The Role of Standardized Protocols in Unplanned Extubations in a Medical Intensive Care Unit

Mary Jarachovic, Maggie Mason, Kathleen Kerber and Molly McNett

Am J Crit Care 2011;20:304-312 doi: 10.4037/ajcc2011334
2011 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright 2011 by AACN. All rights reserved.

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Pulmonary Critical Care

HE

ROLE OF

STANDARDIZED PROTOCOLS IN UNPLANNED EXTUBATIONS IN A MEDICAL INTENSIVE CARE UNIT

By Mary Jarachovic, RN, BSN, Maggie Mason, RN, BSN, Kathleen Kerber, RN, MSN, ACNS, BC, and Molly McNett, RN, PhD
Background Many patients admitted to medical intensive care units require mechanical ventilation to assist with respiratory management. Unplanned extubations of these patients are associated with poor outcomes for patients and organizations. No previous research has investigated the role of standardized protocols in unplanned extubations when examined in conjunction with traditional risk factors. Objective To identify risk factors associated with unplanned extubation among patients receiving mechanical ventilation and determine degree of compliance with pain, sedation, and weaning protocols. Methods A prospective cohort study design was used. Data on all patients admitted to the medical intensive care unit who required mechanical ventilation were gathered daily. Additional data were gathered on those patients who experienced unplanned extubation. Descriptive, correlational, and regression analyses were performed. Results Weaning protocols were a significant predictor of unplanned extubation: patients who had weaning protocols ordered and followed were least likely to experience unplanned extubation. Only 10% of the 190 patients in the study required reintubation, resulting in a significantly shorter ventilation time and unit length of stay among the unplanned extubation group. Conclusions Weaning protocols were associated with decreased incidence of unplanned extubation. Use of standardized protocols was feasible, as compliance among health care providers was high when protocols were medically prescribed. The reintubation rate in this study was low and associated with a significantly shorter ventilatory period and unit length of stay in the unplanned extubation group. (American Journal of Critical Care. 2011;20:304-312)

C E 1.0 Hour
Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: 1. Identify weaning protocols used in assisting planned extubations. 2. Explore types and percentages of unplanned extubations. 3. Examine important implications of unplanned extubations for patient care.
To read this article and take the CE test online, visit www.ajcconline.org and click CE Articles in This Issue. No CE test fee for AACN members.
2011 American Association of Critical-Care Nurses doi: 10.4037/ajcc2011334

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number of patients admitted to medical intensive care units (MICUs) require mechanical ventilation to assist with short- or long-term respiratory management and stabilization. Unplanned extubation (defined as an endotracheal tube being removed by the patient or accidentally) of MICU patients is a potentially lifethreatening situation that continues to occur despite research and educational efforts. Unplanned extubation, whether deliberate or accidental, is associated with a number of medical complications and increased length of stay in the hospital and unit.1,2 Deliberate unplanned extubation occurs when a patient intentionally pulls out an endotracheal tube, whereas accidental unplanned extubation is the unintentional removal of the endotracheal tube by either patient or staff, which can occur with repositioning, procedures, or coughing.

Within our institution, an ongoing quality improvement project indicated that unplanned extubation continued to occur despite implementation of sedation, pain management, and weaning protocols that addressed factors reported in the literature to be associated with unplanned extubation. Additional investigation was needed to explore factors associated with unplanned extubation. Therefore, a research project was initiated with the following study aims: (1) to identify factors associated with unplanned extubation among patients admitted to the MICU who are receiving mechanical ventilation and (2) to determine the degree of compliance of physicians and nurses with sedation, pain, and weaning protocols.

