The Science Journal of the American Association for Respiratory Care

2006 OPEN FORUM Abstracts

POTENTIAL FACTORS AFFECTING UNPLANNED EXTUBATIONS

Bhavisha Y. Patel, BS, RRT, Joseph G. Dwyer, MAEd, RRT

The Johns Hopkins Hospital, Baltimore, Maryland

Introduction:
Unplanned extubations occur in almost every hospital that operates mechanical ventilators. Factors affecting unplanned extubation events appear to be random at first glance, but may prove to have common circumstances involved. The purpose of this abstract is to determine if common factors exist and to identify possible actions to reduce the frequency of unplanned extubations.

Method:
Unplanned extubation event information was gathered using Patient Safety Net (PSN) online event reporting system through University HealthSystem Consortium (UHC). PSN reports include the following data: patient identifiers, demographics, date/time of event, location, harm score, description of event and possible solutions. Additional information was obtained through the Eclipsys® electronic medical documentation system. Eclipsys data confirmed date/time/location of event, ventilator parameter settings, weaning status, sedation administration level, restraint use, and re-intubation post-event if indicated. The data was sorted and grouped in the following categories as pertaining to the event: time of day, unit location, ventilator weaning status (including sedation administration), use of patient restraints, and ventilator settings and modes.

Results:
The following charts depict numbers of reported unplanned extubations per ICU by ventilator mode, and by timeframe of event occurrence.




Figure 1 displays unplanned extubations related to the patients' mode of ventilation and the geographic location at the time of the event. Figure 2 displays the time of day the events occurred.

Conclusions:

Different philosophies are employed in various ICUs and medical services regarding ventilation and weaning strategies. Two ICUs in particular account for the majority of the events, but with mixed results regarding mode of ventilation. Higher total frequencies of events occur during spontaneous modes of ventilation, than during controlled modes. The highest cluster of extubations in one ICU occurred more frequently during controlled ventilation than spontaneous. Review of sedation protocols and weaning guidelines are being evaluated for improvement.

Figure 2 displays three timeframes of particular concern.  Eighteen (18) percent occurred from 0800-1000 which corresponds to patient/health team rounds. Possible solutions could include having available staff to see to immediate ventilation needs during this time. Two section of the chart show fifteen (15) percent rates each from 0400-0600, and 1400-1600. These time frames are associated with preparing patients for weaning, and then for subsequent extubation. Accelerating the process, especially during decreases in sedation levels may positively affect outcomes.

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