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.

Compassionate Removal of Heated High-Flow Nasal Cannula for End of Life: Case Series and Protocol Development.

Patients often receive burdensome care at the end of life in the form of interventions that may need to be removed. Heated high-flow oxygen delivered through a nasal cannula (HHFNC) is one such intervention that can be delivered in the hospital yet is rarely available outside of this setting. During the COVID-19 (coronavirus disease 2019) pandemic, health care systems continue to face the possibility of rationing critical life-sustaining equipment that may include HHFNC. We present a clinical protocol designed for weaning HHFNC to allow a natural death and ensuring adequate symptom management throughout the process. This was a retrospective chart review of 8 patients seen by an inpatient palliative care service of an academic tertiary referral hospital who underwent terminal weaning of HHFNC using a structured protocol to manage dyspnea. Eight patients with diverse medical diagnoses, including COVID-19 pneumonia, underwent terminal weaning of HHFNC according to the clinical protocol with 4 down-titrations of approximately 25% for both fraction of inspired oxygen and liter flow with preemptive boluses of opioid and benzodiazepine. Clinical documentation supported good symptom control throughout the weaning process. This case series provides preliminary evidence that the clinical protocol proposed has the ability to ensure comfort through terminal weaning of HHFNC.

An Evaluation of Risk Factors for Extubation Failure in Surgical Patients in Intensive Care.

BACKGROUND: Reintubations following extubation from mechanical ventilation are costly, resulting in increased morbidity and mortality. The preparation for and timing of extubation from mechanical ventilation can reduce unplanned reintubations. Few studies have investigated reintubation in the surgical intensive care unit (SICU) population. OBJECTIVE: To identify risk factors that predict extubation failure in nontrauma surgical postoperative intensive care patients. METHODS: Retrospective analysis utilizing American College of Surgeons National Surgical Quality Improvement Program data and institutional clinical variables from July 1, 2013, to December 31, 2015, in a sample (N = 93) of surgical patients admitted postoperatively to a SICU with an endotracheal tube in place, requiring invasive mechanical ventilation. Logistic regression analysis was used to model extubation failure as a function of clinical variables in the 24 hours preceding extubation. RESULTS: Of 93 patients, 70 were successfully extubated, and 23 experienced failure. Increasing respiratory rate in the 24 hours preceding extubation significantly predicted failure (odds ratio, 1.086; 95% confidence interval, 1.006-1.172; P = .034). DISCUSSION: Elevated respiratory rates during the 24 hours preceding extubation are an underappreciated risk factor for extubation failure. This has direct implications for nurses who are assessing intensive care unit patients' readiness for extubation. Opportunity exists for nurses to better integrate respiratory rate data into extubation planning to improve unplanned reintubation rates in SICU patients.

The PEST Model: A Quality Improvement Project to Reduce Self-extubation in the Intensive Care Unit.

BACKGROUND: Self-extubation is an adverse patient event that can lead to severe complications. Gaps in clinical practice from the lack of nursing awareness and decision making capacity have often resulted in cases of preventable self-extubation. Review of current evidence suggests that initiatives to support nursing clinical decision making can help prevent adverse patient events such as self-extubation. AIMS: The aim of this study was to reduce the incidence of self-extubation by 50% in a cardiology intensive care unit over 1 year. METHODS: A quality improvement project was undertaken with a PEST model of nursing care introduced from January 2017 to December 2017 in the cardiology intensive care unit to guide nursing staff to assess and render appropriate interventions along patient domains such as pain, endotracheal tube securement, sedation, and tie to prevent incidences of self-extubation. RESULTS: Incidences of self-extubation have reduced to 5 cases in 2017, reflecting a 50% improvement from 10 cases in 2016. CONCLUSIONS: Formalizing practice standards into an easy-to-remember mnemonics or framework can improve patient outcomes. Policy makers must be aware that initiatives to facilitate decision making can improve patient safety.

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.

Nurse-led extubation in the post-anaesthesia care unit.

Weaning of mechanical ventilation occurs in intensive care units by nurses, which stimulates the prospect of nurse-led extubation extending into the PACU environment for improved patient outcomes and reduced demand of hospital resources. Nurse-led patient extubation in the PACU, would involve specially trained nurses weaning mechanical ventilation via an established protocol for a specific patient group, prior to the patient being extubated by an anaesthetist or intensivist.

Validation of a Postextubation Dysphagia Screening Tool for Patients After Prolonged Endotracheal Intubation.

