Prevention of unplanned extubations in the ICU: results of a nurse-driven endotracheal tube care protocol

Introduction

Unplanned extubations (UEs) can be accidental or intentional (autoextubation). The incidence of UE is 1–4/100 ventilator-days and is considered a quality indicator for nursing care in the ICU. We studied the effect of a predominantly nurse-driven endotracheal tube care (ETTC) protocol on incidence, circumstances, and outcome of UEs in orotracheally intubated mechanically ventilated patients.

Methods

A 1-year prospective observational study in a 24-bed mixed medicosurgical ICU in a university hospital. The ETTC protocol includes: endotracheal tube (ETT) fixation with waterproof adhesive plaster and/or adapted tubeholder; wrist fixation in all patients; nurse-driven sedation and analgesia supervised by a dedicated ICU physician; pressure support weaning using a flow trigger and tube compensation when possible, actively steered by a nurse and a respiratory physiotherapist; special care to avoid ETT dislocation during mobilisation or transport of the patient; and prompt pharmacological treatment of the restless or agitated patient.

Results

Six hundred and eighty-eight patients were ventilated during 4,605 days. The incidence of UE was 0.32/100 ventilation-days. Autoextubation occurred in 11 (73%) patients, mostly (82%) during the evening or night shift, and in the absence of a nurse in the patient's room. All patients had been successfully weaned and were free of sedation. No patient had to be reintubated. All accidental extubations (n = 4; 27%) occurred in the immediate postoperative phase following cardiac bypass surgery and in the presence of a nurse and/or physiotherapist at the bedside. Seventy-five percent took place during morning shifts in full-sedated patients and were due to ETT dysfunction. All patients were promptly reintubated. UEs never occurred during patient mobilisation or transport. No patient died as a result of UE.

Conclusion

The implementation of a nurse-driven ETTC protocol for prevention of UE resulted in a very low incidence of UE, in a low number of accidental UEs occurring in relatively controlled circumstances, in no UEs during patient mobilisation, and in no excess morbidity and mortality.