Case-control Study on Risk Factors of Unplanned Extubation Based on Patient Safety Model in Critically Ill Patients with Mechanical Ventilation

Decreasing the incidence of delirium via multi-sensory stimulation in patients receiving mechanical ventilation in the intensive care unit: A protocol for a randomized feasibility study

Introduction

Delirium is a common acute brain dysfunction syndrome in patients admitted to intensive care units (ICUs). Family engagement strategies, based on the theory of multi-sensory stimulation to ameliorate sensory deprivation in patients, may be an effective and scalable method to reduce the burden of delirium.

Methods

/design: This is a assessor-blinded, randomised controlled trial of the feasibility of multi-sensory stimulation (MS) in patients with delirium. A total of 72 mechanically ventilated patients (n = 24 in each group) admitted to the ICU will be randomised to routine non-pharmacological delirium care (control), family multi-sensory stimulation and nurse multi-sensory stimulation groups. All participants except the control group will receive multi-sensory stimulation, including visual, auditory, tactile and kinesthetic stimulation, for 5 days. Our primary aim is to determine the feasibility of the study procedure (recruitment, eligibility, retention and attrition rates, appropriateness of clinical outcome measures), feasibility, acceptability and safety of the intervention (adverse events, satisfaction and other). Our secondary objective is to assess the preliminary efficacy of the MS protocol in reducing the incidence, duration and severity of delirium. Sedation levels and delirium severity will be assessed twice daily. Enrolled participants will be followed in hospital until death, discharge or up to 28 days after treatment.

Ethics and dissemination

The current study was approved by the Ethics Review Board of Huazhong University of Science and Technology Union Shenzhen Hospital, China (KY-2023-031-01). The results of this study will be presented at scientific conferences and submitted for publication in peer-reviewed journals.

Trial registration number

ChiCTR2300071457.

Pediatric unplanned extubation risk score: A predictive model for risk assessment

BACKGROUND

Unplanned extubation is one of the most common preventable adverse events associated with invasive mechanical ventilation.

OBJECTIVE

This research study aimed to develop a predictive model to identify the risk of unplanned extubation in a pediatric intensive care unit (PICU).

METHODS

This single-center, observational study was conducted at the PICU of the Hospital de Clínicas. Patients were included based on the following criteria: aged between 28 days and 14 years, intubated, and using invasive mechanical ventilation.

RESULTS

Over 2 years, 2,153 observations were made using the Pediatric Unplanned Extubation Risk Score predictive model. Unplanned extubation occurred in 73 of 2,153 observations. A total of 286 children participated in the application of the Risk Score. This predictive model was created to categorize the following significant risk factors: 1) inadequate placement and fixation of the endotracheal tube (odds ratio 2.00 [95%CI,1.16-3.36]), 2) Insufficient level of sedation (odds ratio 3.00 [95%CI,1.57-4.37]), 3) age ≤ 12 months (odds ratio 1.27 [95%CI,1.14-1.41]), 4) presence of airway hypersecretion (odds ratio 11.00 [95%CI,2,58-45.26]) inadequate family orientation and/or nurse to patient ratio (odds ratio 5.00 [95%CI,2.64-7.99]), and 6) weaning period from mechanical ventilation (odds ratio 3.00 [95%CI,1.67-4.79]) and 5 risk enhancement factors.

CONCLUSIONS

The scoring system demonstrated effective sensitivity for estimating the risk of UE with the observation of six aspects, which overlap as an isolated risk factor or are associated with a risk enhancement factors.

Prevention of unplanned endotracheal extubation in intensive care unit: An overview of systematic reviews

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.

Risk factors for reintubation and mortality among patients who had unplanned extubation

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.

Validation of a Risk Assessment Tool for Unplanned Endotracheal Extubation: An Observational Study

The purpose of this study was to validate and determine the sensitivity and specificity of the risk assessment tool for unplanned endotracheal extubation. Unplanned endotracheal extubation is a common adverse event. The rate of unplanned endotracheal extubation is an indicator to measure patient safety and medical quality. This study was conducted in five intensive care units in a tertiary-A hospital. A total of 227 samples encounters were obtained from 147 unique patients. The content validity was 0.91, and the item content validity ranged from 0.80 to 1.00. Cronbach's α was .58, the interrater reliability was .93. The area under the curve was 0.89 (95% CI [0.84, 0.94], p < 0.01), the sensitivity was 87.80%, and the specificity was 74.20%. This tool presented good reliability and validity and can be used to assess the risk of unplanned endotracheal extubation in patients with artificial airways.