BACKGROUND: Patients who receive prolonged endotracheal intubation (> 48 hours) are at risk for dysphagia. Nurses should conduct swallowing assessments after extubation because of the high likelihood of aspiration pneumonia developing. No valid and reliable postextubation dysphagia screening tools are available. OBJECTIVES: To establish content validity, analyze interrater reliability, and determine sensitivity and specificity of an evidence-based postextubation dysphagia screening tool developed by a multidisciplinary team. METHODS: A prospective nonexperimental study was conducted in 4 medical-surgical intensive care units in 4 hospitals. The study was conducted in 3 phases: (1) establishing content validity with clinical experts who participated in a Delphi survey, (2) establishing inter-rater reliability by agreement with nurses who simultaneously and independently completed the tool, and (3) establishing sensitivity and specificity with speech language pathologists and nurses who independently and blindly completed the tool for eligible patients. RESULTS: Individual item scores were > 0.82 and the overall content validity index was 0.93, indicating content validity. Interrater reliability was established (Cohen κ = 0.92). In 66 eligible patients, the prevalence of postextubation dysphagia was 56%, sensitivity of the postextubation dysphagia screening tool was 81%, and specificity was 69%. CONCLUSION: The reliability and validity of a postextubation dysphagia screening tool that can help nurses determine an extubated patient's ability to swallow after prolonged endotracheal intubation were established.

The Assessment of the Risk of Unplanned Extubation in an Adult Intensive Care Unit.

BACKGROUND: In order to plan and implement nursing intervention to reduce the incidence rate of unplanned extubation problem in the intensive care unit (ICU), it is necessary to determine the risk factors of unplanned extubation and the patients under risk. AIMS: This study was undertaken with the aim of evaluating the risk of unplanned extubation of endotracheal tube in adult ICU. DESIGN: This was a case-control study. METHODS: The population constituted patients hospitalized in the adult ICU during 1-year period in a university hospital. The sample from this population was composed of patients whose extubation was unplanned (30 patients) and the randomly selected patients (60 patients) who were intubated at the same time in the ICU for each patient whose extubation was unplanned. In data collection, the Richmond Agitation-Sedation Scale, Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation II were utilized. FINDINGS: According to the findings, the variables such as sex, age, mechanical ventilation period, and Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale scores did not have any effect on the unplanned extubation, but variables such as internal medicine diseases and Richmond Agitation-Sedation Scale did have an effect. It was also revealed that there was no extubation plan in most of the unplanned extubation group, the nurse was anticipating the unplanned extubation, the patient was intubated again, and a complication occurred. CONCLUSION: The patients who are provided inadequate sedation and analgesia and who have problems in their respiratory system are under risk of unplanned extubation. RELEVANCE TO CLINICAL PRACTICE: In order to prevent unplanned extubation, an adequate amount of sedation and private nursing care should be provided to patients in the ICU.

How to remove an endotracheal tube.

Rationale and key points The decision to remove an endotracheal tube (extubation) is taken when the patient achieves adequate airway control. This requires an effective cough and an acceptable level of consciousness. Practitioners should be able to identify when a patient is ready for endotracheal tube removal and to recognise contraindications and potential complications. ▶ The Glasgow Coma Scale should be used to assess the patient's level of consciousness. Extubation should not be performed on patients with a score of 8 or less. ▶ The patient is suitable for endotracheal tube removal if their peak expiratory flow rate is more than 60L/minute. Reflective activity Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice when managing a patient with an endotracheal tube. 2. How this article could be used to educate your colleagues. Subscribers can upload their reflective accounts at: rcni.com/portfolio .

Nursing Strategies for Effective Weaning of the Critically Ill Mechanically Ventilated Patient.

The risks imposed by mechanical ventilation can be mitigated by nurses' use of strategies that promote early but appropriate reduction of ventilatory support and timely extubation. Weaning from mechanical ventilation is confounded by the multiple impacts of critical illness on the body's systems. Effective weaning strategies that combine several interventions that optimize weaning readiness and assess readiness to wean, and use a weaning protocol in association with spontaneous breathing trials, are likely to reduce the requirement for mechanical ventilatory support in a timely manner. Weaning strategies should be reviewed and updated regularly to ensure congruence with the best available evidence.

A Two-Group Trial of a Terminal Ventilator Withdrawal Algorithm: Pilot Testing.

