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INTERNI\TIONAL JOURNAL OF S C I E N C E @ O I R E C T a
NURSING
STlJDIES
PERGAMON International Journal of Nursing Studies 41 (2004) 255-262
www.elsevier.comJlocatelijnurstu
Implications of nursing care in the occurrence
and consequences of unplanned extubation in adult
in tensi ve care units
Shu-Hui Yeh
a,*,
Li-Na Lee
b,Tien-Hui Hoc, Ming-Chu Chiang
d,Li-Wei Line
a Chang Gung Institute of Technology, Chang Gung Hospital at Kaohsiung, 12F, #123, Ta-Pei Rd., Niao-Sung,Kaohsiung Hsiang 833, Taiwan
h Kaohsiung Municipal Tatung Hospital, #68, Chung Hwa 3rd Rd., Kaohsiung 801, Taiwan
C Junior College of Nursing, Chung Hwa Institute of Technology, 3F-15, #21, Lane 235, Te-tung Street, East Distring,
Tainan 701, Taiwan
d Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, #123, Ta-Pei Rd., Niao-Sung, Kaohsiung Hsiang 833, Taiwan
eJunior College of Nursing, Fooyin University, #151, Chinhsueh Road, Ta-Liao, Kaohsiung, Hsien831, Taiwan Received 22 August 2002; received in revised form 19 July 2003; accepted 25 July 2003
Abstract
This 18-month study used a structured questionnaire to explore the roles of nursing care on the occurrence and consequences of unplanned endotracheal extubation (UEE) in intensive care units in Taiwan. Experiencing UEE were 225/1176 (22.5%) intubated patients: 91.7% were self-extubations and 8.3% were accidentai. Self-extubations occurred most frequently during night shifts and in the care of nurses with less working experience. Accidental extubations occurrcd most frequently in patients undergoing routine nursing procedures, usually required immediate re-intubation and were associated with more complications. An appropriate nurse-to-patient ratio, better working procedures and continual nursing education programs might help reduce occurrence and complications of UEE.
© 2003 Pu blished by Elsevier Ltd.
Keywords: Unplanned extubation; Endotracheal intubation; Intensive care
1. Introduction
Endotracheal intubation is frequently used in me chanical ventilation. Unplanned endotracheal extuba tion (UEE), either self or accidental extubation, can be followcd by serious complications such as secondary pneumonia, dyspnea, airway trauma, edema, difficulty in reintubation and lengthened hospitalization (Epstein et ai., 2000). Studies from 1994 to 2002 indicate the incidence of UEE ranges from 3 % to 14 % (Betbese et ai.,
*Corresponding author.
E-mail addresses:y470912@adm.cgmh.org.tw (S.-H. Yeh), e3853417@ms45.hinet.net (L.-N. Lee), cushing@gcn.nettw (T.-H. Ho), e2988986@adm.cgmh.org.tw (M.-C. Chiang), liweinsI98@yahoo.com.tw (L.-W. Lin).
0020-7489/$ - see front matter ~g 2003 Published by Elsevier Ltd. uoi: I 0.1 016/S0020-7489(03)00136-6
1998; Boulain, 1998; Chen et ai., 2002; Chevron et aI., 1998; Christie et aI., 1996; Hsu et ai., 2002; Maguire et ai., 1994; Razek et ai., 2000; Tindol et ai., 1994). Of these UEE cases, 77.9-87% were self-extubations; 13-22.1 % were accidental (Chevron et ai., 1998; Christic et aI., 1996).
Medical and surgical reasons for UEE have been identified. Boulain (1998) and Chevron et ai. (1998) found that the incidence of UEE was higher for patients with respiratory failure. Atkins et ai. (1997) found that UEE occurred more frequently in post-operative patients. Because the relationship between nurse- and patient-related risk factors for UEE remains incon clusive, we studied the roles of nurse- and patient related risk factors with respect to UEE in southern Taiwan.
256 S-H Yell III al. I International Journal ol Nursinq SIUe/ies 41 255 262
2. Literature review
Literature review was based on English and Chinese databases which included Medline (Aidsline, Bioethics Line and HealthSTAR) from 1966 to present, CINAHL from 1982 to present, and PerioPath: Index to Chinese Periodical Literature (available at http://www2.read. com.tw/cgi/ncl3/m_ncl3J) at National Central Library in Taipei from 1991 to present.
