Implications of nursing care in the occurrence and consequences of unplanned extubation in adult intensive care units

doi:10.1016/S0020-7489(03)00136-6

International Journal of Nursing Studies

Volume 41, Issue 3, March 2004, Pages 255-262

https://doi.org/10.1016/S0020-7489(03)00136-6 Get rights and content

Abstract

This 18-month study used a structured questionnaire to explore the roles of nursing care on the occurrence and consequences of unplanned endotracheal extubation (UEE) in intensive care units in Taiwan. Experiencing UEE were 225/1176 (22.5%) intubated patients: 91.7% were self-extubations and 8.3% were accidental. Self-extubations occurred most frequently during night shifts and in the care of nurses with less working experience. Accidental extubations occurred most frequently in patients undergoing routine nursing procedures, usually required immediate re-intubation and were associated with more complications. An appropriate nurse-to-patient ratio, better working procedures and continual nursing education programs might help reduce occurrence and complications of UEE.

Introduction

Endotracheal intubation is frequently used in mechanical ventilation. Unplanned endotracheal extubation (UEE), either self or accidental extubation, can be followed by serious complications such as secondary pneumonia, dyspnea, airway trauma, edema, difficulty in reintubation and lengthened hospitalization (Epstein et al., 2000). Studies from 1994 to 2002 indicate the incidence of UEE ranges from 3% to 14% (Betbese et al., 1998; Boulain, 1998; Chen et al., 2002; Chevron et al., 1998; Christie et al., 1996; Hsu et al., 2002; Maguire et al., 1994; Razek et al., 2000; Tindol et al., 1994). Of these UEE cases, 77.9–87% were self-extubations; 13–22.1% were accidental (Chevron et al., 1998; Christie et al., 1996).

Medical and surgical reasons for UEE have been identified. Boulain (1998) and Chevron et al. (1998) found that the incidence of UEE was higher for patients with respiratory failure. Atkins et al. (1997) found that UEE occurred more frequently in post-operative patients. Because the relationship between nurse- and patient-related risk factors for UEE remains inconclusive, we studied the roles of nurse- and patient-related risk factors with respect to UEE in southern Taiwan.

Section snippets

Literature review

Literature review was based on English and Chinese databases which included Medline (Aidsline, BioethicsLine and HealthSTAR) from 1966 to present, CINAHL from 1982 to present, and PerioPath: Index to Chinese Periodical Literature (available at http://www2.read.com.tw/cgi/ncl3/m_ncl3/) at National Central Library in Taipei from 1991 to present.

Subjects studied and data collection

This study was approved by the Institutional Review Board of the medical center, and it was conducted over an 18-month period in a medical center with 11 adult ICUs from 2000 to 2001. A structured questionnaire, issued to nursing staff and double-checked by head nurses, was used to collect demographic data on nurses and patients, nursing and medical procedures, emergent management after UEE and reasons for UEE provided by nurses and patients. Participants were informed of their rights.

Prevalence of UEE

Over 18 months, 6,672 patients were admitted to the studied ICUs: 1176 patients were intubated and 265 incidents of UEE occurred. As shown in Table 1, prevalence of UEE was 22.5%, 243/265 (91.7%) were self-extubations and 22/265 (8.3%) were accidental.

Implications of nursing experience and duty shift in UEE

The mean duration of working experience in nursing was 3.4 years; 22.4% had not worked longer than 1 year, and 16.8% had worked for only 1–2 years. UEE occurred more frequently in the care of nurses with less experience, while experienced nurses

Discussion

The prevalence of UEE in this study was 22.5%. This figure is higher than those found in other studies (Chen et al., 2000; Betbese et al., 1998; Boulain, 1998; Chevron et al., 1998; Tindol et al., 1994). Reasons for this higher incidence may be multifactorial, including medical indications for intubation, patient characteristics and nursing care. We found that nurses with less working experience tended to encounter more UEEs and that UEEs were more prevalent during the night shift instead of

