Incidence Of Unplanned Extubation Research Articles

Implementation Strategies Used to Reduce UEs in the Neonatal Intensive Care Unit.

Unplanned extubation (UE) is the premature or unintended removal of an artificial airway and can cause worse patient outcomes. Study objectives were to describe implementation strategies used to reduce UE in the Hospital for Sick Children neonatal ICU (NICU) and their influence on UE rates, and contributing factors and patient characteristics of infants who had an UE, and compare them between the biological sexes. We hypothesized that the boys would experience more UEs and worse outcomes compared to the girls. The single-center retrospective cohort study included all infants who experienced UE (2007-2019). Outcomes consisted of implementation reduction strategies developed by using the plan-do-study-act quality-improvement methodology and UE characteristics, including patient (eg, sex, length of stay) and unplanned extubation situation characteristics (eg, events and/or procedures, repeats). Five plan-do-study-act cycles were implemented. Analyses included text summaries of all strategies, and quantitative descriptive and comparative statistics. UE per 100 ventilator days decreased from 3.46 to 0.14. Key success factors included setting achievable goals; ensuring that strategies were evaluated and amended; maintaining consistency over the long-term; incorporating strategies in the NICU; having institutional support and validation; and having good communication. There were 302 UE in 257 infants, 141 boys (55%), average ± SD gestational age of 31 ± 6 weeks, and 31 (12%) had 45 repeated UEs. The only significant difference between the biological sexes was that more boys (129 [92%]) versus girls (94 [83%]) received the Hospital for Sick Children NICU endotracheal tube taping protocol (P = .030). The incidence of UE occurred in a 2-peaked pattern, highest for those < 32 weeks and ≥ 32 weeks of gestational age. Infants < 32 weeks of gestational age and with repeated UE had longer durations of invasive mechanical ventilation and length of stay. For infants <32 versus => 32 weeks gestational age, the median (interquartile range) duration of mechanical ventilation was 38 (16-77) d versus 6 (3-13) d and hospital length of stay 61 (30-100) d versus 16 (10-41) d. For infants with repeated versus no repeated unplanned extubations, duration of mechanical ventilation was 69 (26-125) d versus 13 (4-52) d and hospital length of stay 90 (39-137) d versus 32 (12-75) d. Detailed well-planned UE reduction strategies significantly reduced the rate of UEs with key factors of success identified. UE characteristics and infant morbidity did not differ between the biological sexes. Infants < 32 weeks of gestational age and with repeated UE had a longer duration of mechanical ventilation and length of stay.

Prospective multi-center evaluation of the incidence of unplanned extubation and its outcomes in French intensive care units. The Safe-ICU study

BackgroundWe aimed to determine the epidemiology and outcomes of unplanned extubation (UE), both accidental and self-extubation, in ICU. MethodsA multicentre prospective cohort study was conducted in 47 French ICUs. The number of mechanical ventilation (MV) days, and planned and unplanned extubation were recorded in each center over a minimum period of three consecutive months to evaluate UE incidence. Patient characteristics, UE environmental factors, and outcomes were compared based on the UE mechanism (accidental or self-extubation). Self-extubation outcomes were compared with planned extubation using a propensity-matched population. Finally, risk factors for extubation failure (re-intubation before day 7) were determined following self-extubation. ResultsDuring the 12-month inclusion period, we found a pooled UE incidence of 1.0 per 100 MV days. UE accounted for 9% of all endotracheal removals. Of the 605 UE, 88% were self-extubation and 12% were accidental-extubations. The latter had a worse prognosis than self-extubation (34% vs. 8% ICU-mortality, p < 0.001). Self-extubation did not increase mortality compared with planned extubation (8% vs. 11%, p = 0.075). Regardless of the type of extubation, planned or unplanned, extubation failure was independently associated with a poor outcome. Cancer, higher respiratory rate, lower PaO2/FiO2 at the time of extubation, weaning process not-ongoing, and immediate post-extubation respiratory failure were independent predictors of failed self-extubation. ConclusionUnplanned extubation, mostly represented by self-extubation, is common in ICU and accounts for 9% of all endotracheal extubations. While accidental extubations are a serious and infrequent adverse event, self-extubation does not increase mortality compared to planned extubation.

