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Running Head: A COMPARISON OF CLINICAL PROFILES
A Comparison of Clinical Profiles for Critical Care Patients with Unplanned SE versus Planned
Extubation
Ashley Krusel, Sandra Kung, Todd Painter
The University of Akron
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Running Head: A COMPARISON OF CLINICAL PROFILES
Abstract
Background: Mechanical ventilation for critically ill patients is a life-saving intervention. To
accomplish this, a tube in inserted in the patient’s airway. As the patient’s condition improves,
the tube is removed under supervised conditions. However, some patients will remove the tube
themselves before they are ready. Self-extubation can cause trauma to the airway and puts the
patient at increased risk for respiratory failure, bradycardia, hypotension, vocal cord injury, and
death.
Objective: The purpose of this study is to determine differences in demographic and clinical
variables between unplanned self-extubation and planned extubations carried out by staff among
adult patients.
Method: A retrospective survey of medical records was conducted to identify differences in
demographic and clinical variables between the groups.
Findings: Of 109 subjects, lower weight (p=.004), fewer intubation days (p=.001), and a medical
diagnosis (p=.009) were found to be significant influences for self-extubation. The use of
intermittent rather than continuous sedation promoted self-extubation (p = .040). Reasons for SE
noted in the medical record indicated 14 (26%) events were due to agitation, 12 (22%) occurred
during repositioning of the patient, 7 (13%) were attributed to the patient coughing, and 21
(39%) were listed as unknown causes. 69% of the SE group required reintubation.
Conclusion: These findings indicate that patients with medical diagnoses who are within the first
few days of ventilator therapy and are of an average weight are at greater risk for SE. The use of
continuous sedation may deter SE events. Interventions to prevent SE should be instituted in this
population.
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Running Head: A COMPARISON OF CLINICAL PROFILES
A Comparison of Clinical Profiles for Critical Care Patients with Unplanned Self-Extubation
versus Planned Extubation
Background
Mechanical ventilation is used for critically ill patients to improve ventilation and/or
oxygenation in order to reverse potentially lethal conditions such as acidosis and/or hypoxemia
(Urden, Stacy, & Lough, 2009). Mechanical ventilation is the artificial movement of air into and
out of the lungs. Mechanical ventilation is accomplished by the insertion of an artificial airway.
The types of artificial airways that can be used with a mechanical ventilator are an endotracheal
(ET) or tracheotomy tube. A cuff inflated at the end of these tubes holds it in place internally and
tape or a commercial stabilizing device helps to maintain its position externally. A mechanical
ventilator is then attached to the artificial airway and can be set to deliver breaths to the patient
and monitor the respiratory parameters.
Weaning a patient from mechanical ventilation occurs when less ventilatory assistance is
needed, and the ventilator settings are reduced. The patient is weaned from the ventilator and
gradually breathes more on his own over time. Before weaning begins, spontaneous breathing
and arterial blood gases are obtained to determine patient readiness and ability to ventilate and
oxygenate with reduced ventilatory support. Once the patient is ready for the ET tube removal,
the cuff is deflated, and the tube is removed at the bedside by trained personnel (Urden et al.,
2009).
Self-Extubation (SE) is an unplanned extubation that occurs from the patient removing
the artificial airway by pulling it out with their hands. For this study SE will refer to premature
removal of the ET tube by the patient physically pulling the ET tube out of their airway.
Unplanned extubation can cause trauma to the airway and places the patient at increased risk for
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Running Head: A COMPARISON OF CLINICAL PROFILES
vocal cord damage, hypoxia, airway obstruction, respiratory failure, circulatory problems,
bradycardia, hypotension, and death (Moons, Boriau, & Ferdinade, 2008; Curry, Cobb, Kutash,
& Diggs, 2008; Gardner, Cook, Osbourne, & Gardner, 2005; Balon, 2001). SE is a type of
unplanned extubation.
Review of Literature
SE has been linked to lower levels of sedation and increased levels of agitation (Tung,
Tadimeti, Caruana-Montaldo, Mion, Palmer, Slomka, & Mendelson, 2001; Curry, Cobb, Kutash,
& Diggs, 2008; Huang, 2009). One contributor of agitation, the presence of limb restraints, is
often used to prevent SE for the pupose of maintaining safety (Curry, Cobb, Kutash, & Diggs,
2008; Balon, 2001). Curry (2008) found that 87% of the subjects were restrained at the time
they self-extubated, suggesting that restraints do not prevent SE. Agitation was present in 53% of
SE s reported by Balon (2001). Reduced incidences of unplanned extubation are associated with
maintaining appropriate sedation, and preventing and treating agitation (Moons, Sels, De Becker,
Geest & Ferdinade, 2004; Balon, 2001).