Conclusions and implications

In our study, UEE incidents frequently occurred when patients became restless and agitated because of pain, discomfort, inability to communicate and lack of sedation. When nurses did not adequately restrain patients and were not at bedside, UEEs were especially likely to take place. Because of the serious consequences that may follow UEE, nurses often felt responsible and were blamed by patients’ families and administrators. Nevertheless, UEE incidents were sometimes beyond the control of

Limitations

The incidents of UEE were collected in the ICU of one medical center. Our sample may not completely represent all cases of UEE. Although we instructed nurses on how to answer the questionnaire and the head nurses double-checked completed forms, we did not study interrater reliability of answers provided by nurses. This should be examined in future. Another limitation is the measurement of dependency with respect to other ICU patients that were not included in this study. Dependency should be

Acknowledgments

The authors gratefully acknowledge the assistance from Professor Kuender Yang, Professor James Steed, chief Ling-Nu Hsu and Ms. Wen-Hui Hsu in preparation of this manuscript. Appreciation is extended to all the participating administrators, staff and patients, whose cooperation made this study possible.

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Reasons for self-extubation are discussed in the literature and mainly include discomfort or pain resulting from the artificial airway, and anxiety due to patients’ inability to talk or breathe on their own (Abbas and Lutfy, 2019). Although incidents of UE were sometimes beyond the control of nursing staff, previous studies reported that self-extubations occur mainly when nurse staffing is lower (Yeh et al., 2004). This underscores the need for monitoring patients at risk of self-extubation.
Unplanned extubation has been widely recognized as a life-threatening adverse event in intensive care unit patients.
To systematically quantify the global prevalence of unplanned extubation among critically ill adults and reintubation rate after unplanned extubation.
Systematic review and meta-analysis. We identified original peer-reviewed studies through electronic searches of EMBASE, PubMed, ISI Web of Science, and CINAHL databases involving ventilated adult intensive care unit patients. Primary endpoints were prevalence of overall unplanned extubation rate rate, type of unplanned extubation (self-extubation or accidental extubation) and reintubation rate within 48 hours. Two reviewers independently selected studies and extracted data on the outcomes. Random effect meta-analysis of proportions was used to estimate the pooled prevalence rates.
Of 1613 retrieved citations, 38 studies from 18 countries published between 1990 and 2020 were included. The overall methodological quality was low (mean score on Newcastle-Ottawa scale, 2.6/5). The pooled prevalence of unplanned extubation was 6.69% (95% CI, 5.29%-8.24%; 34 studies involving 121,129 subjects) with an incidence density of 1.06 events per 100 ventilator-days (95% CI, 0.7–1.3; 16 studies involving 375,967 ventilation days). The majority of unplanned extubations (84.2%) were self-extubations (95% CI, 79.8%-88.3%; 23 studies involving 2274 unplanned extubations). In addition, 50.2% of subjects with unplanned extubations required reintubation within 48 hours (95% CI, 43.6%-56.9%; 10 studies involving 1564 unplanned extubations).
Despite significant heterogeneity between studies, these data showed that 6.7% of intubated adult subjects in the intensive care unit experience unplanned extubation, most of which are self-extubations. Further well-designed studies are required to better understand unplanned extubation among intubated intensive care unitpatient, using standardized methods of data collection and reporting.
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A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care.
The effects of preoperative education of cardiac patients on haemodynamic parameters, comfort, anxiety and patient-ventilator synchrony: A randomised, controlled trial
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Also, communication tools that are in line with the demands of the patients under mechanical ventilation should be used (Samuelson, 2011a; Samuelson, 2011b). These tools include shaking the head, nodding, lip-reading, gesturing, facial expressions, writing and special cards (Yeh et al., 2004; Grossbach et al., 2011). In this study, we prepared a communication panel in order to maintain communication between the health professionals and the patients.
Patients on mechanical ventilation are likely to suffer stress, which may lead to problems of patient-ventilator synchrony, anxiety, haemodynamic instability and decrease in comfort levels.
The aim of this study is to evaluate the effects of preoperative education regarding haemodynamic parameters, patient comfort and anxiety, and patient-ventilator synchrony provided to patients before they undergo cardiac surgery.