associated with unplanned extubation, it continues to occur and remains a serious complication of translaryngeal intubation. Traditional Risk Factors for Unplanned Extubation Several risk factors contribute to unplanned extubation among patients receiving mechanical ventilation in intensive care units. These factors include patient level variables such as agitation, altered level of consciousness, and inadequate sedation, as well as structure/environmental variables, which include oral intubation, method of securing tube, and the use of physical restraints.5,10,11 A case-control study of unplanned extubation among patients in medical and surgical ICUs indicated that patients who experience unplanned extubation were more likely to be medical patients, to have a current history of smoking, a nosocomial infection, or metabolic disorder, and to be agitated or restless and restrained.7 In a second study,9 researchers reported that all patients who experienced unplanned extubation were orally intubated, and 56% of those patients had to be emergently reintubated. Unplanned extubation is associated with prolonged duration of mechanical ventilation, and longer stays in the ICU and hospital. Other factors associated with unplanned extubation include anxiety, routine care interventions, and a history of previous unplanned extubations.12 Sedation/Agitation: The Role of Pain and Sedation Protocols A key factor that contributes to unplanned selfextubation is inadequate level of sedation, resulting

Background
The reported rates of unplanned extubation range between 7% and 18% in most ICUs.1,3-6 Risks associated with unplanned extubation include bronchospasms, arrhythmias, aspiration, pneumonia, respiratory failure, and cardiopulmonary arrest.7,8 Although mortality rates have not consistently been shown to increase with unplanned extubation, unplanned extubation does result in prolonged mechanical ventilation, longer ICU and hospital stay, and an increased need for chronic care for those patients who do not tolerate an unplanned extubation.1,9 Despite research regarding risk factors

Unplanned extubation, whether deliberate or accidental, increases length of intensive care unit and hospital stay.

About the Authors

Mary Jarachovic is a clinical nurse, Maggie Mason is a nurse manager, and Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and Molly McNett is director of nursing research in the Department of Nursing at MetroHealth Medical Center in Cleveland, Ohio. Corresponding author: Molly McNett, 2500 MetroHealth Drive, Nursing Business Office, MetroHealth Medical Center, Cleveland, OH 44109 (e-mail: mmcnett@ metrohealth.org).

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Variables related to patients Age Primary diagnosis Secondary diagnosis Medical history Level of consciousness Riker score Results of arterial blood gas analysis Length of stay in the MICU No. of days intubated Pain score Ventilator settings

of stay in the hospital and ICU.16,17 Protocol adherence by all members of the health care team is equally important, as such adherence has contributed to decreased use of restraints and shorter stays.18 It is evident that use of pain and sedation protocols with patients receiving mechanical ventilation can improve patients outcomes. By decreasing the level of agitation among patients receiving mechanical ventilation, protocol use addresses a key factor associated with unplanned extubation. However, no studies were found that explored the impact of these protocols on rates of unplanned extubation when combined with traditional risk factors. The Role of Weaning Protocols The use of standardized protocols for weaning from mechanical ventilation has been widely studied.19-26 The use of computerized protocols or protocols directed by the nurse or respiratory therapist is effective in improving outcomes associated with mechanical ventilation, for example, reducing the number of ventilator days, reintubation rates, and rates of ventilator-associated pneumonia.19-24,27 However, additional research is needed to investigate the degree to which these weaning protocols influence unplanned extubation, which is a key ventilatory outcome not considered in previous studies. On the basis of the factors identified in the literature as contributing to unplanned extubation in patients receiving mechanical ventilation, a conceptual framework was created (see Figure). Taggart and Lind8 suggest that variables influencing unplanned extubations can be categorized according to whether they are related to the patient, the structure/environment, or the process. The specific variables used in the present study were therefore categorized as such and are depicted in the Figure. The traditional risk factors identified in previous research studies encompass the patient variables and structure/environmental variables that were included in the present study. To examine how much standardized protocols for pain, sedation, and weaning affected unplanned extubation, we classified these variables as MICU process variables (see Figure).

Variables related to the environment Type of physical restraints Type of device used to secure tube Route of intubation Activities being performed when unplanned extubation occurs Unplanned extubation

Variables related to MICU processes and protocols Compliance with sedation protocol Compliance with pain protocol Compliance with weaning protocol

Figure Conceptual framework for the study.