2.1. Nursing related risk factors for U EE
Findings obtained by researchers regarding nursing related risk factors for UEE have often been contra dictory. Grap et al. (1995) found that nursing workload influenced the incidence of GEE; however, Chevron et al. (1998) demonstrated that it did not. Christie et al. (1996) and Chen et al. (2000) discovered that UEE occurred with equal frequency during all three nursing shifts; however, Grap et al. (1995) found that 43% of UEE took place during the night shift and that 77% oceurred when a nurse was not at bedside. In the study of Grap et al. (1995), 51 % of UEE patients were lying on their backs with their heads elevated. Pesiri (1994) and Tominaga et al. (1995) suggested that restraining an unconscious or restless patient might prevent self extubation. In eontrast, Chevron et al. (1998) indicated that restraint might cause anxiety and increase the possibility of UEE. Tung et al. (2001) suggested that nurses remain alert to these patients, visit and comfort them frequently, and administer sedatives if necessary.
Christie et al. (1996) demonstrated that accidental extu bations occurred more frequently during the 0700-1500 shift. Chen et al. (2000) also found that 12.5% of all UEE incidents happened within the period I h before and after each shift, possibly beeause the nurses were preoccupied by other tasks. In the studies of Boulain (1998), 'Christie et al. (1996) and Grap et al. (1995), the majority of accidental extubations were associated with nursing duties, such as mouth and tube care, changing a patient's position or patient transport. Aeeidental extubations were related to nursing care procedures. Thus, different nursing care procedures may play different roles in self and accidental extubations.
2.2. Patient-related risk factors for UEE
As in the case of nursing-related risk factors for UEE, studies of patient-related risk factors have often yielded conflicting results. Males and younger patients tend to have higher rates of UEE (Betbese et al. , 1998; Chen et ai., 2000; Chevron et aI., 1998). Although some studies have related UEE to consciousness status (Boulain, 1998; Chevron et ai., 1998; Grap et aI., 1995; Tung et al., 2001), others have found UEE to occur regardless of consciousness level (Christie et aI., 1996) or
sta tc of agitation (A tkins ct al., 1997). Patient rcstraint is another risk factor for UEE (Betbese et al., 1998; Chevron et aI., 1998; Tung et ai., 2001).
Routes, types and duration of intubation are also possible risk factors. Boulain (1998), Chevron et al. (1998) and Christie et al. (1996) indicated LEE incidents were significantly higher in orally intubated patients than in nasally intubated patients: however, others have found no such association (Atkins et aI., 1997; Chen et ai., 2000). No significant relationship between UEE and tube diameter has been found (Betbese et ai., 1998; Chen et al., 2000; Chevron et aI., 1998). Chen et al. (2000), Chevron et at. (1998), Listello and Sessler (1994) and Maguire et al. (1994) indicated the duration of intubation was significantly shorter in theirs groups of unplanned extubation patients than in the control groups. Mean duration of intubation ranged from 3.4 to 9.4 days. However, Whelan et al. (1994) demonstrated no significant association between the two.
Few researchers have explored the feelings and perceptions of UEE patients. Discrepancies between patients' and health care providers' care expecta tions often exist (Spector, 1991). Health professionals who care for intubated patients may be unaware of complex cultural and individual factors that influence their patients' perceptions of
rcu
care. Analysis of patients' perception about intubation may help health care providers offer better nursing care and reducc unnecessary intubations and UEE-related complica tions.2.3. Consequence and complications of UEE
Betbese et al. (1998), Boulain (1998), Chevron et al. (1998) and Epstein et al. (2000) found that re-intuba tions after UEE were usually required within the first hour in about 37-61 % of cases. Betbese ct al. (1998), Chevron et a1. (1998) and Epstein et al. (2000) also pointed out that about 27.4-52.8% of UEE cases were self-extubations that occurred while patients were bcing weaned from ventilators and that only 15.6-30% needed re-intubation. The 76.9% re-intubation rate in the accidental extubation group was higher than the 36.9% rate in the self-extubation group (Betbese et al., 1998). Another study by Christie et al. (1996) showed that 80% of accidental extubations needed re-intuba tion. Chevron et al. (1998) demonstrated that rc intubation was significantly correlated with accidental extubation and with a coma index score less than II. Out of 23 re-intubated patients, 9 died, four had tachypnea and one had an arrhythmia. Grap et al. (1995) found a complication rate of 7.4% following UEE or re-intubation. Complications included death, dyspnea, airway trauma, bradycardia, bronchospasm, hoarseness, longer duration of ventilator use and longer hospitalization.