Design and application of small-diameter closed thoracic drainage tube fixation following lung wedge resection: A randomised prospective study.

The use of indwelling closed thoracic drainage tubes in the wedge resection of the lungs is of great significance to postoperative recovery. However, there are potential risks. To explore the design feasibility and application effect of triple-buffer-system-fixed small-diameter (18 F) thoracic closed drainage tubes following lung wedge resection. A total of 136 patients with indwelling thoracic drainage tubes following pulmonary wedge resection were recruited, with 70 patients allocated to the control group and 66 to the experimental group. The drainage tube in the experimental group was fixed with the triple-buffer system, while that in the control group was fixed using the conventional lifting platform method. The incidence of unplanned extubation, the indwelling time of the drainage tube and the time and material costs, as well as information regarding any subcutaneous emphysema and skin tension blisters, were recorded following the operation. The pain and degree of comfort were assessed using a chi-square test and a rank sum t-test to compare the differences between the two groups. There were no statistically significant differences in terms of age, gender and sweating between the two groups. Compared with the control group, the unplanned extubation rate of the experimental group was lower (χ2= 8.513; P= 0.004), the indwelling time of the drainage tube was shorter (t= 2.108; P= 0.037), the cumulative material cost was lower (t= 3.778; P< 0.001), the time cost was also lower (Z= 2.717; P= 0.008), the degree of comfort was higher (Z= 2.752; P= 0.006), and the degree of pain was lower (Z= 4.019; P< 0.001). The incidence of subcutaneous emphysema was significantly lower in the experimental group than in the control group (χ2= 8.513; P= 0.004). The use of the triple-buffer system to fix small-diameter (18 F) thoracic closed drainage tubes can reduce the unplanned extubation rate, indwelling time of the drainage tube and the incidence of adverse reactions.

Unplanned extubation in intensive care pediatric patients — status of the problem: A literature review

Unplanned extubation is any removal of an endotracheal tube from the airway during mechanical ventilation that is not planned, premeditated, or controlled. The frequency of unplanned extubation is one of the most important indicators of the quality of care in the pediatric intensive care unit, and according to the literature, it ranges from 0.11 to 6.4 per 100 days of mechanical ventilation. Unplanned extubation leads to severe complications, worsens outcomes, and increases treatment costs, which determine the urgency of the problem. The search for relevant publications was conducted in PubMed, Google Scholar, and eLibrary.ru. The review included 37 articles published from June 1997 to July 2023. The articles contained information on the incidence of unplanned extubations in pediatric and neonatal intensive care units, their complications, and associated factors. It also presented measures aimed at improving the quality and safety of medical care and reducing the frequency of unplanned extubations, with an analysis of their effectiveness. No studies have focused on the frequency of unplanned extubations in Russia, which is a good motivator for conducting research on unplanned extubations in the national healthcare system. The authors hope to draw the attention of clinicians and healthcare managers to this problem as one of the criteria for the quality and safety of medical care for children.

Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches.

Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE.

Construction and application of prone position ventilation management scheme for severe COVID-19 patients.

Background: Prone position ventilation (PPV) can significantly improve oxygenation index and blood oxygen saturation in most (70%-80%) patients with acute respiratory distress syndrome. However, although PPV is not an invasive procedure, there are many potential PPV-related complications, such as nerve compression, crush injury, venous stasis (e.g., facial oedema), pressure sores, retinal damage, vomiting, and arrhythmia, with an incidence of up to 56.9%. Nursing managers have focused on reducing the occurrence of PPV-related complications and improving safety. Objective: To construct a prone ventilation management scheme for patients with severe coronavirus disease 2019 (COVID-19) and analyse its application effect. Methods: Based on a previous evidence-based study combined with the COVID-19 Diagnosis and Treatment Protocol (Trial Edition 9), a prone ventilation management protocol for severe COVID-19 was formulated and applied to COVID-19 patients in the intensive care unit of a designated hospital. A prospective self-control study was used to compare changes in the oxygenation index and other outcome indicators before and after the intervention. Results: The oxygenation index of patients after intervention (321.22 ± 19.77mmHg) was significantly higher (p < 0.05) than before intervention (151.59 ± 35.49mmHg). The difference in oxygenation index in different prone position ventilation durations was statistically significant (p < 0.05). Nursing quality evaluation indicators showed that the implementation rate of gastric residual volume assessment was 100% and the incidence of occupational exposure and cross-infection was 0%; the incidences of pressure ulcers, drug extravasation, and facial oedema were 13.64% (3/22), 4.54% (1/22), and 4.54% (1/22), respectively. The incidence of unplanned extubation, aspiration, and falls/falls was 0%.