Abbreviation: MICU, medical intensive care unit.

in increased agitation.10 A prospective, multicenter observational study4 showed that a major predisposing factor to unplanned extubation was the lack of intravenous sedation, along with the orotracheal route for intubation, and a lack of strong tube fixation. In a separate prospective study,13 researchers found agitation, common in intensive care units, to be associated with adverse outcomes including prolonged ICU stay, nosocomial infections, and unplanned extubations. Agitation and lack of sufficient sedation have repeatedly been identified as factors contributing to unplanned extubation.3,4,14,15 To address agitation and standardize sedation management practices among patients receiving mechanical ventilation, many institutions have adopted protocols or guidelines for administration of pain and sedation medications. Implementation of these protocols has decreased the variability of the types of medications used, shortened the duration of mechanical ventilation, and decreased length

Methods
Design A prospective cohort study design was used to determine risk factors associated with unplanned extubation among all patients in the MICU who were receiving mechanical ventilation and to document the degree of compliance with the units sedation, pain management, and weaning protocols. Data on the presence of risk factors for unplanned

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extubation were prospectively collected on all patients consecutively admitted to the MICU who required mechanical ventilation. Sample and Setting The study took place in the MICU at MetroHealth Medical Center, a large urban teaching hospital in Cleveland, Ohio. The MICU is a 13-bed unit that admits a mean of 1200 patients per year. The sample comprised all adult patients receiving mechanical ventilation who were admitted to the MICU from September 1, 2007 to September 1, 2008. A power analysis indicated that a sample size of 156 would be sufficient for detecting a medium effect size at 0.80 power. Procedures This study was reviewed and approved by the hospitals institutional review board. All MICU patients receiving mechanical ventilation were screened to verify that the inclusion criteria (adult, cared for under MICU service) were met. Daily data were gathered on all eligible patients. Data on patient, environmental, and MICU process/protocol variables were collected. Patient variables included the patients age, number of days intubated, primary and secondary diagnosis, medical history, scores on Glasgow Coma Scale (GCS), Riker scores (agitation scale of 1-7, where 1 = unarousable and 7 = dangerous agitation), results of arterial blood gas analysis, pain score (recorded once for each 24-hour period, using the mean score from the preceding 24 hours), ventilator settings, and MICU length of stay. Environmental variables were use of restraints, device used to secure the endotracheal tube, route of intubation, and nursing activities. Finally, MICU process/ protocol variables included presence and compliance with sedation, pain, and weaning protocols. If a patient experienced an unplanned extubation, additional data were gathered on specific circumstances at the time of the unplanned extubation: time of unplanned extubation, results of arterial blood gas analysis, ventilator settings, restraints, device used to secure the endotracheal tube, Riker score, presence of protocols for pain, sedation, or weaning, and whether reintubation was necessary. The use of protocols for sedation, pain, and weaning was documented daily. Data were first gathered to determine whether the protocol was ordered by the physician and were coded as yes/no. To examine compliance with each protocol, data were then gathered on the degree to which the protocol was followed by the nursing staff. Response options were yes, no, or moderately. If a protocol were ordered

and each step of the protocol followed and documented within the previous 24 hours, then a yes answer was recorded. If the protocol were ordered, but had not been followed by the staff for the preceding 24 hours, a no response was recorded. Finally, if the protocol were ordered and had been followed to some degree within the preceding 24 hours, but not every component of the protocol had been implemented and documented, then a response of moderately was recorded by the data collectors.

Data Analysis All data were analyzed by using the Statistical Package for the Social Sciences (SPSS) software, version 15.0 (SPSS Inc, Chicago, Illinois). Descriptive statistics, including means, frequencies, and standard deviations, were first calculated. Correlational and logistic regression analyses were then conducted to identify relationships among study variables and to determine which factors were predictive of unplanned extubation.

The study documented degree of compliance with the units sedation, pain management, and weaning protocols.

Results
Data were gathered on 190 patients who met the inclusion criteria. Twenty-nine patients (15%) experienced unplanned extubation. Most patients (n = 110, 57.9%) were between the ages of 46 and 75 years and had a diagnosis of respiratory failure (n = 76, 40%). Table 1 displays the characteristics of the patients who experienced an unplanned extubation and those who did not. Most patients (72.4%) who experienced an unplanned extubation were male. No significant differences were found between the 2 groups for sex, GCS or pain scores, use of restraints, or for the presence of weaning, sedation, and pain protocols. Patients who had an unplanned extubation had slightly higher Riker scores (mean [SD], 3.64 [1.136] vs 3.05 [1.142], P = .009), fewer ventilator days (2.86 [2.371] vs 5.59 [4.508], P < .001), and a shorter MICU length of stay (5.07 [5.464] vs 9.27 [6.666], P < .001) than did the patients who did not experience an unplanned extubation.

