Aug 3: A nurse-led initiative at a New Jersey hospital reversed an upward trend of unplanned extubation rates in its medical intensive care unit and maintained the improvement for five years, according to an article published in Critical Care Nurse.
The rate of unplanned extubations in the 28-bed adult MICU at St. Joseph’s University Medical Center, Paterson, New Jersey, peaked in the last quarter of 2018 at 2.0 per 100 ventilator days, nearly double the internal benchmark of 1.06. After implementing the initiative, the MICU was able to quickly bring the rate down and sustain it below 0.7 per 100 ventilator days through 2023.
Alyson Triolo, MSN, RN, CCRN, ANP-C, an advanced practice nurse, and Jennifer Ricker, MSN, RN, NE-BC, CCRN, a nurse manager in the MICU, led development and implementation of the initiative with an interprofessional project team that included nurses, respiratory therapists, intensivists, and performance and safety improvement coordinators. Their article, “Decreasing Unplanned Extubation Rates on an Adult Medical Intensive Care Unit,” details the specific strategies they implemented based on each intubated patient’s level of risk for unplanned extubation. The authors discussed takeaways from the study in a video interview that accompanies the journal article.
“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,” Triolo said. “We also revised our standards of care for all patients receiving mechanical ventilation to mitigate ongoing risk factors and reinforce prevention.”
Staff awareness and education included the importance of proper patient positioning and daily rounds by nurse leaders for all patients receiving mechanical ventilation. In addition, a sign was placed outside the patient room to alert all staff that the patient was at high risk for unplanned extubation, and their high-risk status was added to all handoff and interprofessional team reports.
The project team developed talking points to help clinicians educate patients’ families about what to do if a patient tries to remove an endotracheal tube. A bedside sign served as a reminder of these conversations, instructing visitors to quickly intervene and alert staff if the patient attempted to self-extubate.
Additional staff education on ventilator weaning, including spontaneous awakening and breathing trials, emphasized liberating patients from the ventilator as quickly as possible. Of 343 unplanned extubations from 2018 to 2023 on the unit, only 82 patients (24.0%) who experienced unplanned extubation required reintubation, underscoring the importance of timely ventilator liberation.
A review of unit data led to a decision to increase use of mitten restraints, either alone or in combination with wrist restraints, when any type of restraints are warranted. During the study period, 251 unplanned extubations (73.2%) occurred in patients who had restraints at the time of the event. Of these, only 12 occurred while a patient was wearing mitten restraints, with or without wrist restraints.
The team treated every unplanned extubation event as a real-time learning opportunity, with frontline team review, postevent huddles with feedback forms, standardized incident reporting and regular distribution of data.
“The focus on proper patient assessment for unplanned extubation risk has become ingrained in the unit’s culture, and the signs are now a visible part of the environment,” Ricker said. “This initiative integrated evidence-based interventions, communication, teamwork and education to foster a culture of safety throughout the care we provide.”
As AACN’s bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients. Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org.