The Performance Gap
Unplanned Extubation (UE) is the unintentional removal of a patients breathing tube, either by self-removal (Self Extubation) or accidental removal due to an external force (Accidental Extubation) causing the tube to become dislodged.
Unplanned extubation, both in the field and in the hospital, is a common and costly problem. Unplanned extubation occurs in approximately 7% (range: 0.5% - 35.8%) of patients undergoing mechanical ventilation in the Intensive Care Unit \cite{da_Silva_2012}, results in over 12,000 deaths \cite{de_Groot_2011}, increases the incidence of pneumonia from 14% to 28% , increases the average ICU length of stay from 9 to 22 days3, and the complications of unplanned extubation result in over $4 Billion in unnecessary healthcare costs \cite{Dasta_2005,Needham_2005}.
Although the incidence of unplanned extubation is likely higher in EMS settings due to the difficulties of transporting critically ill patients in a chaotic environment, unplanned extubation is not tracked in most EMS systems. Similarly, most hospitals do not track unplanned extubation. If we are going to get an accurate measure of the commonness and costliness of unplanned extubation, both in the hospital and in the field, we must develop widespread systems to accurately track all incidences.
Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, practice, and technology plans, examples of which are delineated below for utilization or reference. This is provided to assist hospitals in prioritizing their efforts at designing and implementing evidence-based bundles for reduction of unplanned extubation.
Leadership Plan
- The core multidisciplinary team should consist of the following:
- VP of Quality / Safety
- Physician, nursing, and respiratory care team leaders from ED, OR/PACU, and ICU
- Hospital governance, senior administrative leadership, safety / risk management leadership and clinical leadership must work collaboratively and:
- champion efforts, raising awareness regarding the seriousness (commonness and costliness) of unplanned extubation
- demonstrate commitment and support by shaping a vision of the future, clearly defining goals, and supporting staff as they work through improvement initiatives, measuring results, and communicating progress towards those goals.
- commit to defining performance gaps within the organization (system-wide, hospital-wide and by department)
- support a comprehensive approach to standardized data tracking, quality management and process improvement efforts, and implementation of practice and technology plans necessary to eliminate unplanned extubation.
Practice Plan
Use current evidence-based guidelines and known best practices during airway management of the intubated, mechanically ventilated patient to eliminate incidences of unplanned extubation.
- Implement systems for alerting clinicians to patients with a known difficult airway.
- Position the endotracheal tube with the tip of the tube within the optimal tip position range (2-6 cm above the carina). Proper initial positioning of the endotracheal tube decreases the risk of unplanned extubation should movement of the tube occur.
- Once appropriately positioned, maintain that position with a tube stabilizer that eliminates clinically significant (> 2 cm) total movement of the tube.
- Restrain the patient utilizing a combination of physical restraint and chemical restraint (sedation).
- Institute a continuous sedation protocol with daily interruption of sedatives. Avoid intermittent or no sedation protocols \cite{Chao_2017}.
- Use Continuous Waveform Capnography in ALL intubated patients to ensure rapid recognition of a mal-positioned tube.
- The initial evaluation of any cardiopulmonary arrest in an intubated patient should be to determine if the endotracheal tube is correctly positioned and the patient is being adequately ventilated. Waveform capnography along with clinical evaluation must be used to make this determination. If the evaluation suggests the tracheal tube might be mal-positioned, the tube should be immediately repositioned, unplanned extubation should be considered as the cause of the arrest and a root cause analysis of the extubation performed.
- Develop a Quality Management Process to promote and ensure continuous improvement with an initial goal of eliminating preventable deaths from unplanned extubation and ultimately eliminating all incidences of unplanned extubation.
- Require tracking and reporting of all incidences of unplanned extubation and complications of unplanned extubation (hypoxemia, pneumonia, vocal cord injury, brain injury and death).
