Unplanned Extubation in ICUs NR CNS III Outcomes Analysis Project December 3, 2013 Tania Randell, RN-BC, BSN

Introduction  Unplanned extubation (UPE) is a quality indicator that can be linked to medical and nursing care quality in the ICU, ( Keikkas, 2012)  Reporting UPE, an adverse event, is not yet required. Tracking and improving UPE rates is part of providing safe, high quality care.  UPE can lead to: bronchospasm arrhythmias aspiration pneumonia hypotension cardio-respiratory arrest death (Da Silva, Fonseca, 2012)

Background  Factors contributing to UPE:  nursing  spontaneous Breathing Trials (SBT)  restraints  Sedation  Variables are within our control, plan of action should be based on data  Problem- there is not yet a recognized national benchmark  Unplanned extubations occur at a rate of 0.1 to 3.6 events per 100 intubation days (Da Silva, & Fonseca, 2012)

Methods  Data was collected from ICUs at a large urban academic institution  Data FY 2012 Q2 – FY 2013 Q4  Excel spreadsheet transferred to SPSS  N = 241 (6 patients had repeat events)  Analysis- UPE rate & and reintubation rate  Chi Square analysis- relationship between SBT and reintubation

Methods  data that was collected from all ICUs:  location & time of event  number of events  reintubated (Y/N)  time to reintubation  data collected from Trauma units  demos: gender, age  SBT screening completed  SBT trial completed  restraints prior to event  total ventilator days, ICU days & LOS

Limitations  data for all units should have been analyzed first before going into greater detail on Trauma units  not able to determine sedation level of each UPE patient  sample size for LOS data was small (N = 38)  with more time and FTEs, UPE rates could be calculated for all units (instead of just # of events)  for the trauma patients, some of the SBT screening and trial data was missing from charts

Findings  largest # of reported UPE during time frame- MICU (66)  smallest #- Neuro ICU (18), see Figure 1.  males : females in Trauma 25 : 7  mean ages: male = 44.3 female = 41.0  47.7% of UPE pt’s were reintubated and 52.3% were not  57.5% of the reintubations were within 2 hours while 41.6% were after 2 hrs but within 24  no statistically significant relationship (p =.221) between patients who had an SBT screen & UPE

Figure 1. Number of Reported UPE events by ICU

Discussion  Three trauma units combined average rate of UPE = 0.27 (UPE per 100 ventilator days).  compares to reported national average of (Da Silva & Fonseca, 2012)  this shows that the quality of care on the Trauma units is within the expected range compared to other ICUs across the nation but has room for improvement  other data worth tracking is related to rates over time (See Figure 2.)  reintubation rate varies from 10.3% to 78%, (King & Elliott, 2012). The rate for ICUs in study = 47.7%

Figure 2. UPE rates for MTC FY12Q2 - FY13Q4

Conclusion  UPE and reintubation  poses risk to patients  increases ventilator days  increases length of stay  increases cost  This problem is modifiable and will take effort in terms of data collection, analysis, and planning of interventions

References Da Silva, P.J.L, Fonseca, M.C.M. (2012). Critical Care, Trauma, and Resuscitation: Medical Intelligence Article Unplanned Endotracheal Extubations in the Intensive Care Unit: Systematic Review, Critical Appraisal, and Evidence-Based Recommendations. Anesthesia & Analgesia, 114(5), doi: /ANE.0b013e31824b0296 Kiekkas, P., Aretha, D., Panteli, E., Baltopoulos, G.I., & Filos, K.S. (2012). Unplanned extubation in critically ill adults: clinical review. British Association of Critical Care Nurses, (18)3, doi: /j x King, J.N. & Elliott, V.A. (2012). Self/unplanned extubation: safety, surveillance, and monitoring of the mechanically ventilated patient. Critical Care Nurse Clinics of North America, 24(3), doi: /j.ccell