SELF-EXTUBATIONS IN THE ICU: A REVIEW OF TIME OF DAY AS A POTENTIAL RISK

Abstract

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Self-extubation is an uncommon but real phenomenon occurring in ICUs with harmful and potentially fatal implications. Understanding the surrounding variables and mechanisms at play that put an intubated patient at risk for these events is vital to prevent future unplanned extubations. This study was undertaken to identify the factors placing patients at greatest risk of self-extubation and later need for reintubation, namely time of day. METHODS: 55 patients (62% male) with a mean age of 50 were identified across 5 ICUs and 118 ICU beds from a tertiary medical center in Dallas, TX were identified to have self-extubated from 2019 to 2020. A retrospective cohort review of all unplanned extubations was performed. Patient data was organized into two-by-two contingency tables and analyzed using Fisher’s Exact Test. RESULTS: Neither age nor gender were statistically significant predictors for reintubation after self-extubation (p=0.21 and p=0.61, respectively). 24 self-extubations occurred during the day shift (7am-7pm) and 31 occurred during the night shift (7pm-7am). It was statistically more likely for patients to require reintubation during the night shift (p=0.042). Self-extubation at shift change (6am-8am or 6pm-8pm) was not a statistically significant predictor of need for reintubation (p=0.218). CONCLUSIONS: Patients who self-extubated during night shift were more likely to require reintubation than those during day shift. Despite adequate handoff from providers and other staff, cross-cover night teams may be less familiar with the patients and a lack of multidisciplinary rounding at night may lead to more conservative management and more frequent reintubation. Less frequent physician rounding during night shift also may mean that patients are self-extubating because planned extubations are less likely to occur overnight and physicians are less likely to evaluate a patient unless alerted to a change in clinical status. Additionally, if the primary team is considering a next day extubation, sedation holidays at night may play a role in increasing self-extubation. Ultimately, multiple factors contribute and further research into medications administered, respiratory plan of care, and patient specific factors may be able to identify risk factors for overnight self-extubation. CLINICAL IMPLICATIONS: By attempting to understand why patients are self-extubating we will be able to better care for our ventilated patients and ensure that they are safe while in our care. Patients self-extubating during the night shift are requiring reintubation at a higher rate, indicating potential room for improvement in our ICUs, whether this be in nursing education of the team’s plan, making sure our nursing staff has adequate training and experience to handle ventilated patients, or creating a plan that involves more frequent rounding on patients by physicians and respiratory therapists during the night shift. DISCLOSURES: No relevant relationships by Maythawee Bintvihok, source=Web Response No relevant relationships by Jessica Kent, source=Web Response No relevant relationships by Denizen Kocak, source=Web Response No relevant relationships by Adan (Adam) Mora, source=Web Response No relevant relationships by Jiesu Sun, source=Web Response No relevant relationships by Ciara Wisecup, source=Web Response