Risk factors of self-extubation in intensive care. Retrospective cohort study

Introduction: Acute respiratory failure remains one of the three leading causes of admission to the intensive care unit (ICU). Self-extubation is an adverse outcome requiring reintubation in 50% of cases. Objective: To assess for determinants (risk factors) of self-extubation and mortality in the ICU by using a generalized estimation equation model (GEE). Methods: The data was collected from a retrospective cohort study from 2017-2020 including all patients admitted to the ICU with mechanical ventilation. Univariate and bivariate analyses were performed. Then, a GEE model was conducted to predict the risk of self-extubation and mortality. Results: A total of 857 subjects were included, with a mean age of 60.5 +/- 17 years-old. Most of the subjects were males (55.2%). An 8.99-fold risk (95%CI 3.83-21.1, p<0.01) of self-extubation was identified in patients with agitation. Exposure to infusion of neuromuscular blockade was also found to increase the risk of self-extubation 3.37 times (95%CI 1.31-8.68, p=0.01). No associations were identified between immobilization and self-extubation (OR 1.38 95%CI 0.76-2.51, p=0.29). Finally, light sedation according to the Richmond Sedation Scale (RASS) between 0 to -2 rather than moderate (RASS-3) reduces the risk of mortality (OR 0.57, 95%CI 0.38-0.83, p<0.01). Conclusions: The main factors resulting in self-extubation were: agitation, delirium, and infusion of neuromuscular blocking agents. An association was found between light sedation and a lower risk of mortality. No association was found between the use of physical restraint and the desired outcome.

Magnitude and associated factors of unplanned extubation in intensive care unit: A multi-center prospective observational study

Background

Unplanned extubation is the removal of an endotracheal tube accidently during procedural activities or by the action of the patient. It is one of the commonly reported complications among mechanically ventilated patients in the intensive care unit. This study aimed to assess the magnitude and associated factors of unplanned extubation in intensive care units at referral hospitals in Addis Ababa, Ethiopia, 2021.

Methods

Institutional based prospective observational study was conducted on 317 intubated patients in the intensive care unit at referral hospitals of Addis Ababa, Ethiopia, from January 8, 2021–May 9, 2021. Data were collected using a structured questionnaire. Descriptive statics were expressed in percentages and presented with tables and figures. Both Bivariable and multivariable logistic analysis was done to identify factors associated with unplanned extubation in intensive care unit. P < 0.05 with 95% CI was set as Statistical significance.

Result

The prevalence of unplanned extubation in this study was 19.74%. Being male (AOR = 3.132, 95%CI: 1.276–7.69), duration of intubation <5days (AOR = 2.475, 95% CI: 1.039–5.894), managed by junior resident (AOR = 5.25, 95% CI: 2.125–12.969), being physically restrained (AOR = 4.356, 95%CI: 1.786–10.624), night shift (AOR = 3.282, 95%CI:1.451–7.424)and agitation (AOR = 4.934,95%CI:1.934–12.586) were significantly contribute to the occurrence of unplanned extubation.

Conclusion

and recommendation: This study showed that the prevalence of unplanned extubation was high in the intensive care unit. We suggest to intensive care unit staff to give special attention to early intubated patients, especially male individuals and the stakeholders of hospitals should rearrange the time of shift and physician schedules in the intensive care unit.

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Magnitude of unplanned extubation was high in the intensive care unit.

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Duration of intubation less than 5 days was significantly associated.

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Give special attention to early intubated patients and rearrange the time of shift.

The impact of two distinct endotracheal tube fixation on the formation of pressure ulcer in the intensive care unit: A randomised controlled trial

The most common pressure ulcer associated with medical devices in the ICU is pressure injury associated with the endotracheal tube. We aimed to scrutinise the effects of two different techniques of endotracheal tube securement used in the ICU on the occurrence of pressure ulcers. This randomised clinical trial was conducted in 60 patients, 30 of which were intervention and 30 experimental, admittedin the ICU of a training and research hospitaldata were collected using the descriptive and clinical characteristics from the Braden Scale for predicting Pressure Sore Risk, the Pressure Ulcer Scale for healing, The International Staging System for Pressure Injuries and the Eilers Oral Assessment Guide. Based on the Braden Scale scores of the patients, we found that 98.3% of the cases were in the high‐risk group before and after the intervention. We also found that the recovery was higher among patients in whom the bandage fixation method was applied compared to those in whom the fixation was done with an endotracheal tube holder.

Design of assessment tool for unplanned endotracheal extubation of artificial airway patients

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.

Incidence, risk factors, and outcomes of unplanned extubation in adult patients in a resource-limited teaching hospital in the Philippines: a cohort study

OBJECTIVE

We aimed to determine the incidence, risk factors, and outcomes of unplanned extubation among adult patients.

METHODS

We conducted a prospective cohort study of adult intubated patients admitted to the charity wards of a government tertiary teaching hospital in the Philippines. Patients managed in both intensive care and nonintensive care settings were included. Patients were followed-up until discharge or until seven days postextubation.

