Unplanned Extubation in an Intensive Care Unit in Central Taiwan

Background:  Patients on mechanical ventilation are at risk of experiencing a potentially life-threatening unplanned extubation in the intensive care unit, which can lead to arrhythmias, bronchial aspiration, difficulty in reintubation or even sudden cardiac arrest. Although incidence and outcomes of the phenomenon have been documented in several quantitative studies, no studies have investigated the antecedents as experienced by critical care nurses.

Objectives:  To gain a greater understanding of the antecedents of unplanned extubations.

Methods:  A qualitative study design involving the critical-incident technique. A total of 10 registered nurses who reported one or more episodes of unplanned extubations were involved in an in-depth interview.

Findings:  According to the nurses' experience, episodes of unplanned extubations are determined by predisposing, precipitating and mediating factors. The predisposing factors have been recognised in the (a) weaning programme (expected/unexpected decreased sedation) and in the (b) patient factors (increased needs due to discomfort, restlessness and desire to communicate). The precipitating factors have been divided into (a) organisational (failures in multi-professional communication), (b) environmental (excessive environmental chaos and barriers preventing direct surveillance) and (c) nursing care factors (ensuring privacy by creating barriers, avoiding disturbing other patients and poor nurse-to-patient ratio). Among the mediating factors, which are affected by the precipitating factors, decreased surveillance and mechanical restraints' use have been identified.

Conclusion:  Identifying risk factors of unplanned extubation, specifically those that are modifiable, such as increasing interprofessional communication, reducing excessive environment chaos, implementing strategies aimed at overcoming barriers threatening direct surveillance and ensuring appropriate nurse-to-patient ratio, can prevent the occurrence of these events.