Prevention of Hospital-Acquired Transnasal Tube-Related Pressure Injuries: A Quality Improvement Project

Background. Nurses certified in wound, ostomy, and continence (WOC) monitored an increasing incidence of hospital-acquired transnasal tube-related pressure injuries (TTPIs) in a tertiary hospital. Hospital-acquired pressure injuries are one of the most common preventable complications of hospitalization; however, the significance of TTPI prevention must be considered alongside the safety of tube fixation to prevent unplanned extubations (UEs), which are serious adverse events. Thus, exploring a quality improvement (QI) project to effectively reduce the risk of TTPIs while safeguarding tube safety is urgently needed. Purpose. To decrease the incidence of TTPIs. Methods. Inpatients from 2017 to 2018 were set as the control group, using routine precautions. Inpatients from 2019 to 2020 were set as the experimental group, and a bundle of training and clinical practice interventions was implemented to compare the incidence of TTPIs and UEs between the 2 groups. Results. After improvement, the incidence of TTPIs reduced from 1.20% to 0.69%, the incidence of UEs reduced from 2.40% to 1.63%, and the differences were both statistically significant (P &lt; .05). Conclusion. The QI project reduced the incidence of TTPIs and UEs, thereby protecting the nasal skin/mucosal surfaces, safeguarding tube fixation, and ultimately improving the quality of clinical care.

The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries.

Aim Traditional sedation management consists of doctors adjusting the dosage of sedative drugs or adding other drugs in combination according to the evaluation of nurses; the nurses then execute the orders. The nurses' passive execution in the process is not the ideal model for continuous evaluation and observation of sedation. This study aims to investigate the application and effects of nurse-provided procedural sedation and analgesia for patients in intensive care unit. Methods The experimental group consisted of 354 heart surgery patients who received procedural sedation and analgesia from nurses from November 2020 to August 2021. The control group consisted of 301 patients who had had heart surgery and received the traditional sedation management program from January to October 2020. The differences in levels of the sedative effect, delirium, and unplanned extubation of patients between these two groups were compared. Results There were no significant differences in baseline characteristics between the two groups (P > 0.05). It was found that both insufficient sedation and excessive sedation decreased in the experimental group when compared to the control group, while the appropriate proportion of sedation increased (72.41% versus 37.98%); the difference was statistically significant (P < 0.05). The incidence of delirium was lower for patients in the experimental group than for patients in the control group (37.01% versus 66.45%); the difference was statistically significant (P < 0.05). The incidence of unplanned extubation caused by patient factors was lower for the experimental group than for the control group, but the difference was not statistically significant (P > 0.05). Conclusion The programmed sedation scheme led by nurses can improve the sedation effect and reduce the incidence of delirium. Implications for Practice. The management team gives the sedative goal and establishes the standard flowchart. The sedation management led by the nurse according to the goal and flowchart is better than the traditional sedation management.