One study was performed to specifically look into the relationship between sedation and
SE by Tung, Tadimeti, Caruana-Montaldo, Atkins, Mion, Palmer, Slomka, and Mendelson
(2001) at the Cleveland Clinic Foundation. The study’s sample consisted of adult patients
(N=50) who experienced unplanned SE s during a twelve month period and an additional two
patients who didn’t self-extubate for every patient who did (N=100). Each set of two control
patients were matched by age, gender, dates admitted, and diagnosis to their self-extubated
counterpart. 54% of the SE group was reported as agitated and restless during intubation as
opposed to the 22% who were restless in the control group (Tung et al, 2001). However, 22% of
the SE group was reportedly alert and oriented while 76% of the control group was alert and
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oriented (Tung et al, 2001). Furthermore, more patients who received benzodiazepines selfextubated as opposed to those who did not receive these treatments. While it is easy to conclude
that inadequate sedation can lead to agitation and SE another possible culprit, according to Tung
et al (2001), is the possible overuse of sedation. Incorrect use of midazolam in the ICU,
particularly by healthcare providers who aren’t as specifically trained as anesthesiologists, may
prevent midazolam from achieving the intended effect and may lead to a paradoxical excitatory
effect (Tung et al, 2001). This effect can be the result of extended use, which in turn often leads
to prolonged intubation, and alterations of sleep cycles and circadian rhythms (Tung et al, 2001).
Other factors may contribute to the rate of SE. In a study of 265 self-extubated patients,
65.4% of them were male, whereas 34.6% were female (Yeh, S., Lee, L., Ho, T., Chiang, M. &
Lin, L. 2004). Out of the 82.6% of study participants who provided reasons in survey on why
they self-extubated, 57.7% described the tube as uncomfortable, 13.3% described it as painful,
approximately 11% wanted to breathe on their own or talk, 3.6% felt like they were suffocating
and 3.1% were confused as to why they had a tube in (Yeh et al, 2004). The remaining
participants gave other reasons, such as dreaming or wanting to go home, as reasons for pulling
the tube. Out of those who self-extubated, 41.2% needed to be reintubated (Yeh et al, 2004).
Serious consequences resulting from the extubation include: two patients who experienced
death, one airway bleeding, one hypotension, and four dyspneic subjects. The states of the
patients following SE were as follows: 3.4% comatose, 2.3% semi-comatose, 2.3% lethargic,
8.7% confused, 20.4% restless, and 81.9% alert (Yeh et al, 2004).
Huang (2009) studied 139 ventilated patients in a Taiwanese critical care unit and
reported a SE rate of 6.4%(N=44), of which 75% of self-extubaters were males. Major
contributing factors to SE include the patients admitting unit (p < .05), meeting criteria for
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extubation (p< .001), and age (p< .05.) Their ages averaged 54.32 years. Most self-extubaters,
64% (N=28), were not sedated orready for extubation (Huang, 2009). An Australian study
surveyed over a period of seven years and found that the majority of patients who self-extubated
were male between the ages of 51-55 years (Birkett, K., Southerland, K. & Leslie, G., 2005). In
the seventh survey of this study, 44% of patients were restrained, 27.8% needed re-intubated (of
both accidental and SE s), 27.8% of patients were assessed as being rationale or drowsy and 50%
of patients were either agitated or confused (Birkett et al, 2005).
These previous studies identified a variety of factors found to have a positive correlation
with SE. Sedation, agitation, restraints, gender, and age were most commonly linked with SE.
The results of this study may be used to develop policies that will reduce the SE.
Theoretical Framework
The synergy model is the framework that describes the relationship between the nurse
and patient. Synergy is formed when the patient’s needs and characteristics match the nurse’s
competencies, in which case optimal patient outcomes are the result (“The AACN synergy,”
2010). Nurses need to be competent in the dimensions of nursing practice in order to provide
for the needs of the patient and patient’s family. The Synergy Model has emphasis on the
patient, in which nurses are the contributors to the quality of care, outcomes, and even
containment of costs. The characteristics of patients that help determine patient outcome
include: resiliency, vulnerability, stability, complexity, resource availability, participation in
care, participation in decision-making, and predictability. The characteristics of nurses that also
help determine patient outcome include: clinical judgment, advocacy and moral agency, caring
practices, collaboration, system thinking, response to diversity, facilitation of learning, and
clinical inquiry (“The AACN synergy,” 2010).
