Morgan Crigger
University of Texas Southwestern Medical Center
Dallas, Texas
Disclosure information not submitted.
Natasha Keric, MD, FACS
Associate Professor of Surgery
Banner University Medical Center
Phoenix, Arizona, United States
Disclosure information not submitted.
Patrick Bosarge, MD, FACS,FCCM
Division Chief, Surgical Critical Care, Trauma and Acute Care Surgery
Banner University Medical Center Phoenix, United States
Disclosure information not submitted.
Jessica Sloan, MD
Surgical Critical Care Fellow
University Tennessee Memphis, United States
Disclosure information not submitted.
Allison Tompeck, MD
Medical Director Surgical Critical Care
Banner University Medical Center Phoenix
Phoenix, Arizona, United States
Disclosure information not submitted.
Title: Consistent Event Reporting Decreases Rates of Unplanned Extubations in the Surgical ICU
Introduction: Unplanned Extubations (UE) in the intensive care unit (ICU) lead to increased morbidity, mortality, length of stay and cost. We sought to decrease the rate of UE by developing a consistent reporting system that empowered nurses to initiate report.
Methods: A reporting form was drafted, validated, and implemented to track the causes and rates of UE. The form included ventilator settings, type of sedation used, goal and actual RASS ordered, type of restraints, and clinical outcomes after UE. Surgical residents and nursing staff were responsible for reporting data by end of shift. Two cohorts; pre-implementation (G1) and post-implementation (G2) were studied. 313 intubated patients in the SICU who experienced UE from Feb 2019-May 2020 (G1) were compared to 168 patients who experienced 11 UE from July 2020 - Feb 2021 (G2).
Results: In G1, (15/23) 65% of UE occurred during day shift (7a-7p) with the remainder occurring during night shift (7p-7a). Similar outcomes were noted in G2, with 64% (7/11) occurring during day shift. Twenty-two percent (5/23) of UE occurred during a spontaneous breathing trial (SBT) in G1 compared with 18% (2/11) in G2. Eighty-seven percent (20/23) of patients in group 1 had a target RASS goal of 0. Actual RASS was zero in 48% (11/23), ≥ +1 in 26% (6/23) and ≤ -1 in (5/23) 22%. In G2, 91% (10/11) had a target RASS goal of 0. Actual RASS was zero in 55% (6/11), ≥ + 1 in 36% (4/11) and ≤ -1 in 9% (1/11) (p=0.61). The number of patients remaining extubated was unchanged between the 2 groups 65% (15/23) and 64% (7/11) (p=0.92). Decreased nursing supervision was noted in 48% (11/23) of patients in G1 compared to 18% (2/11) in G2 (p=0.09). UE events decreased from 7.3% to 6.5% between G1 and G2 (p=0.61)
Conclusion: Our study improved the reporting process and collaboration between nursing and providers. The main factors associated with UE were actual RASS scores inconsistent with the goal or recorded value and nursing supervision. Changes implemented included: SBT one hour earlier to avoid overlap with nursing handoff, dedicated respiratory therapists per shift, consistent light sedation (RASS -2 to 0) with nursing education. Improved nursing supervision during SBT trended towards significance. Finally, consistent event reporting led to a 0.8 % decrease in the rate of UE.