BACKGROUND: Terminal ventilator withdrawal entails cessation of mechanical ventilation to allow a natural death. There is little empirical evidence to guide the conduct of this procedure. If the process is not well conducted, patients undergoing terminal ventilator withdrawal are at high risk for experiencing significant respiratory distress. OBJECTIVES: Our aim was to (1) establish the feasibility of a nurse-led algorithmic approach; (2) determine differences in patient comfort between groups; and (3) determine differences in the use of opioids and benzodiazepines. METHODS: A prospective, two-group, repeated measures, observation design was used with nurses from one medical intensive care unit (MICU) conducting the algorithm and nurses from a second MICU providing unstandardized usual care. Patient respiratory comfort/distress was measured with the Respiratory Distress Observation Scale (RDOS). RESULTS: Nurses and respiratory therapists were trained to follow the algorithm in one-hour educational sessions; fidelity to the algorithm was subsequently confirmed. Fourteen patients evenly distributed by ethnicity and gender were enrolled, eight in the control MICU and six in the intervention unit. No significant differences in age, consciousness, illness severity, or baseline RDOS were found. All control patients underwent a one-step terminal extubation process. There were no incidences of post-extubation stridor in the intervention group, whereas three (38%) control patients experienced stridor. Patients in the intervention group had greater respiratory comfort compared with control patients (p<0.05). Differences in medication use were found with lorazepam favored in the control unit; morphine is recommended in the algorithm. CONCLUSIONS: Feasibility and proof of concept for the nurse-led algorithm were established.

[Unplanned extubations in adult intensive care units: an update]. / Estubazioni non pianificate nei pazienti adulti in terapia intensiva: un aggiornamento.

INTRODUCTION: Unplanned extubations (UEs) in adult Intensive Care Units (ICUs), have recently become an indicator of quality and safety of care. METHOD: A literature review published 10 years ago was updated to analyze any changes in UEs. RESULTS: The cumulative incidence of UEs varied between 0.3% and 27%, before 2000, and more recently, from 0.5% to 35.8%, without substantial changes. The rate of Self Extubations (SE) outweighed the Accidental Extubation (AE), amounting to 50%-100% of all UE. The reintubations rate ranged between 1.81% and 88%. The UEs increase the length of the mechanical ventilation, of ICU and hospital stay, and according to few studies the rate of death with UEs is lower. Major risk factors for UE are: APACHE II score ≥17, agitation, physical restraints, administration of midazolam, and higher levels of consciousness. The implementation of ABCDE bundle in ICUs did not involve additional risks of UE. The prevention includes a sedation with drugs different from benzodiazepines, an early detection of patients' readiness to weaning trial from mechanical ventilation, and the adequate stabilization of the endotracheal tube, with securing systems passing behind the patient's neck. The use of physical restraints is inconsistent, since it can be a risk factor for SE. CONCLUSIONS: For preventing UEs the surveillance of nursing staff is fundamental, if the staffing is adequate to the real workloads in ICU.

Role of the clinical nurse specialist in improving patient outcomes after cardiac surgery.

Health care reform continues to focus on improving patient outcomes while reducing costs. Clinical nurse specialists (CNSs) should facilitate this process to ensure that best practice standards are used and patient safety is enhanced. One example of ensuring best practices and patient safety is early extubation after open heart surgery, which is a critical component of fast track protocols that reduces may reduce the development of pulmonary complications in the postoperative period while decreasing overall length of stay in the hospital. This project was an interdisciplinary endeavor, led by the CNS and nurse manager, which combined early extubation protocols with enhanced rounding initiatives to help decrease overall length of ventilation time as well as reduce pulmonary complications in patients in the cardiac surgery intensive care unit. The project resulted in a significant decrease in length of stay and a decrease in pulmonary complications in the postoperative period.

Extubación no programada en UCI y variables no dependientes del enfermo para mejorar la calidad / Unplanned extubation in ICU, and the relevance of non-dependent patient variables the quality of care

