salon 1 15 kasim 09.30 10.30 eunok kwon
TRANSCRIPT
Unplanned extubation of patients in ICU
Eunok Kwon, RN, PhD Nursing Director of Operating room, Seoul national University Hospital, South Korea
10th International Congress of World Federation of Critical Care Nurses, Antalya, Turkey , November 12~ 15th 2014.
Safety Issues in ICU• More than 5 million patients are admitted to intensive
care units each year in the United States.• Mortality rates in patients admitted to the ICU average
10% to 20% in most hospitals.• Overall, approximately 200,000 patients die in U.S.ICU
each year.
Safety issues in ICUClassification of incidents used in the Australian AIMS
• Airway and ventilation: e.g. unplanned extubation and disconnections.
• Drugs and medications: e.g. allergic reactions and drug errors.
• Procedures, equipment and catheters: e.g. inadvertent carotid artery cannulation.
• Patient environment: e.g. a lack of appropriate beds causing pressure sores.
• ICU management: e.g. incidents caused by an over reliance on agency staff.
Patient’s outcome indicators in ICU( European Society of Intensive Care Medicine)
Domain Description Consensus (%)
Structure Intensive Care Unit (ICU) fulfills national requirements to provide Intensive Care.
100
24-h availability of a consultant level Intensivist 94
Adverse event reporting system 100
Process Presence of routine multi-disciplinary clinical ward rounds 100
Standardized Handover procedure for discharging patients 100
The maintenance of continuing medical education according to national standards
77
The maintenance of bed occupancy rates below a threshold level. 82
Outcome Reporting and analysis of standardized mortality ratio (SMR) 100
ICU re-admission rate within 48 h of ICU discharge 94
The rate of central venous catheter-related blood stream infection
100
The rate of unplanned endotracheal extubations 100
The endotracheal re-intubation rate within 48 h of a planned extubation
77
The rate of ventilator-associated pneumonia 77
Therapeutic catheters in ICU
• Types of catheters;
Foley catheter(75%), Central venous
catheter(64%), Endotracheal catheter (62%),
Arterial line(44%) Chest tibe(14%)
• 1995,European Prevalence of Infection in
Intensive Care (EPIC) study; Catheter related
infection & hospital acquired infection,
Unplanned extubation results in fetal patient’s
outcome.
Importance of management catheters
• Complication of accidental removal of catheters
• Intraventricular brain drainage ; hydrocephalus
• Cardiac surgical drainage; cardiac tamponade
• Subclavian or jugular venous catheter reinsertion;
pneumothorax and/or hemothorax.
• Endotracheal reintubation ; nosocomial pneumonia,
• New drains reinsertion; hemorrhage or nosocomial
infection.
Unplanned endotracheal extubations in ICU
Unplanned extubation rate; 0.1~3.6/100 intubation days. Risk factors; male gender, APACHE score≥ 17(OR9.0), COPD,
restlessness/agitation(OR3.3-30.6), lower sedation level(OR2.0-5.4), Higher consciousness level(OR 1.4-2.0), Use of physical restrains (OR3.1). Reintubation rates 1.8-88% of unplanned extubation. Preventive measures; Standardization of procedures, staff education, staff surveillance & identification &
management of high risk patients - decreasing rate; 22~53%
Best methods; securing E tube & use of Physical restraints ??
Anesth Analg.2012 may;114(5);1003-14,Epub 2012 feb 24. Silva PS Analysis 1950 yr~2011yr 50articles
Nurse staffing factors related patient outcomes in ICU
• 28 research RN-to patient ratio vs patient outcome odds ratio
• RN staffing ratio vs ICU mortality OR 0.91(95%Cl)0.86-0.96 surgical 0.84 medical 0.94
• Increase by 1RN per patient day decreased VAP OR 0.7(95%Cl 0.56-0.88) unplanned extubation (OR,0.49;95%Cl),respiratory failure(0.40;95%Cl), cardiac arrest in ICU(OR 0.72;95%Cl),lower risk of failure to rescue in surgical patients(OR0.84;95%Cl), Length of stay was shorter by 24% in ICUs(OR 0.76;95Cl)& 31% in surgical patients(OR,0.69;95%Cl)
• The association of registered nurse staffing levels and patient oucomes;Med care.2007 Dec;45(12)1195-204 Kane RL et al
Introduction- Critical care unit in SNUH
MICU22 bed
SICU1 18bed
CPICU8 bed
CCU8 bed
SICU2 14bed
EICU12 bed
Adult ICU; 70 bed
NICU40bed
PICU20bed
1821 total hospital beds, 154 ICU Beds
Emergency center
Children’s Hospital
Case; SNUH adult ICU• A case-control study over 3 years period from
January 1,2010 through December 31,2012.• A 62-beds medical & surgical intensive care unit
of 1800 beds tertiary hospital
Unplanned VS planned extubation Patients
• Data were retrospectively collected from electronic medical records.