S.-H Yell el aL ! internalional Journal o( Nursing Studies 41 255-262 257
Based on the literature review, it is clear that LEE can be affected by nursing care and patients' physical and perceptional situations. Moreover, relationships be tween nurses and patients may differ in different countries. In order to improve nursing care for intubated patients in Taiwan, we investigated the roles of nursing care on the rate of LEE and analyzed risk factors and consequences associated with UEE.
2.4. Definitions
1. UEE: unplanned endotracheal extubation, including self-extubation or accidental extubation.
2. Duration before UEE: the duration calculated in days from the time patient was first intubated until an UEE occurred.
3. Prevalence of re-intubation: the rate of re-intubation within 8 h after "GEE.
3. Methodology
3.1. Subjects studied and data collection
This study was approved by the Institutional Review Board of the medical center, and it was conducted over an IS-month period in a medical center with 11 adult ICes from 2000 to 200l. A structured questionnaire, issued to nursing staff and double-checked by head nurses, was used to collect demographic data on nurses and patients, nursing and medical procedures, emergent management after VEE and reasons for VEE provided by nurses and patients. Participants were informed of their rights. Anonymity and confidentiality were secure.
3.2. Data analysis
Data were coded, double-checked and analyzed with SPSS Version 12. Descriptive analysis was applied to describe the nurse to patient ratio, nurse working experience in year and incidence of VEE induding self and accidental extubation. Chi-square test was used to examine the independence between patient conditions such as agitation and among certain nursing activities such as nurse working experience in years.
4. Results
4.1. Prevalence of UEE
Over 18 months, 6,672 patients were admitted to the studied JCUs: 1176 patients were intubated and 265 incidents of VEE oeeurred. As shown in Table 1, prevalence of UEE was 22.5%, 243/265 (91.7%) were self-extubations and 22/265 (8.3%) were accidental.
4.2. Implications of nursing experience and duty sh!'{t in U EE
The mean duration of working experience in nursing was 3.4 years; 22.4% had not worked longer than I year, and 16.8% had worked for only 1-2 years. CEE occurred more frequently in the care of nurses with less experience, while experienced nurses (;?: 4 working years) encountered UEE less frequently Table 2).
or
theTable I
Prevalence and consequences of UEE for 6672 patients in 11 ICUs # of Incidents % Intubation 1176 17.6 Unplanned extubation 265 22.5 Type of extubation Self-extubation Accidental extubation 243 22 91.7 8.3 Re-intubation wilhin 8 h (n = 264 j Yes No 118 146 44.7 55.3
Re-intubalionfor self-extubated patients
Yes No 100 143 41.2 58.8
Re-intubationfor accidentally extubated patients Yes No 19 3 86.4 13.6
Condilion after unplanned extubation (n 246) Stable Complications Death 237 7 2 96.3 2.8 0.8 Table 2
Comparison of nursing experience among primary nurses in cases of UEE with nursing experience for the entire nursing staff
Entire nursing staff Primary nurses in
(n 253) cases of UEE (n 265) n % # of % Incidents Working years <2 years 47 18.6 66 24.8 ;;;::2 <4 years 172 68.0 193 72.9 ;;;::4 years 34 13.4 6 2.3
258 S-H. Yell et al. ilnternational Journal
0/
Nursing Studies 41 255-262 primary care nurses, 81.5% took care of two patients pershift. Patient-to-nurse ratios were not significantly different between nurses encountering UEE and the total number of nurses in ICUs vs. 2.1). UEEs occurred morc often during thc night shift: 43% compared with 27.2% and 29.7%, respectively, during day and evening shifts. Forty incidents (25.3%) ofUEEs occurred within 1 h before or after each shift change, and 79.1 % occurred when no nurse was present bedside.
