JOGNN I N F OCUS Unplanned Extubation in the NICU Jessica A. Barber Correspondence Jessica A. Barber MSN, CRNP, NNP-BC, RNC, Children s Hospital of Philadelphia, Neonatal/Infant Intensive Care Unit, 34th and Civic Center Blvd., Philadelphia, PA 19104. jessica.barber@alumni. upenn.edu ABSTRACT Unplanned extubation (UE) in the neonatal intensive care unit (NICU) is a significant patient safety and quality control issue. I describe the implementation of a quality improvement program using multifactorial prevention strategies, including staff education, identification of neonates at risk for UE, extubation and weaning, standardization of procedures, and comprehensive documentation. Additional research on quality improvement with strategies for neonates may prove beneficial in reducing UE rates in neonates. JOGNN, 42, 233-238; 2013. DOI: 10.1111/1552-6909.12009 Accepted October 2012 Keywords unplanned accidental extubation neonatal intensive care quality improvement Jessica A. Barber, MSN, CRNP, NNP-BC, RNC, is a Neonatal Nurse Practitioner, Children s Hospital of Philadelphia, Neonatal/Infant Intensive Care Unit, Philadelphia, PA. The author reports no conflict of interest or relevant financial relationships. Unplanned extubations (UE) in the neonatal intensive care unit (NICU) continue to be a significant patient safety and quality of care concern as assisted ventilation provides the newborn with an increased chance of survival. The accidental displacement of the tracheal tube can occur, and neonates are particularly vulnerable to this adverse event. Neonates present the challenge of securing the tracheal tube to a small face, and an emergent airway placement in this population may cause increased trauma to the fragile larynx, pharynx, and trachea (Veldman, Trautschold, Weib, Fischer, & Bauer, 2006). The incidence of UEs within NICUs is not well defined in the literature, but the associated rates are thought to range between 2 4.8 UEs/100 ventilator days (Carvalho, Mezzacappa, Calil, & Machado, 2010; Loughead et al., 2008; Veldman et al.). Identification of neonates whose UE may lead to an immediate, life-threatening emergency is important (Grap, Glass, & Lindamood, 1995). Although limited data regarding risks and prevention strategies associated with UEs exist, research focusing on quality improvement in relation to UEs in pediatric and adult intensive care environments is more extensive. These continuous quality improvement (QI) initiatives coupled with neonatal strategies may be helpful in reducing rates of UE within the NICU. Review of the Literature I conducted a literature search using the terms unplanned extubation, neonate, and accidental extubation. Of the 34 results, only three specifically focused on UE within a NICU setting and are discussed herein. Veldman et al. (2006) performed a retrospective cohort study in a Level III NICU to analyze characteristics of UE and to develop associated prevention strategies. In the sample of 104 neonates, 12 UEs were identified at a rate of 2 UEs/100 ventilator days, and all patients except one were nasally intubated. The UEs were identified as matching the following criteria: (a) sudden desaturation of respiratory deterioration of an infant with no audible bilateral air entry, (b) negative capnography or no chest movements, and (c) diagnosis confirmed by laryngoscopy. Two highrisk patient groups were discovered. Seven UEs occurred in very preterm infants, gestational ages ranging 25 to 29 weeks and birth weights ranging from 800 to 1045 grams, who received longterm ventilation. Four UEs occurred in term infants, gestational ages ranging 38 to 39 weeks and birth weights ranging from 2600 to 3570 grams, who received short-term ventilation. In the very preterm group, six patients required additional respiratory support with three patients needing to be reintubated and three patients needing nasal continuous positive airway pressure (CPAP). http://jognn.awhonn.org C 2013 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses 233