• A total 230 episodes of deliberate unplanned extubation in 242 patients from 41,207 mechanically ventilated patients for 3 years(frequency 0.53%).
• 460 episodes in 460 patients with planned extubation age, gender & diagnosis-matched controls were analyzed in this case-control study.
Predictors related to unplanned extubation in SNUH cases
Predictors associated with unplanned extubation include •Better motor response (OR 1.3),•Admission route via ER(OR 1.8),•Higher APACHE Ⅱscore(1.061),•Mode of mechanical ventilation (CPAP, PSV: OR4.1, SIMV:3.0), •Peripheral O2 saturation(OR:0.9), heart rate(OR: 1.0), respiration rate(OR:1.0)
Predictors related to unplanned extubation in SNUH cases
• Pain (OR:0.3), • Agitation(OR:9.0),• Delirium(OR:11.6), • Night shift(OR:6.0) &morning care
time(OR:0.5).
Predictors related to unplanned extubation in SNUH cases
The patients’ & organizational outcomes of unplanned extubation were •Reintubation(OR;85.66)•Poor discharge result(OR:0.2)•Longer length of stay in the ICU (adj R-square:7%)and a longer length of stay in the hospital(adj R-square:4.3%).
High predictive factors of unplanned extubation in SNUH cases
• Delirium, agitation, ventilation mode and night shift are high predictive factors of unplanned extubation.
• The outcomes of unplanned extubation were increasing reintubation, a poor patient outcome at the time of discharge and poor organizational outcome including longer length of stay in the ICU and hospital.
DeliriumDelirium
Failure of Failure of weaning weaning ventilatorventilator
Increased Increased mortality & mortality &
medical medical costcost
Low Low satisfaction satisfaction of caregiverof caregiver
Increased Increased length of length of
staystay
Delirium management in SNUH ICU
PAD management in SNUH ICU
Delirium management Delirium management protocol for high risk protocol for high risk
group of deliriumgroup of delirium
Delirium management Delirium management protocol for high risk protocol for high risk
group of deliriumgroup of delirium
High risk group?High risk group?Age>65
Visual acuity defect, hearing
disturbanceCognitive function
impairmentRestraint
High risk group?High risk group?Age>65
Visual acuity defect, hearing
disturbanceCognitive function
impairmentRestraint
Delirium Delirium management management
protocol protocol
Delirium Delirium management management
protocol protocol
2012 ICU QA outcome indicator
Accidental catheter removal
rate,Delirium incidence.
2013 PAD care bundle of ICU in SNUH
iPAD(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
Crit ical Care Nonverbal Pain Scale
i tem tip scoreday
time
1
Facial
expressio
n
Natural expression 0
tears 1
Painful expression 2
Biting endotracheal tube 3
2Physical
response
No movement, relax 0
Slow motion 1
Nodding, try to touch painful site 2
Severe movement 3
3
Synchrony with
ventilator(intubate
d patients)
No alarm sound,no cough 0
Intermittent alarm, cough, 1
Frequent alarm, hyperventilation 2
Asynchrony with ventilator, consistent cough 3
Voice
sound
(extubate
d
patients)
normal 0
moaning 1
Express about pain 2
Loud voice, Cry, aggressive 3
sum
Indication: The patient can’t report by self due to consciousness change, sedation, artificial airway,
mechanical ventilation
Assess: 2 fr ≥ duty, ASSESS
intervention: 3 score ≥ CNPS, give pain killer.
reevaluation:
Pain scale in SNUH ICU
Pain scale in SNUH ICU
Education based on simulation about unplanned extubation
Simulation training related to unplanned extubation
I see you in ICUSafety based nursing
A nurse will always give us hope, an angel with a stethoscope.~Terri Guillemets
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 the European 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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