4.3. Implications of patient characteristics in UEE
Patients who experienced UEEs had a number of characteristics in common Cfable 3): 65.4% were male, 78.2% were alert, and 91 % were communicative. Patient answers to multiple-choice questions regarding ability to communicate prior to an UEE indicated that 62.6% could communicate with body language, 88.3% could nod to express themselves, 23% could write and 9% were not able to communicate with nurses. Within the group of self-cxtubation cases, 82.6% provided several reasons for extubating themselves: 57.7% described the tube as uncomfortable, 13.3% described it as painful, 5.9% wanted to breathe on their own, 5.1 % wanted to talk, 3.6% felt like they were suffocating and 3.1 % were
fable 3
Characteristics of UEE patients (n 265)
# of incidents ~jo Gender Male Female 174 91 65.4 34.6 Conscious Alert Confusion 204 61 78.2 21.8 Communicative Yes No 241 24 91.0 9.0 Type
0/ intubation (n '"
264) Dral Nasal 257 7 97.3 2.7 Extubation in 48 h (n Yes 010 259) 114 145 44.0 56.0 Restraint Yes No 164 101 61.9 38.1 S'edation Yes No 264) 39 225 14.8 85.2confused about the purpose of the tube. The rest (11.3%) provided the following: "Didn't know how to call for help," "Worried about inflammation," "Dream ing," "Felt like going home," and "Could not stand the tube."
4.4. Implications of medical procedures in VEE
Medical procedures in UEEs are listed in Table 4. UEE patients about 97.3% were intubated orally. Mean duration of intubation before UEE was 6 days. Of the all incidents of UEE, 20.5% occurred on the first day of intubation. Another 44.1 % occurred within 2 days, 61.7% of UEE patients were restrained, and 85.2% were not sedated. Occurrence of UEE incidents depcnded on whether patients were agitated or restrained (X2 = 42.80,
P 0.00), or sedated (X2 5.78, P =cc 0.03) (see Table 4). UEE incidents occurred when patients were in different positions: 60.7% when a patient was lying on his back with his head elevated, 31.9% when a patient was supine and 40.5% when a patient was lying on his side.
4.5. Consequences of self and accidental extubation
Re-intubation rates between self and accident extuba tion were different. Overall re-intubation rate within 8 h was 44.7%. Needing re-intubation were 41.2% of self extubation and 86.4% of accidental extubation (Table I). After extubation, 81.9% were alert, 20.4% restless, 8.7% confused, 2.3% lethargic, 2.3% semi-comatose and 3.4% comatose. Serious complications following UEE occurred in 9 (3.6%) of the CEE patients: death (n 2), dyspnea (n 4), airway bleeding (n 1), low blood pressure treated with vasopressors (n
=
1) and comatose (n=
1).In the 22/265 (8.3%) of UEE were accidental extubation cases, 16 were alert, three restless, three comatose and 12 restrained. All accidental extubation cases were intubated orally. Only one had been sedated
Table 4
Unplanned extubation by status with and without restraint or sedation
Agitated before UEE X"0
P No Yes Restrainl With Without 95 97 65 4 42.80 0.00 Sedation With Without 22 109 16 52 5.78 0.03
259
S-H. Yel! el af. / ]l1lernalional JOllrnal of Nursing SllIdies 41 255~262
(diprivan 6 gtts/h). Nurses reported that accidental extubations took place when they were readjusting bandages or performing routine care of a patient's mouth and tube (5 incidents), when changing a patient's position (5 incidents), when a patient coughed (7 inci dents) and when a patient spontaneously ejected the tube with his tongue (3 incidents). Causes of 2 incidents were unknown.
5. Discussion
The prevalence of LlEE in this study was 22.5%. This figure is higher than those found in other studies (Chen et al., 2000; Betbese et aI., 1998; Boulain, 1998; Chevron et aI., 1998; Tindol et aI., 1994). Reasons for this higher incidence may be multifactorial, induding medical indications for intubation, patient characteristics and nursing care. We found that nurses with less working experience tended to encounter more UEEs and that UEEs were more prevalent during the night shift instead of the day or evening shifts. Two-thirds of UEEs occurred within the first 2 days of intubations. Male patients and those in a head-up position were also more prone to UEE. We also found that sedation and restraint were associated with agitation in UEE patients. Whether restraint and sedation are implicated in higher rates of UEE requires further study. In order to provide better care for ICU patients more at risk for UEE, we recommend that ICLl standard procedures be altered to promote more appropriate nursing responses and that continuing education programs include more instruction with respect to factors that increase the likelihood of UEE.