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The synergy model fits the study in a variety of ways. Depending on the complexity of
a patient’s condition, stability may be compromised, resulting in vulnerability to further
complications. All patients who are intubated are at risk for self-extubation, and this risk
decreases as the length of intubation increases (“The AACN synergy,” 2010). A patient’s
resiliency is a factor that influences self-extubation. Nurses have the responsibility to show
clinical judgment to maintain patient safety including medicating, sedating, and restraining.
Additionally, staff need to communicate with and continually reorient the patient of the need to
be intubated, thus reducing the risk of SE by decreasing anxiety.
Nursing should show caring practice by checking the restraints and sedation scores and
vital signs on schedule. They are also responsible for assessing airway to make sure airway is
patent, and that the endotracheal tube has remained in the appropriate place and is continuing
its function. Nurses can advocate for the patient by requesting sedation medication for
agitation, pain, or coughing, as well as requesting weaning parameters from the physician if
they feel it is necessary. Nurses must collaborate with the respiratory therapist and physician if
they feel the ventilator settings are not adequate.
In regards to this model, it is anticipated that nurses who remain vigilant in care,
assessment, therapeutic communication, and medication administration are more likely to
prevent a patient from self-exatubating. This framework will guide the study by examining the
nurse's role in preventing self-extubation by maintaining sedation, preventing agitation, and
using limb restraits.
Purpose
The purpose of this study was to determine differences in demographic and clinical
variables between patients with unplanned SE and those with planned extubations.
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Methods
The design was a retrospective survey of medical records of 109 patients admitted to the
MICU or SICU of a teaching hospital in Northeast Ohio and required mechanical ventilation.
Population:
This study reviewed the medical records of individuals in a Northern Ohio hospital over
the age of 18 years admitted to the Medical Intensive Care Unit (MICU) or Surgical Intensive
Care Unit (SICU) who required mechanical ventilation at any time during their stay. Males and
non-pregnant females and all racial/ethnic groups were included. The sample included 54
individuals who experienced unplanned SE during their ICU stay before May 2010 and 55
individuals who had planned extubation carried out by staff members during the same time
period.
Procedures:
IRB approval was obtained from the site hospital prior to beginning this study. Patients
who met the inclusion criteria were identified by the Clinical Nurse Specialist (CNS) via the
intensivist data base. Medical records for both patient groups were reviewed to gather
demographic and clinical variables including: age, sex, category of admitting diagnosis, weight,
number of ventilated days, ventilator mode, occurrence of SE, need for reintubation, type of
sedation protocol, restraint use, type of restraints, use of restraint policy. Diagnosis was assigned
to one of three categories: a medical diagnoses including patients who had failing body organs,
surgical diagnoses made up of patients with surgeries and strokes, and respiratory diagnoses
which included patients having difficulty with their lungs through conditions such as ARDS,
COPD, and asthma. Additional variables were examined for the SE group including minutes
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between the last sedation dose and SE, whether the restraint policy was followed, reason for SE,
and whether the patient required reintubation.
Data Analysis:
Data was analyzed using SPSS 16, the Statistical Package for Social Sciences.
Descriptive statistics were calculated for the groups for comparison. Independent t-test and chi
square were used to determine if there was a significant difference in variable means. The level
of significance was set at p<0.05.
Results:
Over the course of this study, a total of 109 extubations were studied. 54 were unplanned
extubations and 55 were planned extubations. Table 1 shows the descriptive statistics and
comparisons for the variables. Age and sex were not found to influence SE. Patients with lower
weight (t = -2.20, p = .004) and those with shorter periods of mechanical ventilation (t = -7.217,
p = .001) were more likely to self-extubate. Comparison of the diagnosis categories medical,
respiratory, and surgical indicated that those patients with a medical diagnosis were more likely
to self-extubate (chi-sq = 9.419, p = .009). There were high rates for the use of sedation for both
groups, however; those who received a continuous dose of fentanyl were less likely to selfextubate (chi-sq. = 4.234, p = .040).
The use of limb restraints for both groups was very high the SE group at 96% and the
control group at 100%, however; the restraint protocol was followed for only 55% (N=30)
patients who self-extubated. The time between last sedation dose and SE event ranged from 109132 minutes. Reasons for SE noted in the medical record indicated 26% (N=14) events were due
to agitation, 22% (N=12) occurred during repositioning of the patient, 13% (N=7) were
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attributed to the patient coughing, and 39% (N=21) were listed as unknown causes. 69% (N=39)
of the SE group required reintubation.
Discussion:
The results indicate that patients with a primary medical diagnosis in the early days of
intubation in lower weight categories are at risk for SE. The use of intermittent rather than
continuous sedation also contributes to SE. On average, patients who carried out SE had not
received sedation medication for more than two hours. Although both groups had nearly 100%
use of sedation, the sedation policy was not being followed for nearly half of the SE group.