Patients who had an unplanned extubation had higher Riker scores and shorter intensive care unit lengths of stay.

Risk Factors at the Time of Unplanned Extubation Additional data were gathered from the 29 patients who experienced unplanned extubation.

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Table 1 Characteristics of patients who had an unplanned extubation and patients who did not
Unplanned extubation Characteristic Sex, No. (%) of patients Male Female Score on Glasgow Coma Scale, mean (SD) Pain score, mean (SD) Riker score, mean (SD) Restraints, No. (%) of patients None Bilateral wrist Weaning protocol ordered, No. (%) of patients No Yes Sedation protocol ordered, No. (%) of patients No Yes Pain protocol ordered, No. (%) of patients No Yes Length of stay in medical intensive care unit, mean (SD)
a b

No

Yes

Statistics 3.515a

P .06

83 (51.6) 78 (48.4) 9.80 (3.656) 0.25 (1.064) 3.05 (1.142) 40 (24.8) 121 (83.4) 70 (43.8) 90 (56.3) 39 (24.5) 120 (75.5) 50 (31.4) 109 (68.6) 9.27 (6.666)

21 (72.4) 8 (27.6) 9.96 (3.024) 0.80 (2.255) 3.64 (1.136) 5 (17.2) 24 (82.8) 0.17a 14 (50) 14 (50) .01a 6 (21.4) 22 (78.6) .36a 12 (39.3) 17 (60.7) 5.07 (5.464) -3.920b <.001 .55 .91 .68 -0.034b -0.863b -2.625b .79a .97 .39 .009 .38

Analyzed by using the 2 test. Analyzed using the Mann-Whitney U test.

Table 2 displays a summary of the risk factors that were present among these patients at the time of unplanned extubation. Of the 29 patients who experienced an unplanned extubation, 26 (89.7%) did not require reintubation. The mean Riker score at the time of unplanned extubation was 4.04 (range, 3-6; SD, 0.744), which was slightly increased from the mean Riker score that had been documented before the unplanned extubation (mean, 3.56; range, 2-6; SD, 0.847). Results of Regression Analyses: Predictors of Unplanned Extubation A series of logistic regression models were created to explore the degree to which daily data were predictive of unplanned extubation. Daily clinical and ventilator variables were gathered on all patients and entered into the regression analyses. These variables included the presence of protocols (weaning, sedation, and pain), ventilator settings, GCS and Riker scores, pain scores, and the presence of restraints. A summary of the regression coefficients for each variable is provided in Table 3. The only variable that was significant in predicting unplanned extubation was the presence of weaning protocols. Patients who had weaning protocols ordered and

followed were least likely to experience unplanned extubation (test statistic = 5.875 [1 degree of freedom], P = .02). Compliance with Protocols A secondary aim of this study was to examine the degree of physicians and nurses compliance with sedation, pain, and weaning protocols for ventilator patients. Physicians compliance with protocols was measured by documenting whether the protocol was ordered for the patient. Response options were either yes (protocol was ordered) or no (protocol was not ordered) for this variable. Nurses compliance was determined by examining the degree to which the protocol was followed once it was ordered, as measured by yes (fully compliant), no (not compliant at all), or moderately (followed some aspects of the protocol, but not in its entirety). Physician compliance with ordering the protocols was fairly high for pain protocols (72%), but less so for weaning (59%) and sedation (57%). Full nursing compliance when the protocols were ordered (ie, protocol was followed in its entirety when it was ordered by the physician) was highest for weaning protocols (96%) and moderately high for pain (80%) and sedation (80%).