Objetivo: Evaluar durante un año consecutivo la magnitud de la auto-extubación (AE), buscando las variables no dependientes del enfermo relacionadas. Material y métodos: Estudio prospectivo y observacional de casos y controles en una unidad de cuidados intensivos polivalente, dentro de un complejo hospitalario de tercer nivel. Fueron considerados casos enfermos con ventilación mecánica superior a las 24 h que presentaban un episodio de AE. Se realizó recogida prospectiva de variables de casos. Como principales variables de interés se estudiaron momento de AE (recogida horaria), identificación del box donde el enfermo se encontraba ingresado, presencia y tipo de contención física, desarrollo de neumonía asociada a ventilación mecánica (NAVM) y fallecimiento. Resultados: Se produjeron 17 AE en 15 pacientes, 1,21 AE por cada 100 días de VM. Las AE tuvieron una distribución espacial (número de box) no homogénea. La distribución horaria de los casos, comparada con los controles, evidenció diferencias de distribución horaria significativas (p = 0,02). El análisis comparativo entre los casos y los controles evidenció mayor mortalidad, mayor estancia en la UCI, mayor estancia hospitalaria y mayor riesgo de contraer una NAVM cuando los enfermos sufren un episodio de AE. Discusión: La AE ocurre con mayor frecuencia en una franja horaria determinada del día, pudiendo jugar un papel la situación espacial del enfermo; ocurre con mayor frecuencia en enfermos que se encuentran en proceso de destete de la ventilación mecánica, y desarrollan mayor NAVM (AU)

Objective: To evaluate, for a consecutive year, the magnitude of unplanned extubation, looking for non-dependent patient variables. Material and methods: Prospective, observational study of cases and controls in a mixed intensive care unit within in a tertiary hospital. Patients were considered cases with more than 24 hours who had an episode of unplanned extubation. Prospective collection of variables case as time of unplanned extubation (collection time), identification of the box where the patient was admitted, presence and type of physical restraint, development of ventilator-associated pneumonia (VAP) and death. Results: There were 17 unplanned extubation in 15 patients, 1.21 unplanned extubation per 100 days of MV. The unplanned extubation had an inhomogeneous spatial distribution (number of boxes). The time distribution of cases compared with controls showed significant differences in time distribution (P = .02). The comparative analysis between cases and controls, showed increased mortality, increased length of ICU stay, longer hospital stay and increased risk for VAP when patients suffer an episode of unplanned extubation. Discussion: Unplanned extubation occurs most frequently in a given time slot of the day, may play a role in the spatial location of the patient; occurs most often in patients who are in the process of weaning from mechanical ventilation, and develop greater VAP (AU)

Acciones de enfermería para la prevención de la neumonía asociada a ventilación mecánica: revisión sistemática / Ações de enfermagem para prevenção de pneumonia associada à ventilação mecânica: revisão sistemática / Nursing actions for the prevention of ventilator associated pneumonia: systematic review

Objetivo: Identificar acciones de enfermería implementadas en la prevención de la neumonía asociada a ventilación mecánica en los pacientes intubados en la Unidad de Cuidados Intensivos. Método: Revisión sistemática en las bases: PubMed, BVS y Scielo utilizando los descriptores: "Atención de Enfermería" y "Neumonía Asociada al Ventilador". La muestra constaba de 13 artículos. La calidad interna se evaluó mediante la clasificación de Jadad. Resultados: Los destaques fueron las acciones: elevación de decúbito de 30º; higiene oral; formación de las enfermeras; Protocolo Francés Destete de la Ventilación Mecánica dirigido a las enfermeras; proporción entre el número de enfermeras por turno, y evitar la reutilización de succión. Conclusión: Los cuidados de enfermería presentados deben ser utilizados en la prevención de la neumonía asociada a ventilación mecánica en los pacientes intubados en la Unidad de Cuidados Intensivos, ya que a través de los resultados de los artículos originales demostraron la eficacia de dichas acciones (AU)

Objetivo: Identificar as ações de enfermagem implementadas na prevenção da pneumonia associada à ventilação mecânica nos pacientes intubados em Unidade de Terapia Intensiva. Método: Revisão sistemática nas bases: PubMed, BVS e SciELO, através dos descritores: "Nursing Care" and "Pneumonia, Ventilator Associated". A amostra foi composta por 13 artigos. A qualidade interna foi avaliada pela classificação de Jadad. Resultados: Destacaram-se as ações: elevação do decúbito superior a 30o; higienização oral; capacitação dos enfermeiros; Protocolo Francês de Desmame de Ventilação Mecânica dirigido às enfermeiras; dimensionamento de enfermeiros por plantão; e evitar a reutilização de equipamentos de aspiração. Conclusão: Os cuidados de enfermagem apresentados devem ser empregados na prevenção da pneumonia associada à ventilação mecânica nos pacientes intubados em Unidade de Terapia Intensiva, uma vez que através dos artigos originais apresentados as referidas ações demonstraram eficácia

