Unplanned Extubation In Intensive Care Units (ICU) CMC Experience. Presented by: Fadwa Jabboury, RN, MSN

Transcription

1 Unplanned Extubation In Intensive Care Units (ICU) CMC Experience Presented by: Fadwa Jabboury, RN, MSN

2 Introduction Basic Definitions: 1. Endotracheal intubation: A life saving procedure for critically ill patients in need of mechanical ventilation. Contributes to improving critically ill patients survival and reducing mortality.

3 Introduction (cont d) 2. Unplanned extubation (UE): is defined as premature removal of the endotracheal tube. Classified as either: - Deliberate unplanned extubation/self-extubation (USE) OR - Accidental extubation : induced by staff during nursing and/or medical care

4 Introduction (cont d) 4 Incidence: Unplanned extubation occurs at a rate of 1.1 to 22.5%. (Moons, Boriau, & Ferdinande, 2008) Reintubation rates ranged from 13.3% to 58.3% of unplanned extubation. Every day on mechanical ventilation increased unplanned extubation risk 3%

5 Introduction (cont d) 5 Risk factors associated with UE includes: Male gender APACHE score >or=17 Chronic obstructive pulmonary disease Restlessness/agitation Lower sedation level Higher consciousness level Use of physical restraints

6 Introduction (cont d) UE is a patient safety issue. Complications associated with UE are: Bronchospasm Laryngeal edema Aspiration pneumonia Hypotension Arrhythmias Cardiorespiratory arrest Death

7 Introduction (cont d) UE is also a potentially devastating costly event because it can result in increased (Outcomes) mortality morbidity length of stay.

8 Clemenceau Medical Center Intensive Care Unit

9 Clemenceau Medical Center Intensive Care Unit Clemenceau Medical Center is a 100- bed medical center. Affiliated with Johns Hopkins International and accredited by the Joint Commission International. ICU is a 6-bed unit: - Deals with a diversity of critical care patients, who are in need of continuous monitoring and/or acute phase attention. Medical Medical Surgical Surgical Medical Medical

10 Clemenceau Medical Center Intensive Care Unit It also includes within its premises the cardiac surgery unit, hosting routine, as well as state-of-the are care for special surgical procedures.

11 ICU Staffing Nurse Manager Charge Nurse Respiratory Therapist Manager Nurse Respiratory Therapist Intensivists and ICU fellow Nurse: Patient ratio = 1:2 & 1 RT in any given shift

12 ICU performance measurements UE is a one of the ICU s performance measurement. Related data are collected on monthly basis and analyzed on quarterly basis. Till the end of 2013, UE performance indicator was within the set target. Sudden increase in UE rate experienced in the second quarter of 2014.

13 % of UE Distribution of UE 30% 25% 20% 22% 25% 15% 10% 5% 0% 0% 0% 0% 0% Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Months

14 What You re Doing Is Getting You What You re Getting & To GET something different, you have to DO something different.

15 Performance Improvement Plan (PIP) In order to reduce the UE incidents and ensure patient safety and quality care, a performance improvement plan was developed in June, FOCUS-PDCA,a quality improvement method adopted by CMC for performance improvement development, was used.

16 PIP (cont d) F O C Intubation process Multidisciplinary team formed: physicians, NM, RNs, RTs Process drawn and clarified

17 PIP (cont d) U Case-control study done, data collected. Root-cause analysis done. S P Literature reviewed for best practices done. Selection of initiatives done. Plan plotted. Responsibilities distributed along with deadlines and needed resources.

18 PIP (cont d) D Plan put into action C A Follow up after action achievement and effectiveness Plan plotted. Responsibilities distributed along with deadlines and needed resources.

19 Data collection method 19 Data collection tool developed by the team and consisted of : 1. Patient characteristics: gender, age, days of intubation, diagnosis 2. Nurse characteristics: years of experience (senior staff > 2 years and Junior staff< 2 years), work shift 3. Outcome measures: Type of extubation; use of restraints; history of sedation; associated complications; re-intubation.

20 Literature review Related studies conducted from were reviewed (N=22). They were either case-control, observational or systemic review studies. From high impact journals. Risk factors and strategies for improvement were utilized in our performance improvement plan.