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Table 2 Risk factors at time of unplanned extubation

Discussion
Findings from this study contribute information about risk factors associated with unplanned extubation and the role of standardized protocols in reducing rates of unplanned extubation. Our rate of unplanned extubation (15%) was consistent with rates reported in the literature, which range from 7% to 18%.1,3-6 The percentage of patients in our study who required reintubation (10.3%), however, was low; researchers in other studies1-7,11,14,15,28 have reported reintubation rates of 31% to 78%. This finding, in conjunction with the fact that those patients in our study who experienced unplanned extubation had significantly shorter stays in the MICU and fewer ventilator days suggests that most patients who had unplanned extubation were essentially ready to be extubated. The need for tracheostomy and its effect on unplanned extubation were not evaluated in this study, as the mean ventilation time for both patients who did and patients who did not experience unplanned extubation was less than 5 days, and no studies were found that linked early tracheostomy with a lower incidence of unplanned extubation. In our study, the use of bilateral soft wrist restraints was common, as evidenced by an 83% restraint rate in both the patients who experienced an unplanned extubation and those who did not. This rate falls within the wide range reported in the literature (41%-91%) related to unplanned extubation.29 Per hospital policy, all patients in our study were on an established restraint protocol, which is in compliance with regulations from federal and private accrediting agencies. These restraint protocols included the need for a physicians order for restraint every 24 hours, use of the least restrictive type of restraint, documentation of restraint alternatives, and monitoring of restraint use every 2 hours by a registered nurse. Despite the use of restraints in our study, unplanned extubations continued to occur, which is consistent with findings from other studies.5,7,10,11 Quality improvement efforts are currently under way to examine additional alternatives to use of restraints in this critical care setting. However, in our study, the variable of physical restraint use was not a significant risk factor for unplanned extubation. Findings from previous studies on the effects of unplanned extubation yield mixed results. Several groups have reported that unplanned extubation is associated with longer stays and duration of mechanical ventilation.1,2,5,7,9 In one study,10 however, researchers found that patients who had unplanned extubations had shorter durations of mechanical ventilation and

Risk factor Method of securing tube Commercial tube holder Cloth tape Endotracheal tube ties Mechanism of unplanned extubation Not witnessed Patient pulled Nursing procedure being performed Patient coughed out tube Patient tongued out tube On weaning protocol at unplanned extubation No Yes On sedation protocol at unplanned extubation No Yes Pain protocol No Yes Restrained at unplanned extubation No restraints Yes, bilateral wrist restraints Yes, wrist and ankle restraints Require reintubation No Yes

No. (%)

24 (82.8) 2 (6.9) 3 (10.3) 6 (20.7) 17 (58.6) 1 (3.4) 4 (13.8) 1 (3.4) 24 (82.8) 5 (17.2) 6 (20.7) 23 (79.3) 27 (93.1) 2 (6.9) 2 (6.9) 25 (86.2) 2 (6.9) 26 (89.7) 3 (10.3)

Table 3 Logistic regression models: risk factors for unplanned extubation, adjusted for ventilator days
Variable Weaning protocol ordered and followed Sedation protocol ordered and followed Pain protocol ordered and followed On nonprotocol sedation/pain medications Score on Glasgow Coma Scale Riker score Pain score Patient restrained 0.661 -0.0809 -0.226 0.123 0.049 0.218 -0.142 0.491 t 5.875 0.070 0.587 0.109 0.520 1.112 0.252 1.116 P .02 .79 .44 .74 .47 .29 .62 .29

hospital stays, whereas researchers in another study4 reported no significant differences in duration of mechanical ventilation when patients who had an unplanned extubation were compared with patients who did not. Chevron et al10 concluded, however, that patients who required reintubation had longer periods of mechanical ventilation and longer ICU stays.

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The restraint rate was the same in patients who experienced an unplanned extubation and those who did not.

Weaning protocols decreased the incidence of unplanned extubation.