Incidence of Unplanned Extubation and Related Factors of Reintubation in the Neonatal Intensive Care Unit

Purpose: This descriptive study aimed to identify the incidence and related factors of reintubation after unplanned extubation in the neonatal intensive care unit.Methods: A secondary data analysis was conducted using electronic medical records. All events of unplanned extubation were audited from January 2020 to August 2021. The data were analyzed by chi-square test using IBM SPSS Statistics ver. 24.0 program.Results: Fifty-eight unplanned extubation events were identified for 20 months. The incidence was 2.6 per 100 ventilation days during the study period. After unplanned extubation, 35 neonates (60.3%) were immediately reintubated. There was a statistically significant difference between the gestational age (p=0.018) and postconceptional age at unplanned extubation (p=0.044) and the total intubation period (p=0.003) between the reintubation and nonreintubation groups.Conclusion: These findings indicate that the incidence of unplanned extubation was significantly higher than that of an adult in South Korea. According to this study, targeting interventions are required to prevent unplanned extubation and ensure patient safety.

Superficial placement of endotracheal tubes associated with unplanned extubation: A case-control study.

Unplanned extubations (UEs) refer to the inadvertent removal of endotracheal tubes (ETTs). Superficially placed ETTs anecdotally increases the risk of UEs. This study aims to assess the impact of ETT position as well as other factors that could be associated with risk of UEs. A retrospective case-control study was conducted at NewYork-Presbyterian Queens Hospital from January 2017 to February 2020. All adults admitted to intensive care units (ICUs) who received mechanical ventilation (MV) through ETTs were screened to identify UEs. For each case with UE, two controls with planned extubation were identified. A multivariate logistic regression was conducted to identify risk factors associated with UEs. 1100 patients received MV through ETTs during the time period. The incidence of UE was 4.9%. 53 patients with UEs and 106 patients with planned extubation were included for statistical analysis. Overall, patients with UE had higher in-hospital mortality rates (26.4% versus 11.3%, P=0.02) and reintubation rates (28.3% versus 6.6%, P<0.001). Within the UE group, patients who required reintubation had significantly higher in-hospital mortality rates than those who did not require reintubation (53.3% versus 15.8%, P=0.005). Multivariate logistic regression showed higher APACHE II scores (Odds ratios (OR) 1.07; 95% Confidence interval (CI), 1 to 1.13), distance of ETT tips to carina ≥6cm (OR 6.41; 95% CI, 1.1 to 37.3), physical restraint use (OR 2.98; 95% CI, 1.28 to 6.95) and continuous infusions of sedatives and/or analgesics (OR 10.72, 95% CI, 4.19 to 27.43) were associated with UE. UE and the need for reintubation is associated with worse outcomes. Distance of ETT tips to carina ≥6cm may be associated with higher risks of UE. Further prospective studies are needed to establish the optimal position of ETT to prevent UE.

63 Characterizing Organizational Risk Factors and Clinical Impacts of Unplanned Extubations among Infants in the Neonatal Intensive Care Unit

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Organizational factors in neonatal intensive care units (NICUs) can increase the risk of adverse events, such as unplanned extubations (UPEs). UPE is the premature and unanticipated removal of an endotracheal tube. UPE and subsequent reintubation may increase the risk for lung injury and bronchopulmonary dysplasia (BPD) among preterm infants. Objectives First, we aimed to assess the association between daily nursing overtime and UPEs in the NICU. Second, we aimed to evaluate the association between UPE, re-intubation after UPE, and BPD in the sub-group of infants born &amp;lt; 29 weeks’ gestational age (GA). Design/Methods We conducted a retrospective cohort study including infants admitted to a tertiary care NICU between 2016-2019. Daily nursing hours were obtained from local administrative databases. Patient data was collected from the local Canadian Neonatal Network database. Association between ratio of daily nursing overtime hours/total nursing hours (OTR) was compared between days with and without UPEs, using logistic regression analyses. Associations between UPE and BPD among infants born &amp;lt;29 weeks requiring mechanical ventilation was evaluated in a 1:1 propensity-score matched (PSM) cohort. Infants were matched based on GA ± 2 weeks, mechanical ventilation days at time of UPE ± 5 days and SNAPII&amp;gt;20. Results There were 108/1370 (7.8%) days with ≥ 1 UPE, for a total of 116 UPE events from 87 patients (23-42 weeks GA). Higher median OTR was observed on days with UPE compared to days without (3.3% vs. 2.5%, p=0.01). OTR was associated with higher adjusted odds of UPE (aOR 1.09, 95% CI 1.01-1.18), while other organizational variables were not (Table 1). Among ventilated infants &amp;lt;29 weeks’ GA (n=XX), UPE rate was 31% (59), BPD rate was 42% (81) and re-intubation rate after UPE was 59% (35). In the PSM cohort of infants &amp;lt;29 weeks, re-intubation after UPE, was associated with increased length of mechanical ventilation (aOR 16.45; CI 6.18, 26.72) as well as increased odds of BPD, when compared to infants not requiring re-intubation (aOR 4.97, 95% CI 1.54-18.27) (Table 2). Conclusion Higher nursing overtime was associated with increased UPEs in the NICU. Re-intubation was frequently required after a UPE. Among the infants born &amp;lt; 29 weeks’ GA, UPE requiring reintubation was associated with increased total length of mechanical ventilation and increased risk of BPD. Our findings highlight the role of workforce management in improving outcomes in the NICU, through reducing the incidence of UPEs.

