The Role of Standardized Protocols in Unplanned Extubations in a Medical Intensive Care Unit

Abstract

Background Many patients admitted to medical intensive care units require mechanical ventilation to assist with respiratory management. Unplanned extubations of these patients are associated with poor outcomes for patients and organizations. No previous research has investigated the role of standardized protocols in unplanned extubations when examined in conjunction with traditional risk factors. Objective To identify risk factors associated with unplanned extubation among patients receiving mechanical ventilation and determine degree of compliance with pain, sedation, and weaning protocols. Methods A prospective cohort study design was used. Data on all patients admitted to the medical intensive care unit who required mechanical ventilation were gathered daily. Additional data were gathered on those patients who experienced unplanned extubation. Descriptive, correlational, and regression analyses were performed. Results Weaning protocols were a significant predictor of unplanned extubation: patients who had weaning protocols ordered and followed were least likely to experience unplanned extubation. Only 10% of the 190 patients in the study required reintubation, resulting in a significantly shorter ventilation time and unit length of stay among the unplanned extubation group. Conclusions Weaning protocols were associated with decreased incidence of unplanned extubation. Use of standardized protocols was feasible, as compliance among health care providers was high when protocols were medically prescribed. The reintubation rate in this study was low and associated with a significantly shorter ventilatory period and unit length of stay in the unplanned extubation group. (American Journal of Critical Care. 2011;20:304- Within our institution, an ongoing quality improvement project indicated that unplanned extubation continued to occur despite implementation of sedation, pain management, and weaning protocols that addressed factors reported in the literature to be associated with unplanned extubation. Additional investigation was needed to explore factors associated with unplanned extubation. Therefore, a research project was initiated with the following study aims: (1) to identify factors associated with unplanned extubation among patients admitted to the MICU who are receiving mechanical ventilation and (2) to determine the degree of compliance of physicians and nurses with sedation, pain, and weaning protocols.

In-Hospital Mortality Prediction in Patients Receiving Mechanical Ventilation in Taiwan

“…Meanwhile, high-volume physicians in high-volume hospitals are most likely to achieve good outcomes for patients because such physicians are usually assisted by highly skilled and interdisciplinary care teams. [23][24][25] Predictors of in-hospital mortality identified in the current study included CCI and LOS, similar to the findings in other previous reports of ANN models for predicting patient mortality. 7,25 Morbid patients receiving mechanical ventilation are typically burdened by a host of comorbid conditions related to mechanical ventilation that increase their risk of medical complications.…”

“…[22][23][24] Therefore, the treatment strategies of high-volume hospitals should be carefully analyzed and emulated. If in-hospital mortality is considered a benchmark, hospital volume, which is a major predictor of Table 6 Comparative performance indices of logistic regression and the multilayer perceptron (MLP) and radial basis function (RBF) models when using 100 new data sets to predict in-hospital mortality clinical trial data due to possible errors in the coding of primary diagnoses.…”

Ventilator-Related Adverse Events: A Taxonomy and Findings From 3 Incident Reporting Systems

“…The literature suggests that the rate of unplanned extubations in adult patients ranges from about 2 to 22%. [6][7][8][9][10][11][12][13] Similar to our findings, most unplanned extubations are self-extubations. 7,9,10 These events can result in inadequate respiratory function, hypoxemia, cardiopulmonary arrest, and death.…”

“…7,9,10 These events can result in inadequate respiratory function, hypoxemia, cardiopulmonary arrest, and death. [12][13][14] Accidental removal or self-removal of the ETT can result in upper airway injuries, bronchospasm, arrhythmias, aspiration, and pneumonia. 7,11,13 Approximately 50% of these patients will require re-intubation (range of 10 -78%).…”

“…7,11,13 Approximately 50% of these patients will require re-intubation (range of 10 -78%). [6][7][8]11,13,15,16 Based upon the literature, successful strategies for the prevention of unplanned extubations include standardized protocols for securing the tracheal tube, 15,[17][18][19][20] titration of sedation, [15][16][17]21 weaning patients off mechanical ventilation, 16,20 tube suctioning, patient hygiene, and transport. 15 Although it may seem intuitive that restraining patients might prevent self-extubations, the rate of patients in restraints at the time of unplanned extubation is roughly 60%.…”