Results of previous studies of unplanned extubation indicate that sedation, agitation, use of physical restraints, altered level of consciousness, oral intubation, and method for securing the tube are linked with the occurrence of unplanned extubation.5,10,11 However, no studies had investigated the role of these variables in conjunction with the presence of standardized protocols (ie, weaning, sedation, and pain protocols) on unplanned extubation. In this study, we found that the presence of weaning protocols was the strongest predictor of unplanned extubation: those who had weaning protocols ordered were least likely to experience unplanned extubation. This finding is supported by the fact that 82.8% of patients who experienced unplanned extubation were not on weaning protocols at the time of the unplanned extubation. Results of other studies indicate that the presence of weaning protocols is associated with positive outcomes, including a reduction in duration of mechanical ventilation, rates of ventilator-associated pneumonia, rates of reintubation, and hospital costs.19-24,27 Use of these protocols is feasible, as reports on user compliance are typically high.19,26,27 In our study, weaning protocols were ordered by a member of the physician team 59% of the time. However, nursing compliance with this protocol, once it was ordered, was very high (96%). Thus, compliance with protocols was high when the protocols were medically prescribed. Compliance of the nursing staff with pain protocols tended to be high as well (80%). These protocols were ordered 72% of the time by physician staff. Although many of the patients (93%) were not on the pain protocol at the time of the unplanned extubation, pain scores recorded at the time of and before the unplanned extubation suggest that pain was not a reason for the unplanned extubation (mean at time of unplanned extubation, 0.00; SD, 0.000; mean before unplanned extubation, 0.29; SD, 1.512). In addition, the variable of pain did not prove to be statistically significant in the bivariate or regression analyses, which supports this conclusion. Several studies have investigated reasons why health care practitioners do not order or comply with established guidelines for weaning, pain, or sedation within the ICU setting. Patient-specific

factors, lack of familiarity of resident physicians with the protocols, physicians personal preference, lack of nursing support, and fear of oversedation have been cited as reasons associated with noncompliance with protocols.18,30,31 When examining use of protocols, it has been reported that practitioners working in larger or university-affiliated ICUs are more likely to use sedation or pain protocols,32 and protocol use ranges from 20% to 90%.18,30-33 Actual adherence, however, ranges from 20% to 58%.18 The percentage of the time that protocols were ordered in our study was consistent with the percentages reported in the literature; however, our adherence rates were much higher than those reported in other studies. The protocols for pain, weaning, and sedation that were investigated in our study were created collaboratively by the nursing, respiratory, and medical staff and have been in place for several years. The protocols are to be routinely ordered on all ventilator patients; however, findings from this study indicate that physicians compliance with routinely ordering protocols was low. Protocols are validated annually by the attending physicians, clinical nurse specialist, and nurse manager on the basis of current evidence-based respiratory recommendations for medical and nursing critical care. Work is currently underway collaboratively in our MICU with the attending physician team and nursing staff to ensure that all physicians (ie, residents, fellows, attendings) are educated about the importance of these protocols and that quality initiatives are in place to monitor compliance with protocol ordering and use. Findings from these quality projects will be used to determine whether future refinement of protocols is needed, particularly before annual review. Limitations of this study include the fact that it was conducted in the MICU of only 1 medical center. Thus, findings cannot be widely generalized. In addition, although this study explored a number of risk factors for unplanned extubation, several other variables that were not included in this study may influence unplanned extubation, such as delirium, hypoxia, nurse staffing levels, and the method of endotracheal tube fixation in both groups. Future studies incorporating these variables may yield additional information on risk factors. Despite these limitations, findings from this study do contribute to what is known about factors associated with unplanned extubation, and the study is one of the first to investigate the role of standardized protocols on unplanned extubation. Weaning protocols specifically in this study were feasible and decreased patients risk of unplanned extubation. Additional research is necessary to substantiate this finding further.

