1. 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.

2. The incidence of accidental extubation in January – July 2014 was 35
The incidence of accidental extubation in January – July 2014 was 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.

3. 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.

4. 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

5. 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.

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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 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.

15. 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.

17. Thank you for your Attention