I N F OCUS Unplanned Extubation in the NICU Unplanned extubations in neonates compromise patient safety in relation to respiratory decompensation and airway trauma. Few publications address this concern. In contrast, the term infants did not need reintubations. Considering the demographics for the patients with UE, no differences were found in birth weight or gestational age in patients experiencing UEs compared to the total number of intubated patients. Although mortality was not increased in those patients with an UE, the length of stay in the NICU (statistically significant, p =.008) and duration of ventilator time were increased. In the order of occurrence, the reported rationales for the UEs included poor fixation of the tracheal tube, method of handling the infant including tube manipulation and kangaroo care, infant activity without handling, and other undocumented reasons. Veldman et al. (2006) ruled out nursing experience as a risk factor, but did discover a higher than usual nursing workload. During the shifts in which an UE event occurred, the nurse to patient ratio ranged between one nurse per 1.8 to 5 neonates (median = 3.85 patients), whereas in the entire study group, the nurse-to-patient ratio ranged between one nurse per 1.6 to 6 neonates (median = 3 patients). Even though the shifts with UE events had higher than average nurse-to-patient staffing ratios, these ratios were statistically nonsignificant. Also, the administration of sedation to the patients with UEs was similar to the intubated patients in the entire group. The investigators speculated that UE occurrence may have been increased in the NICU when compared to the pediatric and adult intensive care units due to difficult fixation of tubes to the small patients, increased activity due to lack of cognitive awareness, and less frequent weaning protocols. Because only 25% of the UEs required immediate intubation, and a weaning protocol was not in effect, the investigators hypothesized that perhaps the majority of the patients warranted weaning from the ventilator prior to the adverse event (Veldman et al.). Loughead et al. (2008) initiated a process improvement project within a Level III tertiary care NICU to identify modifications in care processes that may reduce and ultimately eliminate UEs. These investigators defined UEs as any endotracheal removal not specifically intended by a physician. In 2002, a retrospective medical record review was conducted to establish baseline data regarding the number of ventilated patients, ventilator days, and intubations or reintubations. Of the 445 infants admitted to the NICU during that time frame, 91 were intubated for a total of 987 ventilator days in which there were 47 UEs at a rate of 4.8 UEs/100 ventilator days, with reintubation necessary 51% of the time. Factors associated with the UEs included excessive secretions (51%), unsupported ventilator tubing, patient procedure, sedation related, loose tape, plugged endotracheal tube (ETT), and loose skin-protective barrier (Loughead et al.). In 2003, an interdisciplinary process improvement team was formed to reduce this elevated rate. Extubations were prospectively tracked by a newly developed data collection tool that included demographic information, clinical factors possibly contributing to the UE, and the need for reintubation. This tool was completed during the shift in which the UE occurred and reviewed by a member of the process improvement team within 72 hours to ensure completion. Researchers used ranges of UE in neonatal literature to identify an initial goal of 1.8 UEs/100 ventilator days (Loughead et al.). During the baseline portion of this study, the method for taping and securing the oral endotracheal tube was based on practitioner discretion. Therefore, the first intervention performed was to secure the tube in a standardized method that ultimately improved the UE rate to 3.4 to 4.2 UEs/100 ventilator days, which did not meet the target goal. The researchers then explored different stabilization methods and instituted a modified umbilical clamp method. This second intervention was initiated following in-service and competency demonstrations and resulted in an immediate decrease in UEs. The rate of UEs for the following 3.25 years after the implementation of the umbilical clamp method averaged 0.9 UEs/100 ventilator days indicating a significant decrease from baseline and well under the target rate. The investigators further commented that patient characteristics, staffing levels, use of sedation, nursing practices, and types of ventilators remained consistent (Loughead et al., 2008). Another prospective cohort study was performed by Carvalho and colleagues (2010) to determine the incidence and risk factors of UEs in the NICU. Variables considered included intubation route, birth weight, gender, gestational age, use of sedation and analgesia, and total ventilation time. Infants on assisted ventilation received a continuous infusion of fentanyl. The UE rate of the 222 newborns was 2.7 UEs/100 ventilator days. Univariate analysis revealed several risk factors for UE 234 JOGNN, 42, 233-238; 2013. DOI: 10.1111/1552-6909.12009 http://jognn.awhonn.org