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Conclusion
In this study, we explored risk factors associated with unplanned extubation and the role of standardized protocols among patients in a MICU who were receiving mechanical ventilation. The sedation, pain, and weaning protocols in this study were feasible, because compliance was high among health care practitioners where protocols were medically prescribed. Weaning protocols in particular were associated with a decreased incidence of unplanned extubation. Only 10.3% of patients who experienced unplanned extubation in this study required reintubation, which highlights the need to ensure that unit processes are in place to ensure timely extubation of patients who indicate readiness. Future quality improvement initiatives may be effective at exploring the effectiveness of protocol-driven extubations. Implementation of unit processes in addition to standardized protocols can have potential impact on patients outcomes and hospital costs.
ACKNOWLEDGMENTS The authors gratefully acknowledge the nursing staff of the medical intensive care unit, who routinely care for intubated patients and strive to prevent unplanned extubation. FINANCIAL DISCLOSURES None reported. eLetters
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REFERENCES 1. Krinsley JS, Barone JE. The drive to survive: unplanned extubations in the ICU. Chest. 2005;128:560-566. 2. Bouza C, Garcia E, Diaz M, Segovia E, Rodreguez, I. Unplanned extubation in orally intubated medical patients in the intensive care unit: a prospective cohort study. Heart Lung. 2007;36(4):270-276. 3. Mion LC, Minnick AF Leipzig RM, Catrambone CD, Johnson , ME. Patient-initiated device removal in intensive care units: a national prevalence study. Crit Care Med. 2007;35 (12):2714-2720. 4. Boulain T. Unplanned extubations in the adult intensive care unit: a prospective multi-center study. Am J Respir Crit Care Med. 1998;157:1131-1137. 5. Chang LY, Wang KK, Chao, YF Influence of physical restraint . on unplanned extubation of adult intensive care patients: a case-control study. Am J Crit Care. 2008;17:408-415. 6. Coppolo DP May JJ. Self-extubations: a 12-month experi, ence. Chest. 1990;98:165-169. 7. Atkins PM, Mion LC, Mendelson W, et al. Characteristics and outcomes of patients who self-extubate from ventilatory support: a case control study. Chest. 1997;112:1317-1323. 8. Taggart J, Lind, M. Evaluating unplanned endotracheal extubations. Dimens Crit Care Nurs. 1994;13:114-120. 9. Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med. 2000;161:1912-1916. 10. Chevron VM, Menard JF Richard JC, et al. Unplanned extu, bation: risk factors of development and predictive criteria for reintubation. Crit Care Med. 1998;26:1049-1053. 11. Tindol GA, Dibenedetto RJ, Kosciuk L. Unplanned extubations. Chest. 1994;105:1804-1807.

12. Maguire GP DeLorenzo LJ, Moggio RA. Unplanned extubation in the intensive care unit: a quality of care concern. Crit Care Nurs Q. 1994;17:40-47. 13. Jaber S, Chanques G, Altairac C, et al. A prospective study of agitation in a medical-surgical ICU: incidence, risk factors, and outcomes. Chest. 2005;128:2749-2757. 14. Curry K, Cobb S, Kutash M, Diggs C. Characteristics associated with unplanned extubations in a surgical intensive care unit. Am J Crit Care. 2008;17(1):45-51. 15. Balon J. Common factors of spontaneous self-extubation in a critical care setting. Int J Trauma Nurs. 2001;7:93-99. 16. MacLaren R, Plamondon JM, Ramsay KB, Rocker GM, Ward DP , Hall RJ. A prospective evaluation of empiric versus protocolbased sedation and analgesia. Pharmacotherapy. 2000;20(6): 662-672. 17. Brook AD, Ahrens RS, Schaiff R, Prenice D, Sherman G, Shannon W, Kollef MH. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med. 1999;27(12):2609-2615. 18. Bair N, Bobek M, Hoffman-Hogg L, Mion LC, Slomka J, Arroliga A. Introduction of sedative, analgesic, and neuromuscular blocking agent guidelines in a medical intensive care unit: physician and nurse adherence. Crit Care Med. 2000;28(3):707-713. 19. Grap MJ, Strickland D, Tormey L, et al. Collaborative Practice: Development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. Am J Crit Care. 2003;12:454-460. 20. Marelich GP Murin S, Battistella F Inciardi J, Vierra T, Roby M. , , Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2001;118:459-467. 21. Ely EW, Baker AM, Dunagan DP et al. Effect on the duration , of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335:1864-1869. 22. Kollef MH, Shapiro SD, Silver P et al. A randomized controlled , trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25:567-574. 23. Strickland JH, Hasson JH. A computer-controlled ventilator weaning system. Chest. 1993;103:1220-1226. 24. Duane TM, Riblet JL, Golay D, Cole FJ, Weireter LJ, Britt LD. Protocol-driven ventilator management in a trauma intensive care unit population. Arch Surg. 2002;137:1223-1227. 25. Krishnan JA, Moore D, Robeson C, et al. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med. 2004; 169:673-678. 26. Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF Large scale implementation of a respiratory ther. apist-driven protocol for ventilator weaning. Am J Respir Crit Care Med. 1999;159:439-446. 27. McLean SE, Jensen LA, Schroeder DG, Gibney NR, Skjodt NM. Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. Am J Crit Care. 2006;15:299-309. 28. Whelan J, Simpson SQ, Levy H. Unplanned extubation: predictors of successful termination of mechanical ventilatory support. Chest. 1994;105:1808-1812. 29. Happ MB. Treatment interference in acutely and critically ill adults. Am J Crit Care. 1998;7:224-235. 30. Slomka J, Hoffman-Hogg L, Mion LC, Bair N, Bobek M, Arroliga AC. Influence of clinicians values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation. Am J Crit Care. 2000;9:412-418. 31. Tanios MA, Wit M, Epstein SK, Devlin JW. Perceived barriers to use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care. 2009;24:66-73. 32. Mehta S, Burry L, Fischer S, et al. Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients. Crit Care Med. 2006;34:374-380. 33. Patel RP Gambrell M, Speroff T, et al. Delirium and sedation in , the intensive care unit: survey of behaviors and attitudes of 1384 healthcare professionals. Crit Care Med. 2009;37:825-832.