Preventative Value of Predictive Health Interventions on PICC-Related Thrombosis in Patients with Severe Burns

Background Burn mainly refers to the damage caused by high temperature to the skin and mucous membrane tissue. Seriously, it causes damage to the subcutaneous tissue or subcutaneous mucous membrane, which is easy to induce infection and poses a threat to the life safety of patients.For patients with deep burns, surgical removal of damaged skin and mucosal tissue, Postoperative,immediate coverage of surgical wounds,avoid infection due to body fluid and energy loss with related tissue necrosis.The clinical treatment period for critical burn patients is longer and high incidence of postoperative complications.The corresponding nursing intervention while undergoing treatment can help to eliminate the impact of the bad psychological state on the patients, improve the treatment compliance, and reduce the occurrence of complications. Objective Evaluation of the value of predictive health intervention in preventing thrombosis associated with Peripherally Inserted Central Catheter (PICC) via peripheral vein in critically ill burn patients Methods Select 90 patients with severe burn treated by PICC infusion from January 2019- February 2021, Group by reference to intervention methods, with 45 using conventional health intervention (control group) and another 45 using predictive health interventions (observation group). The incidence of pulmonary and wound infection, the incidence of adverse events associated with PICC catheterization and wound healing time were recorded in the two groups. The degree of pain was evaluated by visual simulation (VAS) score, and the differences of platelet, D- dimer (D-D) and hemodynamics were detected in the two groups Results The incidence of pulmonary infection, PICC associated thrombus and total adverse events in the observation group was lower, and higher rate of functional recovery,but less wound healing time with control group,which had statistical significance (P&lt;0.05) .Incidence of wound infection, incidence of catheter blockage, incidence of unplanned extubation,the difference was not statistically significant (P&gt;0.05) .Comparison before intervention/The pain score decreased at 7 ck 14d&gt; 21d (P&lt;0.05), and the observation group was lower than the control group (P&lt;0.05) .Intervention of the 7d, 14d two sets all platelet elevation (P&lt; 0.05) ,but D-D concentration decreases (P&lt; 0.05) .Intervention of the 7d&gt; 14d two sets was increased of the intrathoracic blood volume index (ITBVI) (P&lt;0.05) , but extravascular lung water index (EVLWI) and mean arterial pressure (MAP) the difference was not statistically significant (P&gt;0.05). Conclusions Predictive health intervention can reduce the pain degree of critically burned patients, reduce the incidence of adverse events such as infection and PICC-related thrombosis, and promote wound recovery.