Barber,J.A. I N F OCUS including total ventilation time, duration per each intubation route, naso- and orotracheal intubation routes, and number of ventilated days. Multivariate analysis showed assisted ventilation duration as the only significant independent predictor of UE, and every day on mechanical ventilation had an increased UE risk of 2% to 3%. Even though weight and gestational age were not considered significant, a trend for an increase risk in infants weighing fewer than 1,000 grams and fewer than 28 weeks gestation was found. The researchers concluded that the results suggested implementing measures for reducing UEs, such as an appropriate nurse-to-patient ratio, education programs, early extubation, and use of noninvasive ventilation techniques. Specific factors related to unplanned extubations include mechanical issues, handling and procedures, nursing workload, and the implementation of a quality improvement program. kangaroo care with two to three staff members assisting following specific transfer instructions from incubator to kangaroo care and back to the incubator, draping and not taping the tubing, and providing suctioning of tracheal tube secretions during kangaroo care. Accidental extubations did not occur in studied population of mechanically ventilated infants weighing <600 g and <26 weeks gestation experiencing kangaroo care with the developed criteria and protocol. Specific Factors Related to UEs Mechanical Considerations Poor fixation of the tracheal tube, a malpositioned tube, copious secretions, and unsupported ventilator tubing were identified in the literature as possible catalysts to an UE event. In a meta-analysis focused on tube security, researchers did not find a decreased rate of UEs in nasally intubated patients compared to their orally intubated counterparts (Spence & Barr, 2000). Ensuring the tracheal tube is correctly positioned, ensuring tube security in accordance to unit policy, providing suctioning as needed, and supporting ventilator tubing help minimize risk of UEs. Handling Although developmental positioning and minimal handling decrease stimulation and the potential risk for UEs, handling must still occur for patient care. For instance, kangaroo care or skinto-skin contact between infant and parent is being used more widely with infants needing mechanical ventilation. This contact involves a major position change for the neonate as well as the ventilator equipment. In the study conducted by Veldman et al. (2006), despite having a protocol to prevent UEs, one infant experienced an UE during kangaroo care in the NICU. Ludington-Hoe, Ferreira, Swinth, and Ceccardi (2003) strived to establish safe criteria and procedures for kangaroo care with intubated preterm infants. They conducted an experimental study comparing their own stable criteria and protocol for kangaroo care to published data. Stable criteria included infants being ventilated for at least 24 hours, stable on low ventilator settings (rate <35 breaths per minute, FiO 2 < 50%), stable vital signs, and not on vasopressors. The protocol included a standing transfer to Nursing Workload Another important factor is the relationship of UEs and nursing workload. Although the neonatal specific articles did not reveal a significant correlation, researchers found an increased rate of UEs with higher nurse-to-patient acuity ratios within a pediatric intensive care unit (PICU). Ream et al. (2007) conducted a prospective cohort study that examined nurse to patient staffing ratios in a PICU and the relationship of these ratios to UEs. A patient acuity level classification system was selected, and a strong correlation was found between the acuity level and the therapeutic intervention scoring system points, a measure of nursing workload. The patient acuity levels estimated the nursing workload during the occurrence of UEs and found nearly a fourfold risk increase. The researchers suggested that UEs in the PICU may have an increased sensitivity to staffing ratios due to the patient s immature cognitive status, smaller airways, frequent use of oral and uncuffed tracheal tubes, and limited positioning of the tube requiring increased nursing surveillance. Inadequate documentation of UEs within this study restricted identification of confounding variables and was considered a main study limitation and quality of care concern. Quality Improvement Programs Instituting a quality improvement program in attempt to reduce UEs is not a new concept, and positive outcomes in adult and PICUs are well documented in the literature. Chiang, Lee, Lee, and Wei (1996) concluded that the institution of a QI program is effective in reducing incidence of UEs. In this prospective study, the major components of the QI program included (a) organizing a multidisciplinary task force; (b) in-service JOGNN 2013; Vol. 42, Issue 2 235