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CE Test Test ID A1120042: The Role of Standardized Protocols in Unplanned Extubations in a Medical Intensive Care Unit. Learning objectives: 1. Identify weaning protocols used in assisting planned extubations. 2. Explore types and percentages of unplanned extubations. 3. Examine important implications of unplanned extubations for patient care.
1. Which of the following is an example of deliberate unplanned extubation? a. Occurs with repositioning b. Occurs during a procedure c. Occurs with coughing d. Occurs when the patient pulls the tube out 2. The reported rates of unplanned extubations in most intensive care units (ICUs) are which of the following? a. 2% to 12% c. 9% to 24% b. 7% to 18% d. 13% to 33% 3. Which of the following risks are associated with unplanned extubations? a. Laryngeal collapse, acute respiratory distress syndrome, heart block b. Bronchospasms, arrhythmias, cardiopulmonary arrest c. Laryngitis, aspiration, septic shock d. Epiglotitis, sick sinus syndrome, pneumonia 7. Which of the following protocols was ordered most by physicians in this study? a. Sedation b. Pain management c. Nutritional d. Weaning 8. Which of the following protocols was followed in full compliance by nursing staff ? a. Sedation b. Pain management c. Nutritional d. Weaning

9. Which of the following statements is true? a. The percentage of required reintubations for this study was 10.3%. b. Findings in this study can be generalized to other medical centers. c. Variables such as delirium and hypoxia play no role in unplanned extubations. 4. Which of the following statements is true? d. Most health care professionals do not order and do not comply a. Postoperative surgical patients are more likely to extubate themselves. with pain protocols. b. Nonsmokers are more likely to extubate themselves. c. Patients with agitation are more likely to extubate themselves. 10. Which of the following statements is true? d. Patients with pain are more likely to extubate themselves. a. The variable of physical restraint was a significant risk factor for unplanned extubations in this study. 5. Which of the following levels of arousal do you expect from b. The variable of pain control protocol was a significant risk factor a patient with a Riker score of 7? for reducing unplanned extubations in this study. a. Comatose c. The variable of weaning protocol was a significant risk factor for b. Sedated, rouses to deep pain reducing unplanned extubations in this study. c. Lightly sedated, responds to commands d. The variable of sedation protocol was a significant risk factor for d. Dangerous agitation reducing unplanned extubations in this study. 6. Which of the following variables was signif icant in predicting the minimal amount of unplanned extubations? a. Sedation protocol b. Pain management protocol c. Nutritional protocol d. Weaning protocol
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11. Which of the following patients is most likely to extubate? a. Diabetic smoker with a Riker score of 5 b. Nonsmoking cardiac patient with a Riker score 2 c. Postoperative cardiac valve patient with a Glasgow score of 6 d. Patient with a closed head injury and a Glasgow score of 3

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