An initiative led by nurses at a New Jersey medical intensive care unit (MICU) was able to reverse a trend of rising unplanned extubations, bringing them back under the benchmark.
An advanced practice nurse and a nurse manager responded to an unplanned-intubation rate that was nearly double the internal benchmark of 1.06 per 100 ventilator days by developing a quality improvement project to identify patients at the highest risk and the high-risk times that might prompt an attempt to self-extubate. Their team then developed interventions based on risk level, according to their article published in Critical Care Nurse last month.
“Decreasing unplanned extubation rates in critically ill patients is an important element of care in the intensive care unit,” they wrote. “However, most available literature on unplanned extubation addresses its prevalence, risk factors, and patient outcomes; few articles offer specific, reproducible interventions for preventing unplanned extubation.”
Their initiative emphasized:
- Staff education about proper patient positioning
- Daily rounds by nurse leaders of all patients receiving mechanical ventilation
- Signs outside the rooms of patients who were high risk.
- Education of patient families about what to do if a patient tried to remove an endotracheal tube.
- Staff education that emphasized the importance of timely ventilator liberation.
A data review also led to an increased use of mitten restraints when any kind of restraint was used. Durning the study period only 12 of 251 unplanned extubations occurred with patients whose restraints included mittens.
“Our three-level algorithm of associated risk factors helped us identify which patients were at the highest risk for unplanned extubation, as well as the high-risk moments that may trigger an attempt to self-extubate,” said one of the authors, Alyson Triolo, MSN, RN, CCRN, ANP-C. “We also revised our standards of care for all patients receiving mechanical ventilation to mitigate ongoing risk factors and reinforce prevention.”