- Develop a quality management process to:
- review all incidences of unplanned extubation
- determine root causes
- inadequate stabilization of the endotracheal tube
- inadequate sedation (chemical restraint)
- inadequate physical restraint
- plan and implement changes to the system based upon findings from reviews
- track UE to determine if the implemented processes effect improvement
- Airway management in the field (EMS / Military) should incorporate the same prevention, tracking, and quality management concepts as described above for medical facilities. However, there are a few concepts that apply specifically to out of hospital management of unplanned extubation.
- All incidences of unplanned extubation in the field must be reported to the receiving facility during hand-off communications. The incidence of pneumonia doubles in mechanically ventilated patients who experience an unplanned extubation. To prevent pneumonia in a known unplanned extubation in the field, the EMS airway provider must communicate the incident to the critical care physician and the critical care physician must consider antibiotic therapy.
Technology Plan
- Standardize tracheal tube restraint devices
- The current methods and devices for stabilizing endotracheal tubes include adhesive tape, cotton twill ties and multiple commercial devices. The current literature does not clearly identify any device or technique currently on the market that is superior at preventing movement against externally applied forces. However, numerous devices on the market are clearly inferior in their ability to restrain the tube against extubation forces. Therefore, when choosing an endotracheal tube stabilizer, the device’s ability to restrain against applied force should be the primary consideration. Other considerations, such as ease of use or ability to prevent skin breakdown should be secondary considerations.
- A review article, published in 2012 in Anesthesia and Analgesia \cite{da_Silva_2012}, which evaluated more than 50 studies published worldwide, demonstrated an average rate of unplanned extubation of 7.3% (range = 0.5% - 35.8%). This high rate of unplanned extubation suggests that current stabilization techniques and devices are inadequate and therefore further research into developing better stabilization systems should be supported to achieve zero preventable deaths by 2020.
(Note: A study completed at the University of Colorado, Department of Biomedical Engineering, compared seven methods of endotracheal tube restraint systems and found one device to restrain against significantly higher forces compared to the other systems tested . This restraint system is currently undergoing final stages of research and development and the manufacturer expects market clearance by the FDA in mid-2018.)
- Optimal endotracheal tube stabilizers should:
- be secure.
- The stabilizer should, at minimum, prevent clinically significant movement (> 2 cm) that could result in an unplanned extubation; Optimally, it should prevent any movement of the endotracheal tube relative to the stabilizer. Even small incremental movements can result in unplanned extubation.
- be fast and easy to apply.
- provide easy access to the mouth for routine oral care.
- be repositionable and not exert any major pressure points to the skin or oral mucosa that would cause ischemic tissue injury.
- Mandate the use of Waveform Capnography in ALL intubated patients to ensure rapid recognition of a mal-positioned tracheal tube.
- This important technology has become the standard of care for intubated patients in the UK and parts of Europe. United States Intensive Care Units, Emergency Departments and Emergency Medical Services are beginning to adopt this technology, but significant gaps exist. Continuous Waveform Capnography should become a mandated safety practice for all intubated patients. Systems for in hospital and transport use are manufactured by Masimo, Medtronic (Oridion/Covidien), Nonin, Philips (Respironics) and Welch Allyn.
Metrics
Topic
Unplanned Extubation in Mechanically Ventilated Patients
Rate of unplanned extubation for patients undergoing mechanical ventilation via endotracheal tube
Outcome Measure Formula
Numerator: Number of incidences of unplanned extubation in patients mechanically ventilated via an endotracheal tube
Denominator: Total number of mechanical ventilation days
*Rate of unplanned extubation is expressed in terms of: Number of unplanned extubation incidences per 100 mechanical ventilation days
Metric Recommendations
Direct Impact: All patients undergoing mechanical ventilation via endotracheal tube
Lives Spared Harm:
\(Lives\ =\ \left(Unplanned\ Extubation\ Rate_{baseline}\ -\ Unplanned\ Extubation_{measurement}\right)\times \ Vent\ Days^*\ _{baseline}\)
* Vent Days is the Outcome Measure Formula Denominator: (Total Number of Mechanical Ventilation Days)
Data Collection: