The Development of Clinical Nursing Practice Guidelines in the Prevention of : Accidental Extubation in Neonatal Intensive Care Unit, Songklanagarind Hospital Researchers Anothai Chomchey BN.S. Ratchanee Sangsawang MN.S.

The incidence of accidental extubation in January – July 2014 was 35 The incidence of accidental extubation in January – July 2014 was 35.65 per 1,000 Ventilator’s days. NICU doesn’t have any written Clinical Nursing Practice Guidelines (CNPG) in the Prevention of: Accidental Extubation - The nurses provide nursing cares to the newborn with prevention of accidental extubation differently. Background Songklanagarind Hospital is a hospital with 853 beds. Based on statistic from NICU the most commonly with prematurity (42.2%), heart disease (8.8%), surgery (13.3%), and lung disease (4.4%) Endotracheal tube intubation averagely there are 21 cases per month.

Purposes 1.To develop CNPG in the Prevention of: Accidental Extubation in Neonatal Intensive Care Unit, Songklanagarind Hospital 2.To examine the result of the use of CNPG in the Prevention of: Accidental Extubation in Neonatal Intensive Care Unit, Songklanagarind Hospital.

2. Dissemination and Implementation Phase 1. Development Phase There are 8 activities in the development phase : Activity 1: To determine the problem and scope of the problem Activity 2: To set a working team to develop the CNPG Activity 3: To set objectives, target group, and results Activity 4: To search and evaluate empirical evidence Activity 5: To draft the CNPG Activity 6: To test validity and reliability by the experts Activity 7 : Implementation of the CNPG Activity 8 : Evaluation of CNPG National Health and Medical Research Council (NHMRC), guidelines for the development of clinical practice guidelines in 3 phases: Conceptual Framework 3. Evaluation Phase

Population and Sample -Using Krejcie& Morgan Table (Krejcie& Morgan, 1970) - Including 41 nurses in NICU of Songklanagarind Hospital who has been working for 1 year at lease - 31 newborn with Intubation before applying the CNPG and 31 newborn with Intubation after applying the CNPG, 62 newborns in total.

Data Analysis Instruments Results Data were analyzed by using frequency and percentage Data Analysis Research instruments consist of: 1. Evaluation of nursing practice for newborns to prevent unplanned endotracheal tube extubation 2. Questionnaire on the satisfaction of nurses on the use of nursing practice 3. Endotracheal tube extubation record Content validity index (CVI) of the instruments were 1.0, 0.93, 0.98 respectively. The reliability test using Cronbach’s alpha coefficient was 1. Instruments Results There are 4 parts of results presentation : Part 1. General Information of the Samples Part 2. Results of the Implementation of Nursing Practice in NICU Part 3. Incidence of Accidental Extubation in NICU Part 4. Nurses’ Satisfaction on the Use of Nursing Practice

The table 1 : General information. General characteristics:  Before using Guidelines N = 31  After using Guidelines N = 31 The number of patients % Per cent % Per cent Sex Boys Girls   11 20 35.48 64.52 23 8 74.19 25.81 Weight ( gram) Less than 1,000 1,000 – 2,000 2,001 – 3,000 More than 3,000 4 10 7 12.90 32.26 22.58 2 12 13 6.45 38.71 41.94 Gestational age (weeks.) 25-30 31-36 37-40 More than 40 3 9.68 14 1 45.16 25.80 3.23 Diagnosis Premature Heart disease. Surgery disease. PPHN* Birth Asphyxia After the surgery. 17 54.84 22.57 21 0. 67.74 - Intubation Patient in NICU Intubation from another. 19 61.29 * Persistent Pulmonary Hypertension of the Newborn: PPHN

Nursing Practice Practicable (Times) Practicable % Table 2: Evaluation of the CNPG for Prevent Accidental Extubation in Neonatal Intensive Care Unit (NICU), Songklanagarind Hospital  Nursing Practice Frequency (Time)*  Practicable (Times) Practicable % 1. Care to reduce the risk of accidental extubation 1.1 Newborn Swaddling/Restraint 93 50 53.76 1.2 Comfort 1.2.1 Solving the problems of uncomforting 1) Tepid Sponge 32 34.40 2) Diapers Change 92 98.92 3) Solving Problems of Airway Obstruction - Suctioning 100 - Unbent tube - No water in the ventilator circuit 4) Reduce Flatulence - Head-Up laying position - Stomach aspiration every 2 hours or before feeding.

Table 2: Evaluation of the CNPG for Prevent Accidental Extubation in Neonatal Intensive Care Unit (NICU), Songklanagarind Hospital  Nursing Practice Frequency (Time) *  Practicable (Times) Practicable % 1.2.2 Reduction of stimuli / sensory stimuli 1) Cover the incubator with cloth or light shields 93 92 98.92 2) Adjust the light in the ward to be appropriate 100 3) Open or close the incubator gently 87 93.54 4) Turn off medical device’s alarm 5) Do not place noisy equipment close to the newborn 6) Interfering with the newborn as minimum as possible 7) Comfortable lying position

Table 2: Evaluation of the CNPG for Prevent Accidental Extubation in Neonatal Intensive Care Unit (NICU), Songklanagarind Hospital  Nursing Practice Frequency (Time) * Practicable (Times ) % 1.3 Pain Measurement (according to NIPS) and Pain Management 1.3.1 Mild Pain: Reduction of external stimulation, rearrange lying position, using pacifier 93 77 82.79 1.3.2 Moderate Pain - Non Pharmacologic Treatment by reduction of external stimulation, rearrange lying position, using pacifier 47 50.54 - Pharmacologic Treatment 46 49.46 1.3.3 Severe Pain: Pharmacologic Treatment 30 32.25 2. Effective endotracheal tube stabilization - Correct endotracheal tube stabilization 100

3.7 To stabilize the endotracheal tube, two nurses are required. Table 2: Evaluation of the CNPG for Prevent Accidental Extubation in Neonatal Intensive Care Unit (NICU), Songklanagarind Hospital  Nursing Practice Frequency (Time) * Practicable (Times ) % Practicable 3. Care to prevent unplanned endotracheal tube extubation 3.1 Label the record of the size and position of endotracheal tube 93 84 90.32 3.2 Use tubing holder 100 3.3 Check the size and depth of endotracheal tube 3.4 Record the size and position of endotracheal tube 3.5 Check the position of endotracheal tube after nursing care 3.6 Change new sticking plaster once the existing one is wet 3.7 To stabilize the endotracheal tube, two nurses are required. * number of time to perform the task per morning , afternoon and night shift during the period of 1 month.

The table 3 : Comparison of Accidental Extubation Before using the guidelines After using the guidelines Accidental Extubation (times)   Intubation’s Day (date) /1,000 Ventilator Day 3  187 16.04 1 157 6.37

The table 4 : Nurses’s Satisfaction on the use of CNPG   Satisfaction. Highest High Medium  Low Frequency. % Percent Convenient in practice. 22 51.16 21 48.84 0. Content clarity. 18 41.86 24 55.81 1 2.33 Applicable. 30 69.77 13 30.23 Useful for the working unit 71.43 12 28.57 Agree with the implementation of guidelines 27 62.79 16 37.21

Discussion 1. Result of CNPG to prevent accidental extubation in NICU, Songklanagarind Hospital revealed that most of the nurses followed the practice (90%) 2. Comparison of the incidence of Accidental extubation pre- and post- implementation of CNPG revealed a decrease from 16.04 to 6.37 per 1,000 Ventilator’s days. 3. Nurses’ satisfaction on the implementation of CNPG in the NICU, was at high to highest level.

Suggestion 2.To obtain the success in implementation of this CNPG, there should be an emphasis on the personnel to understand the practice guidelines fully so that they would be able to perform the practice in the same manner. There should be a review and improvement of the practice’s content to be up-to-date, and there should also be regular follow up and inspection which will lead to continual practice. 1.The limitation of this study is that the study only examine of the incidence of accidental extubation pre- and post implementation of the nursing practice in percentage. No statistical difference was indicated. Therefore, to use of the results from this study as a reference is limited. Further studies should be developed by adding a statistic value indicating the statistical difference.

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