The key findings noted in this study were diagnosis, weight, and the number of intubation
days. Similar to a study done by Curry, Cobb, Kutashy, and Diggs in 2008, restraints have not
proven effective in improving SE rates. Also, like Balon (2001) and Curry (2008), agitation has
shown to be a predictor of SE. A study done in at the Cleveland Clinic Foundation found that
54% of the SE group reported agitation (Tung et al, 2001). A study done by Burkette,
Southerland, and Leslie in 2005 showed that the majority of patients who self-extubated were
between the ages of 51 and 55, contrasting this study’s mean age of 61.6 (SD=18.4).
Conclusion:
These findings indicate that patients with medical diagnoses who are within the first few
days of ventilator therapy and are of an average weight are at greater risk for SE. The use of
continuous sedation may deter SE events. Interventions to prevent SE should be instituted in this
population.
Limitations of the findings include a small sample size from one hospital, the age of
patients, and the data was collected within a six month time frame. Implications of these findings
are to promote the awareness of factors contributing to SE and to educate healthcare providers
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on prevention of SE . In the future, other studies should include other clinical risk factors such as
smoking history, pain scale evaluation, as well as staffing rations, education and experience of
the nurse.
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References
Balon, J. (2001). Common factors of spontaneous SE in a critical care setting. International
Journal of Trauma Nursing, 7-(3), 93-99.
Birkett, K., Southerland, K., & Leslie, G. (2005). Reporting unplanned extubation. Intensive and
Critical Care Nursing, 21, 65-75
Curry, K., Cobb, S., Kutash, M., & Diggs, C. (2008). Characteristics associated with unplanned
extubations in a surgical intensive care unit. American Journal of Critical Care, 17-(1),
45-51.
Gardner, A., Hughes, D., Cook, R., Henson, R., Osborne, S., & Gardner, G. (2005). Best practice
in stabilization of oral endotracheal tubes: a systematic review. Australian Critical Care,
18-(4), 158-165.
Huang, Y. T. (2009). Factors leading to SE of endotracheal tubes in the intensive care u nit.
Nursing in Critical Care, 14-(2), 68-71.
Moons, P., Sels, K., De Becker, W., De Geest, S., & Ferdinande, P. (2004). Development of a
risk assessment tool for deliberate SE in intensive care patients. Intensive Care
Medicine, 30-(7), 1348-1355.
The AACN synergy model for patient care. (2010). Retrieved from
http://www.aacn.org/wd/certifications/content/synmodel.pcms?menu=certification
Tung, A., Caruana-Montaldo, P., Atkins, P. M., Mion, L. C., Palmer, R. M., Slomka, J., &
Mendelson, W. (2001). The relationship of sedation to deliberate SE . Journal of
Clinical Anesthesia, 13-(1), 24-29.
Urden, L.D., Stacy, K.M., & Lough, M.E. (2009). Critical care nursing: Diagnosis and
management. St. Louis, MO: Mosby.
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Yeh, S., Lee, L., Ho, T., Chiang, M., & Lin, L. (2004). Implications of nursing care in the
occurrence and consequences of unplanned extubation in adult intensive care units.
International Journal of Nursing Studies, 41, 255-262.
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Table 1: Demographic Data comparison between Self-Extubation Group and Control Group
SelfExtubation
N=54
Control
N= 55
Mean
SD
Mean
SD
t-test
p-value
Age
61.6
18.4
62.3
17.0
-2.70
.165
Weight
81.9
19.1
93.3
30.6
-2.20
.004
Intubation days
3.1
3.2
11.0
7.2
-7.271
.001
Chi-square
Sex-Male
35 (65%)
28 (51%)
Diagnosis
Respiratory
16 (30%)
28 (51%)
Medical
28 (52%)
13 (24%)
Surgical
10 (18%)
14 (25%)
0.077
.143
9.419
.009
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Table 2: Comparison of Clinical Variables Between Self-Extubation Group and Control Group
Self-Extubation
N=54
Control
N=55
Chi-square
Restraints
52 (96%)
55 (100%)
50 (97%)
55 (100%)
49 (91%)
54 (98%)
p-value
0.036
.153
0.067
.090
4.235
.040
Restraint Type
Wrist
Sedation
Sedation Type
Intermittent
36 (73%)
49 (90%)
Continuous
13 (27%)
6 (10%)
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Table 3: Additional Clinical Variables for SE Group
Self-Extubation
N=54
Minutes since sedation
119.45-mean
108.7-131.9-range
Sedation policy followed
30 (55%)
Reason for Self-Extubation
Agitation
14 (26%)
Positioning
12 (22%)
Coughing
7 (13%)
Unknown
21 (39%)
Reintubated
37 (69%)