Unplanned Extubation of ICU Patients with Mechanical...

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Unplanned Extubation of ICU Patients with Mechanical Ventilation Eunok Kwon RN,PhD Nursing Director of Seoul National University Hospital

Transcript of Unplanned Extubation of ICU Patients with Mechanical...

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Unplanned Extubation ofICU Patients with

Mechanical Ventilation

Eunok Kwon RN,PhD

Nursing Director of Seoul National University Hospital

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Contents

• Patient’s safety issues in ICU

• Importance of planned extubation & weaning from mechanical ventilation;

(Ι) SNUH Cases; routine cares for intubated patients

• Risk factors of unplanned extubation(Ⅱ)SNUH cases ;unplanned extubation of ICU patients with mechanical ventilation

• Outcome of unplanned extubation

• Coping & prevention of unplanned extubation in ICU.

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Patient’s safety issues in ICU-Quality indicator ESICM 2012

Domain Description of indicator Consensus (%)

1 Structure Intensive Care Unit (ICU) fulfils national requirements to provide Intensive Care. 100

2 24-h availability of a consultant level Intensivist 94

3 Adverse event reporting system 100

4 Process Presence of routine multi-disciplinary clinical ward rounds 100

5 Standardized Handover procedure for discharging patients 100

6 The maintenance of continuing medical education according to national standards 77

7 The maintenance of bed occupancy rates below a threshold level. 82

8 Outcome Reporting and analysis of standardized mortality ratio (SMR) 100

9 ICU re-admission rate within 48 h of ICU discharge. 94

10 The rate of central venous catheter-related blood stream infection. 100

11 The rate of unplanned endotracheal extubations 100

12 The endotracheal re-intubation rate within 48 h of a planned extubation 77

13 The rate of ventilator-associated pneumonia 77

75% consensus from the group in the final stage of the Delphi Process

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Patient’s safety issues in ICU-ICU Quality Indicators

1 ICU fulfils national requirements to provide Intensive Care

2 24-h availability of a consultant level Intensivist

3 Adverse event reporting system

4 Presence of routine multidisciplinary clinical ward rounds

5 Standardized Handover procedure for discharging patients

6 Reporting and analysis of SMR

7 ICU re-admission rate within 48 h of ICU discharge.

8 The rate of central venous catheter-related blood stream infection

9 The rate of unplanned endotracheal extubations.

ESICM 2012

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Patient’s safety issues in ICU-Accidental removal of catheters

• Types of catheters in ICU;

Foley catheter(75%), Central venous catheter(64%),

Endotracheal catheter (62%), Arterial line(44%)

Chest tube(14%)

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Patient’s safety issues in ICU-Accidental removal of catheters

• Complication of accidental removal of catheters

Intraventricular brain drainage hydrocephalus

Cardiac surgical drainagecardiac tamponade

Subclavian or jugular venous catheter pneumothorax and/or

hemothorax.

New drains reinsertion; hemorrhage or nosocomial infection

Endotracheal reintubation ; nosocomial pneumonia, fetal arrhythmia…

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Importance of planned extubation & weaning from mechanical ventilationUnplanned extubation rate; 0.1~3.6/100 intubation days.Anesth Analg.2012 may;114(5);1003-14,Epub 2012 feb 24. Silva PS

Analysis 1950 yr~2011yr 50articles

SNUH cases; A total 230 episodes of deliberate unplanned extubation in 242 patients from 41,207 mechanically ventilated patients for 3 years(frequency 0.53%). 2010-2012yr

(2013,south korea,E.O.Kwon)

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SNUH Cases; routine cares for intubated patients

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Risk factors of unplanned extubation

Factors Elements

Person

Gender, age, diagnosis.

GCS-Eye opening, GCS-Motor response,

Admission route, Days of intubation, APACHE Ⅱ

SPO2, Systolic BP, Diastolic BP, Mean BP,

Heart Rate, Respiration Rate, Body temperature,

PAD(Pain, Agitation, Delirium)

Technology &

ToolsType of intubation, Fixation of E tube, Mode of mechanical ventilation

Tasks WMSCN group, WMSCN score

Environment Restraint, ICU type

Organization Time of extubation, Duty of nurse, RN Present ICU career, RN Total ICU career

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Risk factors of unplanned extubation

• Gender; Male↑OR 4.8

• Severity of disease; APACHE ↑(OR 9.0)

• Type of Ds ; COPD ↑

• Sedation level; restless, Agitated(OR 3.3.-30.6)

low sedation level(OR 2.0-5.4)

High consciousness (OR 1.4-2.0)

• Physical restraint apply ↑(OR 3.1)Silva PS& Fonseca MC(2012)

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Risk factors of unplanned extubation

• Physical restraint ↑(OR 3.11),nosocomial infection ↑(OR 2.02), GCS> 9↑ (admission time of ICU). Chang etc (2008)

• HR, APACHE Ⅱ score, Career of nurse in hospital↓, Career of nurse in ICU↓, Graduation level of nurse↓. Chang etc (2011)

• Sedation score(OR: 30.25) Gender( Male↑), Type of ICU, Length of stay in ICU, Midazolam infusion at the time of intubation. Groot etc(2011)

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Risk factors of unplanned extubation

• Staffing of Night duty, Night time,

Career of nurse(Curry, Cobb, Kutash & Diggs, 2008; Jeffrey et al.,2005; Battles & Lilford, 2003).

