• Curry, K., Cobb, S., Kutash, M., & Diggs, C(2008). Characteristics associated with unplanned extubations in a surgical intensive care unit. American Journal of Critical Care, 17(1), 45–51

• Da Silva, Lucas, Fonseca & Machado(2012). Unplanned extubation in the intensive Care unit: systematic review, Critical Appraisal, and Evidence-Based recommendations. Anesthesia & Analgesia, 114(5), 1003-1014.

• Juliana Barr, et al(2013). Clinical Practice Guidelines for the Ma- nagement of pain, Agitation, and Delirium in Adult Patients in the intensive care unit. Critical care medicine 41(1), 263-306.

• L-C Chang, P-F Liu, Y-L Huang, S-S Yang,W-Y Chang(2011). Risk factors associated with unplanned endotracheal self extubation of hospitalized intubated patients: a 3-year re- trospective case-control study. Applied Nursing Research 24, 188–192.

• Mary Jarachovic, Maggie Mason, Kathleen Kerber & Molly McNett (2011). The role of standardized protocols in unplanned extubations in a medical intensive care unit. Am J Crit Care. 20, 304-312.

Thank you !! eunokkwon@nate.com