21 Results Patient characteristics Total number of admitted patients Total number of intubated patients Total number of USE Gender Age Days of intubation (27%) 6 (5.6%) F=72 (67%) M=35 (33%) Median = 55 yrs Average = 6 days

22 Results Nurse Characteristics Years of experience Work shift < 2 years = 50% > 2 years = 50% Night = 70% Day = 30%

23 Results: outcome measures 83 % 17 % Accidental Etubation by staff Delibrate extubation by patient

24 Results: outcome measures (cont d) All patient were on restraints maintained on intermittent sedation Re-intubation done in 50% of cases No associated complications

25 Root-cause Analysis Root cause analysis done Pareto concept used (80/20) Patient agitation versus low level of sedation constitute the majority of the contributing factors followed by Improper monitoring during the weaning process Improper restraint

26 Performance Improvement (PI) Initiatives

27 PI initiatives Preventive measures Root Causes

28 PI initiatives 1 Adaptation of pain agitation delirium monitoring scale 2 Integration of this scale within our system: policies and ICU flowsheet 3 Educate medical and nursing staff about the new scale

29 PI initiatives 4 Conduct competency testing related to the use of the new scale 5 Assign one RN to one patient during the weaning process 6 Implement appropriate restraints

30 PI initiatives 7 Monitor the implementation process 8 Measure the implementation process: documentation audit and UE rate

31 rate Ongoing results Distribution of UE 30% 25% 20% 22% 25% 15% 10% 13% 8% 5% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Months

32 Step-1 Step-2 Monitoring system of Pain, Agitation & Delirium Assess LOC (RASS) Apply the CAM-ICU- Content of consciousness

33 Monitoring system of Pain, Agitation & Delirium (cont d) Step-1 Assess LOC (RASS)

34 Scale Label Description +4 Combative Overtly combative, violent, immediate danger to stuff +3 Very Agitated Pulls or remove tube(s) or catheter(s), aggressive +2 Agitated Frequent non-purposeful movement, fights ventilators +1 Restless Anxious but movement not aggressive or vigorous 0 Alert & Calm Alert and calm -1 Drowsy Not fully alert but has sustained awakening (eye opening or eye contact) in response to voice (>10seconds) -2 Light sedation Briefly awakens with eye contact to voice(<10seconds) -3 Moderate sedation Movement or eye opening to voice, but no eye contact V O I C E If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative) -4 Deep sedation No response to voice, but movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation 1. T O U C H If RASS is -4 or -5 stop (patient unconscious), recheck later Clemenceau Medical Center- February

35 Monitoring system of Pain, Agitation & Delirium (cont d) Step-2 Apply the CAM-ICU-Content of consciousness

36 Feature-1: Acute onset of mental status changes or a fluctuating course And Feature-2: Inattention And Feature-3: Altered level of consciousness Or Feature-4: Disorganized thinking Clemenceau Medical Center- February

37 CAM-ICU Worksheet Clemenceau Medical Center- February

38 rate Conclusion Distribution of UE PIP developed PIP implemented 30% 25% 20% 22% 25% 15% 13% 10% 5% 0% 0% 0% 0% 0% Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 8% 0% 0% 0% 0% 0% Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Months

39 39

40 References 1. Chang, L. Lieu, P. Huang, Y. Yan, S. (2009). Risk factors associated with unplanned endotracheal self-extubation of hospitalized intubated patients: a 3-year retrospective casecontrol study. Applied Nursing Research, 24 (2011), Confusion Assessment Method for the ICU (CAM-ICU). The Complete Training Manual (2014) Da Silva, P. Fonseca, M. (2012). Unplanned Endotracheal Extubation in the Intensive Care Unit: Systematic Review, Critical Appraisal, and Evidence-Based Recommendations. International Anesthesia Research Society, 114 (5),

41 References 4. Tanios, M. Epstein, S. Grzeskowiak, M. Nguyen, M. (2014). Influence of sedation strategies on unplanned extubation in a mixed intensive care unit. American Journal of critical care unit, 23(4), Richmond, A. Jargon, D. Hanson, V. (2004). Unplanned Extubation in Adult Critical Care Quality Improvement and Education Payoff. Critical care nurse, 24(1),