• Time of extubation of endotracheal tube,

Severity of Disease, Sedative drugs, Physical restraint,

Level of consciousness, Patient’s behavior,

Predictors of intubation,

Vital sign changes(H.Y.Kim, 2004; Y.K.Choi; 2001).

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SNUH cases ;unplanned extubation of ICU patients with mechanical ventilation

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Outcome of unplanned extubation

Patient outcomes

Expire

Discharge

Transfer to general ward

Reintubation

Organizational outcomesLOS of ICU

LOS of hospital

Reintubation rates were reported 1.8-88% of unplanned extubation in previous researchs.

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Outcome of unplanned extubation

• Reintubation rate; 1.8-88%

(Silva PS & Fonseca MC, 2012)

• Factors of reintubation; GCS< 11, not patient,s self extubationbut health care person’s error, PaO2/FIO2<200 mmHg

(Chevron, 1998)

• Severe complication↑5~28%. Complication(life threatening situation ,nosocomial infection↑, Days of mechanical ventilation↑, Length of hospital stay↑, Length of ICU stay↑,reintubation.

(Arnaud de Lassence et al., 2002)

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Outcome of unplanned extubation

• Mortality rate↓

(unplanned extubation group10 % VS planned extubationgroup 30%)

reintubation rate; 47%.

Groot etc(2011)

• Reintubation rate 51.5%,

mortality rate, length of stay in hospital, length of stay in ICU

J.J.Lee(1996).

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Coping & prevention of unplanned extubation in ICU

Preventive measures; Standardization of procedures,

staff education, staff surveillance & identification & management of high risk patients decreasing rate; 22~53%Anesth Analg.2012 may;114(5);1003-14,Epub 2012 feb 24. Silva PS

Analysis 1950 yr~2011yr 50articles

Increase by 1RN per patient day decreased unplanned extubation(OR,0.49;95%Cl)

The association of registered nurse staffing levels and patient oucomes;Med care.2007 Dec;45(12)1195-204 Kane RL et al

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Coping & prevention of unplanned extubation in ICU

• Mechanical ventilation patient in MICU

Prevention of unplanned extubation Protocol (Assessing sedation, pain, consciousness level, applying of weaning protocol. Jarachovic (2011)

• Prevention of unplanned extubation; education of health care staff, caring of high risk patient

-> unplanned extubation 22 ~ 53% ↓. Silva PS& Fonseca MC (2012)

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Coping & prevention of unplanned extubation in ICU

• Applying of physical restraint & sedation for safety of patient in SICU for 4 years ,

Physical restraint applying rate; 50%- 90% ↑

sedation 39%- 77%↑.

unplanned extubation rate 10%- 4%↓

Ermenegildo etc(2000)

• Fixation method of E tube; New fixation tool apply unplanned extubation rate ↓

E.H. Choi(2006), J.S.Km(2009)

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So what can we do for now?

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PAD care bundle of ICU in SNUHiPAD(ICU Pain, Agitation, Delirium) Care Bundle

PAIN AGITATION DELIRIUM

ASSESS

Assess pain ≥ 2/shiftPatient able to self-report → NRS (0-10)Unable to self-report → CNPS (0-9)

Assess agitation, sedation ≥ 2/shiftRASS (-5 to +4)

Assess delirium Q shiftCAM-ICU (+ or -)Delirium present if CAM-ICU is positive

TREAT

Treat pain with analgesia therapy

Targeted sedation: RASS -2 to 0(light sedation)Treat with sedatives for light sedation

Treat patients with nursing intervention: • Reorient patients• Use patient`s eyeglasses,

hearing aids• Familiarize surroundings

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Establishing monitoring system of Delirium in Adult ICU; CAM ICU

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Education based on simulation about unplanned extubation

Simulation training related to unplanned extubation

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Safety is first!!I see you in ICUSafety based nursing

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References

• A. Rhodes, R. P. Moreno, E. Azoulay, M. Capuzzo, J. D. Chiche, J. Eddleston. et al(2012). Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of theEuropean Society of Intensive Care Medicine (ESICM), Intensive Care Med 38, 598–605.

• Atkins, P. M., Mion, L. C., Mendelson, W., Palmer, R. M., Slomka, J., & Franko, T.(1997). Characteristics and outcomes of patients who selfextubate from ventilatory support: A case- control study. Chest, 112(5),1317–1323.

• Curry, K., Cobb, S., Kutash, M., & Diggs, C(2008). Characteristics associated with unplanned extubations in a surgical intensive care unit. American Journal of Critical Care, 17(1), 45–51

• Da Silva, Lucas, Fonseca & Machado(2012). Unplanned extubation in the intensive Care unit: systematic review, Critical Appraisal, and Evidence-Based recommendations. Anesthesia & Analgesia, 114(5), 1003-1014.

• Juliana Barr, et al(2013). Clinical Practice Guidelines for the Ma- nagement of pain, Agitation, and Delirium in Adult Patients in the intensive care unit. Critical care medicine 41(1), 263-306.

• L-C Chang, P-F Liu, Y-L Huang, S-S Yang,W-Y Chang(2011). Risk factors associated with unplanned endotracheal self extubation of hospitalized intubated patients: a 3-year re- trospective case-control study. Applied Nursing Research 24, 188–192.

• Mary Jarachovic, Maggie Mason, Kathleen Kerber & Molly McNett (2011). The role of standardized protocols in unplanned extubations in a medical intensive care unit. Am J Crit Care. 20, 304-312.

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