The study is a randomised, controlled clinical study, it was conducted at the cardiovascular surgery clinic of a teaching hospital in Turkey. The study was conducted on 200 patients who underwent cardiac surgery and received mechanical ventilation. Using the block randomisation method, the patients were grouped into intervention and control groups, with 100 patients in each group. The patients in the intervention group received preoperative education on mechanical ventilation and the usage of the communication panel that patients under mechanical ventilation use to communicate with health personnel, the control group received no education. Data was collected while the patients were on mechanical ventilation support in the intensive care unit on their second postoperative day.
The difference between the patient-ventilator synchrony levels of the patients to the mechanical ventilation treatment in the intervention and control groups was found statistically significant (p < 0.05). The differences between the haemodynamic measurements of the patients in both groups, which were measured after the patients woke up and before extubation, were also statistically significant (p < 0.05). Median scores obtained by the patients in the intervention group on the Perianaesthesia Comfort Questionnaire and the Tension-Anxiety subscale of the Profile of Mood Scale were 5.7 and 2.0, respectively. The median scores obtained by the patients in the control group on the same scales were 4.1 and 24.0, respectively.
Compared to the participants in the control group, the participants in the intervention group who received education had higher patient-ventilator synchrony, comfort and haemodynamic stability levels, as well as lower anxiety levels when they were under mechanical ventilation, showing that results were better in the intervention group than the control group.
What nursing sensitive outcomes have been studied to-date among patients cared for in intensive care units? Findings from a scoping review
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Although many studies have considered mortality and adverse effects as outcomes sensitive to nursing practice, it seems that other outcomes of nursing care in intensive care units have been explored less commonly.
To describe the state-of-science in research in the field of nursing sensitive outcomes in intensive care units and to synthesize outcomes that have been documented to date as being influenced by nursing care.
A scoping review study based on the framework proposed by Arksey and O'Malley, further refined by the Levac and Joanna Briggs Institute was performed in 2019.
The Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Google Scholar electronic databases were searched. In addition, the reference list of included articles was screened.
Two researchers independently identified publications on the basis of the following criteria: (a) articles that reported nursing sensitive outcomes on critically-ill adult patients admitted to the intensive care unit, (b) as primary and secondary studies, (c) written in English, and (d) without any time frame limitation.
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While the first can occur while patients are transported to undergo diagnostic procedures or during some interventions e.g., secretions removal and coughing, deliberate self-extubation occurs when patients under certain situations intentionally remove the endotracheal tube (Ismaeil et al., 2014). While accidental extubations (8.3%) have been reported to occur mostly among patients undergoing basic nursing care e.g. mouth and tube care, mobilisation or transport, deliberate self-extubations have been reported to occur mainly when the nurse is not at the bedside (Yeh et al., 2004). The incidence rate of UE has been documented ranging from 3.4% to 22.5% (Kwon and Choi, 2017; Yeh et al., 2004) and re-intubation rates from 1.8% to 88% of all UEs (da Silva and Fonseca, 2012).
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.
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Implications of nursing care in the occurrence and consequences of unplanned extubation in adult intensive care units

Abstract

Introduction

Section snippets

Literature review

Subjects studied and data collection

Prevalence of UEE

Implications of nursing experience and duty shift in UEE

Discussion

Conclusions and implications

Limitations

Acknowledgments

Chest

Journal of Clinical Anesthesia

Chest

Heart & Lung

Chest

Critical Care Clinics

American Journal of Surgery

Journal of Clinical Anesthesia

Chest

A prospective study of unplanned endotracheal extubation in intensive care unit patients

Critical Care Medicine

Early versus late tracheostomy in patients who require prolonged mechanical ventilation

American Journal of Critical Care

Unplanned extubation in the adult intensive care unita prospective multicenter study

American Journal of Respiratory & Critical Care Medicine

Accidental removal of endotracheal and nasogastric tubes and intravascular catheters

Critical Care Medicine

To prevent accidental UE and self-extubation

Nursing Administration Best Works

A study of risk factors of unplanned extubation

The Journal of Health Science

Factors predicting reintubation after unplanned extubation

Journal of Formosa Medical Association

Unplanned extubationrisk factors of development and predictive criteria for reintubation

Critical Care Medicine