I N F OCUS Unplanned Extubation in the NICU Implementing a quality improvement program that incorporates standardized procedures and protocols may substantially lessen the risk of unplanned extubation in the vulnerable neonatal population. educational courses; (c) design of an incident report; (c) procedure standardization; (d) encouragement of active communication; (e) avoidance of delayed extubation; (f) identification of high-risk patients; (g) development of guidelines for use of sedatives, analgesics, and psychotropic medications; (h) establishment of a threshold for evaluation, collecting, organizing, and analyzing pertinent data; (i) evaluating care, identifying actions to solve problems and assessing these actions; and (j) documenting improvement. After implementation of the CQI program, the UE rate significantly decreased from 2.6% to 1.5% in the second trimester and 1.2% in the third trimester of the program. This reduction was mainly observed in the orally intubated patients whereas UEs in nasally intubated patients remained similar at 1.2%, 1.4%, and 1.4%, respectively, for the three trimesters. More recently, quality improvement programs initiated in PICUs have been described as effective in reducing UE rates. Sadowski et al. (2004) provided educational sessions and care management protocols as targeted interventions. The rate of UEs decreased from 1.5 UEs/100 ventilator days in the first year to 0.8 UEs/100 ventilator days in the fifth and final year of the study. During this investigation, several factors were identified as being associated with an increased likelihood of reintubation, including children with large amounts of secretions, who had just received sedation, with prolonged courses of respiratory failure, and with an UE occurring during caregiver activity. The investigators found the CQI program paramount in reducing UEs. Patients with UEs had longer durations of ventilator dependence, longer stays in the PICU, and longer hospital stays. Similarly, Rachman, Watson, Woods, and Mink (2009) provided educational sessions for staff about sedation for the ventilated patient, complications of UEs, and an endotracheal tube taping policy was developed. During the initial period, 6.4 UEs/100 ventilator days occurred in which 20% of patients required reintubation. Factors precipitating these events included inadequate patient sedation, poor taping, improper positioning of the endotracheal tube, or unknown reasons. After the quality improvement program, UEs dropped significantly to 1/100 ventilator days. Table 1: Risk Factors Relating to Unplanned Extubations Risk Factors Poor fixation of tracheal tube Excessive secretions Plugged tracheal tube Unsupported ventilator tubing Handling and procedures Increased patient activity Previous unplanned extubation Lack of weaning protocols Lack of standardization and education Increased nursing work load Table 2: Proposed Safety Checklist for Prevention of Unplanned Extubation Checklist Tracheal tube is in correct placement Taping is secure and as per unit policy Ventilator tubing is well supported Secretions are managed Patient without increased activity level Implications for Clinical Practice Researchers have reported a decreased incidence of UEs following implementation of QI initiatives. Although researchers primarily have focused on adult and pediatric intensive care patients, common threads may also prove useful in the NICU. Recurring implementation strategies include an educational component, recognition of patient risk, addressing extubation readiness, standardization of procedures, and comprehensive documentation. As with all improvement projects, it is imperative to obtain baseline data to determine how the results have affected the identified problem. A task force may prove beneficial as it may aid in the development and outcome of the initiative. A key component in developing a QI project is to educate all involved with patient care and management. Changes and additions to unit procedures and documentation should take into consideration staff input and dissemination of the evidence based rationales provided. Several 236 JOGNN, 42, 233-238; 2013. DOI: 10.1111/1552-6909.12009 http://jognn.awhonn.org
Barber,J.A. I N F OCUS Figure 1. Unplanned extubation event report. factors related to an increased rate of UE are detailed in Table 1. Birth weight, gestational age, sedation status, and nasal versus oral intubation were not found statistically significant for UE. Staff should have an increased awareness of neonates considered high risk of UEs, and this status must be effectively communicated as an integral component of the nursing and respiratory therapy report, neonatology sign-out, and rounds. A patient safety checklist could be incorporated as an audit during rounds to further the discussion of UE risk level and identify specific risk factors to the patient on an individualized basis (see Table 2). Also, adoption of a weaning protocol and daily evaluation of extubation readiness during rounds may be beneficial considering many infants with UEs did not need immediate reintubation. To further decrease the risk of UEs, procedures should be standardized. Using the same taping technique may increase staff awareness of an unsecure tube, and vigilant yet judicious suctioning may abate excessive secretions as well as a plugged tube. Developmental positioning and JOGNN 2013; Vol. 42, Issue 2 237
