1. Unplanned Extubation in ICUs NR.110.522- CNS III Outcomes Analysis Project December 3, 2013 Tania Randell, RN-BC, BSN

2. 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)

3. 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)

4. 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

5. 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

6. 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

7. 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

8. Figure 1. Number of Reported UPE events by ICU

9. Discussion  Three trauma units combined average rate of UPE = 0.27 (UPE per 100 ventilator days).  compares to reported national average of 0.1 - 3.6 (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%

10. Figure 2. UPE rates for MTC FY12Q2 - FY13Q4

11. 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

12. 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), 1003-1014. doi: 10.1213/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, 123-134. doi: 10.1111/j.1478- 5153.2012.00542.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), 469-479. doi: 10.1016/j.ccell.2012.06.004.