Effectiveness of Teaching Program on Knowledge of Clinical Nurses Regarding Risk of Unplanned Extubation of Patients with Mechanical Ventilation at a Selected Hospital, Bangalore

Background: Mechanical ventilation (MV) is one of the therapeutic pillars of intensive care medicine. Technique and practice in emergency airway management varies between ICUs and in different countries and as a result, complication rates may also differ. Unplanned extubation is a frequent event after endotracheal intubation for respiratory support in critically ill patients and is associated with increased morbidity and mortality. The incidence of unplanned extubation among intubated patients is reported to vary from 0.3% to 1.4%. Unplanned extubation account for approximately 10% of reintubations. An Unplanned Extubation is also associated with prolonged duration of mechanical ventilation, ICU stay and hospital stay. Objective: to assess the knowledge of clinical nurses regarding risk of unplanned extubation of patients with mechanical ventilation at Kempegowda institute of medical science and research Hospital, Bangalore, Karnataka. Materials and Methods: Quantitative research approach and a pre-experimental one group pre-test post-test research design were used to accomplish the stated objectives. The investigator selected a sample of 50 nurses who were working in KIMS hospital. The data were collected by using a self administered structured knowledge questionnaire. Planned teaching was given with appropriate A-V aid followed by pretest. Result: Inferential and descriptive statistical analysis was performed by using SPSS-IBM 20. Results were calculated by using p value &lt; 0.05. The results revealed that, in pretest 80% of the nurses had inadequate knowledge where as in posttest 82% of the nurses had gained moderately adequate knowledge and the improvement was statistically significant at P&lt;0.05. Conclusion: The study result shows that after intervention knowledge regarding risk of unplanned extubation among nurses were improved significantly. Keywords: Effectiveness planned teaching, risk of unplanned extubation, knowledge of staff nurses and mechanical ventilation protocol.

Development and Validation of Unplanned Extubation Prediction Models Using Intensive Care Unit Data: Retrospective, Comparative, Machine Learning Study.

BackgroundPatient safety in the intensive care unit (ICU) is one of the most critical issues, and unplanned extubation (UE) is considered the most adverse event for patient safety. Prevention and early detection of such an event is an essential but difficult component of quality care.ObjectiveThis study aimed to develop and validate prediction models for UE in ICU patients using machine learning.MethodsThis study was conducted in an academic tertiary hospital in Seoul, Republic of Korea. The hospital had approximately 2000 inpatient beds and 120 ICU beds. As of January 2019, the hospital had approximately 9000 outpatients on a daily basis. The number of annual ICU admissions was approximately 10,000. We conducted a retrospective study between January 1, 2010, and December 31, 2018. A total of 6914 extubation cases were included. We developed a UE prediction model using machine learning algorithms, which included random forest (RF), logistic regression (LR), artificial neural network (ANN), and support vector machine (SVM). For evaluating the model’s performance, we used the area under the receiver operating characteristic curve (AUROC). The sensitivity, specificity, positive predictive value, negative predictive value, and F1 score were also determined for each model. For performance evaluation, we also used a calibration curve, the Brier score, and the integrated calibration index (ICI) to compare different models. The potential clinical usefulness of the best model at the best threshold was assessed through a net benefit approach using a decision curve.ResultsAmong the 6914 extubation cases, 248 underwent UE. In the UE group, there were more males than females, higher use of physical restraints, and fewer surgeries. The incidence of UE was higher during the night shift as compared to the planned extubation group. The rate of reintubation within 24 hours and hospital mortality were higher in the UE group. The UE prediction algorithm was developed, and the AUROC for RF was 0.787, for LR was 0.762, for ANN was 0.763, and for SVM was 0.740.ConclusionsWe successfully developed and validated machine learning–based prediction models to predict UE in ICU patients using electronic health record data. The best AUROC was 0.787 and the sensitivity was 0.949, which was obtained using the RF algorithm. The RF model was well-calibrated, and the Brier score and ICI were 0.129 and 0.048, respectively. The proposed prediction model uses widely available variables to limit the additional workload on the clinician. Further, this evaluation suggests that the model holds potential for clinical usefulness.