I N F OCUS Unplanned Extubation in the NICU minimal handling decreases stimulation and therefore potential risk for UEs. In the event of an UE, documentation is crucial as it provides an understanding of the circumstances surrounding the adverse event. The proposed data collection tool (Figure 1) includes pertinent information with which to identify areas for further improvement. The tool should be completed in a timely fashion and reviewed by designated team members for evaluation. Conclusion Unintended extubation in the NICU continues as a patient safety and quality of care concern. Published research focusing specifically on the neonatal population is scarce. The main rationales for UE events were poor fixation of the tracheal tube, excessive secretions, handling during care interventions, and active infants that self ex-tubate. Standardization of procedures such as tube fixation and kangaroo care may diminish risks. Greater nursing workloads and lack of sedation administration were risk factors in some studies but not statistically significant in those solely related to neonatal patients. Birth weight and gestational age were also not considered risk factors in the neonatal studies. Because reintubation was not necessary with a majority of events, weaning protocols and recognition of extubation readiness may further decrease UEs. Successful quality improvement programs involve educating the NICU team, identifying those considered high risk, scrutinizing extubation readiness, standardization of procedures, and comprehensive documentation. By examining factors related to UEs in the NICU and implementing a CQI program, the incidence of UEs may be greatly reduced. REFERENCES Carvalho, F., Mezzacappa, M., Calil, R., & Machado, H. (2010). Incidence and risk factors of accidental extubation in a neonatal intensive care unit. Jornal de Pediatria, 86(3), 189 195. doi:10.2223/jped.1999 Chiang, A., Lee, K., Lee, J., & Wei, C. (1996). Effectiveness of a continuous quality improvement program aiming to reduce unplanned extubation: A prospective study. Intensive Care Medicine, 22, 1269 1271. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9120125 Grap, M., Glass, C., & Lindamood, M. (1995). Factors related to unplanned extubation of endotracheal tubes. Critical Care Nurse, 15(2), 57 63. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7774248 Loughead, J., Brennan, R., DeJuilio, P., Camposeo, V., Wengert, J., & Cooke, D. (2008). Reducing accidental extubation in neonates. Joint Commission Journal on Quality and Patient Safety, 34(3), 164 170. doi:10.1177/0884217503257618 Ludington-Hoe, S., Ferreira, C., Swinth, J., & Ceccardi, J. (2003). Safe criteria and procedure for kangaroo care with intubated preterm infants. Journal of Obstetric, Gynecologic & Neonatal Nursing, 32, 579 588. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/14565736 Rachman, B., Watson, R., Woods, N., & Mink, R. (2009). Reducing unplanned extubations in a pediatric intensive care unit: A systematic approach. International Journal of Pediatrics, 1 5. doi:10.1155/2009/820495 Ream, R., Mackey, K., Leet, T., Green, C., Andreone, T., Loftis, L.,... Lynch, R. (2007). Association of nursing workload and unplanned extubations in a pediatric intensive care unit. Pediatric Critical Care Medicine, 8(4), 366 371. doi:10.1097/01.pcc.0000269379.40748.af Sadowski, R., Dechert, R., Bandy, K., Juno, J., Bhatt-Mehta, V., Custer, J.,... Bratton, S. (2004). Continuous quality improvement: Reducing unplanned extubations in a pediatric intensive care unit. Pediatrics, 114(3), 628 632. doi:10.1542/peds.2003-0735-l Spence, K., & Barr, P. (2000). Nasal versus oral intubation for mechanical ventilation of newborn infants. Cochrane Database of Systematic Reviews, 2, CD000948. doi:10.1002/14651858.cd000948 Veldman, A., Trautschold, T., Weib, K., Fischer, D., & Bauer, K. (2006). Characteristics and outcome of unplanned extubation in ventilated preterm and term newborns on a neonatal intensive care unit. Pediatric Anesthesia, 16, 968 973. doi:10.1111/j.1460-9592.2006.01902.x 238 JOGNN, 42, 233-238; 2013. DOI: 10.1111/1552-6909.12009 http://jognn.awhonn.org