RESULTS

The outcomes of the 191 included patients were planned extubation (35%), unplanned extubation (19%), death (39%), and discharge against advice (7%). Competing risk regression showed that male sex (Crude OR: 2.25, 95%CI: 1.10 - 4.63) and age (Crude OR 0.976, 95%CI: 0.957 - 0.996) were significant baseline factors. The night shift (Crude OR: 24.6, 95%CI: 2.87 - 211) was also consistently associated with more unplanned extubations. Among postextubation outcomes, reintubation (unplanned extubation: 61.1% versus planned extubation: 25.4%), acute respiratory failure (unplanned extubation: 38.9% versus planned extubation: 17.5%), and cardiovascular events (unplanned extubation: 8.33% versus planned extubation: 1.49%) occurred significantly more often among the unplanned extubation patients. Admission in an intensive care unit was not associated with a lower risk of unplanned extubation (Crude OR 1.15, 95%CI: 0.594 - 2.21).

CONCLUSION

Many intubated patients had unplanned extubation. Patients admitted in nonintensive care unit settings did not have significantly higher odds of unplanned extubation.

Unplanned extubations in an intensive care unit: Findings from a critical incident technique

BACKGROUND

Patients on mechanical ventilation are at risk of experiencing a potentially life-threatening unplanned extubation in the intensive care unit, which can lead to arrhythmias, bronchial aspiration, difficulty in reintubation or even sudden cardiac arrest. Although incidence and outcomes of the phenomenon have been documented in several quantitative studies, no studies have investigated the antecedents as experienced by critical care nurses.

OBJECTIVES

To gain a greater understanding of the antecedents of unplanned extubations.

METHODS

A qualitative study design involving the critical-incident technique. A total of 10 registered nurses who reported one or more episodes of unplanned extubations were involved in an in-depth interview.

FINDINGS

According to the nurses' experience, episodes of unplanned extubations are determined by predisposing, precipitating and mediating factors. The predisposing factors have been recognised in the (a) weaning programme (expected/unexpected decreased sedation) and in the (b) patient factors (increased needs due to discomfort, restlessness and desire to communicate). The precipitating factors have been divided into (a) organisational (failures in multi-professional communication), (b) environmental (excessive environmental chaos and barriers preventing direct surveillance) and (c) nursing care factors (ensuring privacy by creating barriers, avoiding disturbing other patients and poor nurse-to-patient ratio). Among the mediating factors, which are affected by the precipitating factors, decreased surveillance and mechanical restraints' use have been identified.

CONCLUSION

Identifying risk factors of unplanned extubation, specifically those that are modifiable, such as increasing interprofessional communication, reducing excessive environment chaos, implementing strategies aimed at overcoming barriers threatening direct surveillance and ensuring appropriate nurse-to-patient ratio, can prevent the occurrence of these events.

Unplanned extubations in general intensive care unit: A nine-year retrospective analysis

Background and aim: Unplanned extubation (UE) in Intensive Care Units (ICU) is an indicator of quality and safety of care. UEs are classified in: accidental extubations, if involuntarily caused during nursing care or medical procedures; self-extubation, if determined by the patient him/herself. In scientific literature, the cumulative incidence of UEs varies from 0.3% to 35.8%. The aim of this study is to explore the incidence of UEs in an Italian university general ICU adopting a well-established protocol of tracheal tube nursing management and fixation. Methods: retrospective observational study. We enrolled all patients undergone to invasive mechanical ventilation from 1^st January 2008 to 31^st December 2016. Results: in the studied period 3422 patients underwent to endotracheal intubation. The UEs were 35: 33 self extubations (94%) and 2 accidental extubations (6%). The incidence of UEs calculated on 1497 patients intubated for more than 24 hours was 2.34%. Instead, it was 1.02%, if we consider the whole number of intubated patients. Only in 9 (26%) cases out of 35 UEs the patient was re-intubated. No deaths consequent to UE were recorded. Conclusions: The incidence of UEs in this study showed rates according to the minimal values reported in scientific literature. A standardized program of endotracheal tube management (based on an effective and comfortable fixing system) seems to be a safe and a valid foundation in order to maintain the UE episodes at minimum rates.

Unplanned Extubations in Intensive Care Unit: evidences for risk factors. A literature review

Background and aim: Unplanned extubations (UE) are getting more and more relevant in Critical Care, becoming a quality and care safeness outcome. This happens because after an UE the patient can face some complications concerning the airway management, respiratory and hemodynamic problems, lengthen in the hospital stay and in the mechanical ventilation time. The aim of this review is identify and classify the factors that could increase UE risk. Methodology: A systematic review of scientific articles was performed consulting the databases PubMed, Cinahl, Medline, EBSCOhost and Google Scholar. Articles from 2006 to 2011 were included. Pediatric Care settings were excluded. Results: 21 articles were selected. From the results emerged that risk factors associated to the patient are widely controversial. Yet restlessness, a low level of sedation and a high level of consciousness seem to be highly related to UE. Organizational risk factors, as workload, nurse:patient ratio, and the use of interdisciplinary protocols seem to play an important role in UE. Conclusion: According the current literature, the research on UE still has to handle a wide uncertainty. There is the need for more studies developing conclusive evidences on the role of different risk factors. Anyway, literature highlights the importance of the nurse and of the healthcare system organization in reducing UE incidence.