Risk factors for unplanned extubation in ventilated neonates in South Korea

PurposeAlthough unplanned extubation (UE) is a common occurrence in neonatal intensive care units (NICUs), the factors influencing UE have not been clearly identified in South Korea. Therefore, we investigated the incidence of UE along with its risk factors among neonates in the NICU. Design and methodsThis retrospective cohort study was conducted in a single NICU in B city. The electronic medical records of 137 ventilated neonates admitted between January 2017 and June 2018 were analyzed using an audit tool on extubation. Kaplan–Meier estimation and univariate and multivariate Cox proportional hazards models were used for statistical analyses. ResultsThe rate of UE was 32.1%, with an incidence of 6.56 per 100 ventilation days during the 18-month study period. Risk factors for UE were the use of sedatives or analgesics; no re-fixation of the endotracheal tube (ETT); suction frequency; a high nurse–patient ratio; and working night shifts (weekdays 5 p.m. to 8 a.m.), weekends, or holidays. ConclusionsThe rate of UE among neonates was found to be considerably higher than that of other countries. Among the various factors, nursing-related factors were most commonly associated with the risk of UE. Application to practiceVarious prevention strategies, including complete ETT fixation, maintaining ETT placement, a low nurse–patient ratio, and close observation of the ETT may help reduce UE in the NICU.

Clinico-etiological profile of children who had unplanned extubation and subsequent re-intubation in level-4 pediatric intensive care unit

Background: There are few studies on unplanned extubation (UE) in pediatric intensive care units (PICU). This study is to identify factors associated with UE in PICUs. Subjects and Methods: In this observational study, the data of UE from January 1, 2013, to May 31, 2019, in a level-4 PICU were analyzed with an objective to study the etiology of UE and its impact on therapeutic outcomes. Results: Of 7079 patients hospitalized in PICU, 1721 were invasively ventilated (mean ventilator days 4.33 days). UE occurred in 39 patients (2.26% of intubated patients) at 0.52 UE events per 100 ventilation days. The median age was 14 months. The most common cause of UE was inadequate sedation (n = 24, 61.53%), endotracheal tube suctioning (n = 05, 20.8%), one during adjusting ET tube (4.1%), one during central venous line insertion (4.1%), and one during Foley's catheter insertion (4.1%) and 7 unexplained (29.1%). As long as the appropriate nurse: patient ratio was maintained, the incidence of UE was un-affected by day versus night shift or high versus low bed occupancy rates. Re-intubation rate in UE cohort was higher (74.35%) than planned-extubation cohort 0.11% (P &lt; 0.001). All re-intubations were within 2 h of UE. Most common cause of re-intubation following UE was respiratory distress (72.41%), stridor (17.24%), and apnea (10.34%). Re-intubations following UE showed higher incidence of ventilator-associated pneumonia but statistically not significant (P = 0.54). Conclusion: UE is associated with a significantly high incidence of re-intubations and associated complications arising from re-intubations. Maintaining a pool of skilled nurses in adequate nurse-to-patient ratio may play an important role in preventing UE. UE can be minimized by optimizing sedation and monitoring during common ICU procedures. Multicentric studies are warranted to design a uniform standard of care of ventilated patients aimed at reducing the incidence of UE.

The impact of the addition of nurse practitioners to surgical intensive care units: A retrospective cohort study

BackgroundDemand for surgical critical care is increasing, but work-hour restrictions on residents have affected many hospitals. Recently, the use of nurse practitioners (NPs) as providers in the intensive care unit (ICU) has expanded rapidly, although the impacts on quality of care have not been evaluated. ObjectivesTo compare the outcomes of critically ill surgical patients before and after the addition of NPs to the ICU team. MethodsWe conducted a retrospective cohort study in a Taiwanese surgical ICU. We compared the outcomes of patients admitted to ICU during the 2-year period before and after the addition of NPs to the ICU team. Patients admitted in the 1-year transition phase were excluded from comparisons. The primary endpoint was ICU mortality. Secondary endpoints included ICU length of stay and incidence of unplanned extubation. ResultsA total of 8747 patients were included in the study. For all eligible admissions, primary and secondary outcomes did not differ significantly between the two groups. For scheduled ICU admissions, ICU mortality was significantly lower after the addition of NPs (2.2% before vs. 1.1% after addition of NPs, p = 0.014). For unscheduled ICU admissions, ICU mortality did not differ significantly between the two groups. In the multivariate analysis, admission after the addition of NPs was associated with significantly reduced ICU mortality (odds ratio = 0.481; 95% confidence interval = 0.263–0.865; p = 0.015) among scheduled admissions. ConclusionIncorporating NPs in the ICU team was associated with improved outcomes in scheduled admissions to surgical ICU when compared with a traditional, resident-based team.