Objective: To identify the nursing actions implemented in the prevention of ventilator-associated pneumonia in intubated and hospitalized patients in the Intensive Care Unit. Method: systematic review of the databases: PubMed, VHL and Scielo using the keywords: "Nursing Care" and "Pneumonia, Ventilator-Associated". The sample consisted of 13 articles. The internal quality was assessed by Jadad classification. Results: the highlights were the actions: elevation of decubitus than 30°; oral hygiene; training of nurses; French Protocol Weaning of Mechanical Ventilation directed to nurses; nurses proportion per shift; and avoiding the reuse of suctioning equipment. Conclusion: nursing care provided must be used in the prevention of ventilator-associated pneumonia in patients intubated in the Intensive Care Unit, as shown through original articles that demonstrated the effectiveness of such actions (AU)

Nursing perceptions of high-flow nasal cannulae treatment for very preterm infants.

AIM: This study aims to assess nursing perceptions of high-flow nasal cannulae (HFNC) in comparison with nasal continuous positive airway pressure (NCPAP) as post-extubation respiratory support for very preterm infants. METHODS: A standardised questionnaire form was distributed in person to nursing staff in The Royal Women's Hospital neonatal unit, where HFNC had been recently introduced in the context of a clinical trial. Nursing staff were eligible to participate if they routinely cared for infants receiving respiratory support. RESULTS: The survey was completed by 99/144 eligible nurses. The majority of the 99 nurses surveyed felt that HFNC was less likely than NCPAP to prevent re-intubation of infants 24-26 weeks' gestation but equally likely to prevent re-intubation of infants 28-30 weeks' gestation. Nurses preferred NCPAP for post-extubation support of 24- and 26-week infants, and HFNC for 28- and 30-week infants, despite being less experienced with HFNC. Perceptions of HFNC compared with NCPAP included increased ease-of-use, improved infant comfort and reduced nasal trauma. CONCLUSIONS: Neonatal nurses preferred NCPAP for post-extubation support of infants <28 weeks' gestation and HFNC for infants of 28 or 30 weeks' gestation. Nurses accurately predicted varying efficacy of HFNC across different gestational ages, consistent with the findings of a contemporaneous randomised trial. In the context of clinical non-inferiority, as shown in the randomised trial, nursing preference for HFNC over NCPAP in preterm infants ≥28 weeks' gestation supports the use of HFNC as post-extubation support in this population.

Reducing unplanned extubations in the NICU.

BACKGROUND AND OBJECTIVES: Unplanned extubation can be a significant event that places the patient at risk for adverse events. Our goal was to reduce unplanned extubations to <1 unplanned extubation per 100 patient-intubated days. METHODS: All unplanned extubations in the NICU beginning in October 2009 were audited. Data collected included time of day, patient weight, and patient care activity at the time of the event. Bundles of potentially better practices were implemented in sequential Plan-Do-Study-Act cycles. Rates of unplanned extubation (number per patient-intubated day) for each month were analyzed by using control charts, and causes of unplanned extubation were analyzed by using Pareto charts. RESULTS: We found a significant decrease in the unplanned extubation rate after implementation of the first bundle of potentially better practices in May 2010 (2.38 to 0.41 per 100 patient-intubated days). Several more Plan-Do-Study-Act cycles were conducted to sustain this improvement. A persistent reduction in the unplanned extubation rate (0.58 per 100 patient-intubated days) began in February 2013. Causes included dislodgement during care and procedures and variation in the fixation of the endotracheal tube. The majority of events occurred in very low birth weight infants during the daytime shift. CONCLUSIONS: Unplanned extubations in the NICU can be reduced by education of staff and by implementing standard practices of care. Sustainability of any practice change to improve quality is critically dependent on culture change within the NICU. We suggest that the benchmark for unplanned extubation should be a rate <1 per 100 patient-intubated days.

[Methods for endotracheal tube fixation. Results of a survey of intensive care nurses]. / Praxis der Fixierung des Endotrachealtubus. Ergebnisse einer Umfrage unter Intensivpflegenden.

There are a wide variety of strategies and methods used in securing and managing the oral endotracheal tube and mouth and oral care in German clinical intensive care nursing for mechanically ventilated patients. There are no nationally recognized guidelines or recommendations on this topic. A survey among intensive care nurses identified the most widely used nursing strategies and methods. Regarding the results of the survey and international literature findings, the commonly used strategies and methods are discussed. Following these discussions, there are recommendations for improving nursing care of orally intubated patients in intensive care, including the aspects of evidence identified, currently used methods and patient needs. Also included are aspects of patient safety, potential complications and quality-orientated nursing care within a system having limited overall nursing care resources.