Unplanned tracheal extubation in the pediatric intensive care unit before and after quality management

Objective To analyze the causes of unplanned tracheal extubation in mechanically ventilated patients in the pediatric intensive care unit using quality management practices and observe the changes of extubation rates before and after implementing these practices. Methods In the first place, we set up quality management group in June 2014.Second, the team formulated a risk factor checklist for unplanned tracheal extubation based on literature research, and analyzed the main causes requiring tracheal extubation.The last time, we developed some management measures for important reasons in 2014, and established and implemented a quality management strategy between 2015 and 2016.The incidence frequency of unplanned tracheal extubation, i.e.the number of extubation cases per 100 days with a tube in place(mechanical ventilation days), was used to evaluate the change of the extubation rates before and after implementing the new measures.The cases in 2014 were retrospectively analyzed, and cases from 2015 to 2016 were prospectively collected.The number of interval days for two continuity unplanned extubation was considered to be a means of quality control. Results Rick factors associated with unplanned extubation in the pediatric intensive care unit before implementing quality management were a delay of the replacing adhesive bandage, lack of sedation assessment, which were related to frequent physician replacement and insufficient training and supervision.In consideration of the identified risk factors, a standard operating procedure was formulated to prevent unplanned extubation, including standard operating procedure of tracheal catheter fixation and the sedation assessment.There were 484 mechanical ventilation in 2014, and the incidence of unplanned extubation was 0.8%, and the median number of days of separation was 8.0(4, 20) d. Between 2015 and 2016, there were 1 379 mechanical ventilations, and the incidence of unplanned extubation was 0.2%, and the median number of days of separation was 34.0(19, 61) d. The incidence of unplanned extubation in 2015 to 2016 was lower than that in 2014(χ2=5.936, P=0.018). Ramsay scoring usage increased from 28.6% in 2014 to 57.1% between 2015 and 2016, while Ramsay scored 3-4 points from 2015 to 2016 was higher than 2014(P< 0.05). Conclusion Establishing the quality management group according to the requirements of each hospital and implementing quality management strategies can reduce the incidence of unplanned extubation, thereby improving the quality of care in pediatric intensive care unit. Key words: Pediatric intensive care unit; Unplanned extubation; Quality management; Endotracheal intubation; Risk factors

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 1st January 2008 to 31st 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.

The Effect of Family Member Reminders on Reducing Anxiety and Unplanned Extubation in ICU Patients

Patients with endotracheal intubation often experience anxiety because they are unable to express their needs freely. However, the family members of these patients are able to provide encouragement, comfort, and substantive support. The aims of the present study were: (1) to compare the anxiety scores, vital signs, and incidence of unplanned extubation (UE) between the two comparison groups; (2) to compare the differences in vital signs before and after the intervention in the experimental group; and (3) to explore the satisfaction of patients in the experimental group with the intervention. A quasi-experimental, pretest-posttest design was carried out. A convenience sampling was adopted to recruit patients with endotracheal intubation in intensive care units (ICUs). The experimental group listened to the UE-prevention reminders of their family members for three times a day for 4 days. The control group was provided with usual care. (1) No significant difference was observed in the anxiety scores between the two groups (t = -1.282, p = .205). (2) A repeated-measures analysis found no significant difference in vital signs, taken nightly at 10 p.m., between the experimental and control groups (p > .05). (3) The experimental group registered significantly lower heart rates, systolic blood pressure, diastolic blood pressure, and mean arterial pressure after the conclusion of the intervention (p < .05). However, no significant pre-test / posttest difference in breathing rate was observed for this group. (4) A large majority (89%) of the experimental group expressed satisfaction with the intervention treatment program. The present study, which used a DVD of family reminders encouraging and reminding patients about intubation safety, achieved a very high level of patient satisfaction and reduced their anxiety-related vital signs. The results may serve as a reference for providing intervention treatment to patients with endotracheal intubation in ICUs.