When we compared the working experience of nurses who experienced UEEs with that of the entire nurses in the intensive care units, we found that the less experienced and experienced groups were disproportio nately represented. Experienced nurses (~4 years) who comprised 13.4% of totaliCU nurses encountered fewer (2.6%) UEEs. Few studies have investigated how working experience of nurses influence incidences of
UEEs. To reduce the incidence of UEE, we recommend modifying nursing standard procedures, on-the-job training and continuing education of nursing staff about UEEs, especially for less experienced nurses.
Previous studies (Chen et al., 2000; Chevron et al., 1998; Christie et aI., 1996) have indicated that UEE occurred with equal frequency during different nursing shifts. We found that a majority of UEEs occurred during night shifts. This conflict between our finding, which corroborates the findings of Grap et al. (1995) and Chang et al. (1993), and other findings may be due to different types of nursing shifts. Some studies were done in hospitals with two nursing shifts, while others were done in hospitals with three.
More importantly, we found that UEEs occurred more frequently within I h before or after a shift change and were found in absence of nurse at the bedside. This finding is similar to the 77% incidence when a nurse was not bedside found in the study by Grap et al. (1995). Because nurses during shift change were not bedside at the time of UEEs, we recommend revising the nursing procedure for nurses' shift report. Reports could be performed bedside instead of at the nurses' station. Also, the tube should be secured as well as possible before and after shift reports and during routine nursing care.
While some studies have found UEE not to be associated with patients' level of consciousness (Christie et aL, 1996) or with use of sedatives (Atkins et aI., 1997), the data obtained by Chen et al. (2000) indicated that the UEE group received more sedatives than the non UEE group. In our study, we found that patients who were not sedated or inadequately restrained were more prone to UEE. This finding agrees with those obtained by Atkins et al. (1997), Boulain (1998), Chevron et al. (1998) and Tung et al. (2001). Conflicting results may be due to differences in type or dosage of sedative, in evaluation of consciousness and in application of restraints. More than 37% of UEE incidents occurred in agitated and confused patients. This compares favorably to the 32-42% reported in other studies for agitated and confused patients who experience UEEs (Atkins et aI., 1997; Chen et al., 2000; Hsu et aI., 2002). Of the UEE patient in our study, 14.8% were sedated. This percentage is lower than 25-62% reported by Boulain (1998), Chen et al. (2000), Chevron et al. (1998), Christie et al. (1996) and Hsu et al. (2002). In this study, 16/68 (23.5%) UEEs occurred in agitated patients who had been sedated, while 52/68 (76.5%) UEEs occurred in agitated patients who had not been sedated.
Dasta et al. (1995) reported that only 27% of their patients in surgical ICUs received the maximum allowed sedative dose. Sharp (1996) found that 40% of their ICU patients reported that they had experienced from moderate to severe to intolerable pain. Pain was the main reason for anxiety and agitation led to UEE (Tang, 1999). It is likely that the prevalence of UEEs in our study was higher than in other studies because fewer of our intubated patients in pain were adequately sedated. Atkins et al. (1997) and Dasta et al. (1995) pointed out that even though 90% of doctors prescribed sedatives pm, their instructions did not specify situations requir ing sedation. Consequently, administration decisions were often left to nurses. Leisifer (1990) found that 68 % of nurses worry about sedative addiction and that 32% of nurses based their decisions to administer sedatives pm on patient requests. A study performed by Wu and Wong (2000) had similar results.
In our study, 25.6% of UEE patients were restrained by wrist belts that had been tied to bedside railings. In this situation, a patient could easily reach and pull out
260 S.-H Yell et al. Ilnlernational.Journal of Nllrsinq Sill dies 41 (2004) 255~262
the tube by moving his head. Therefore, nursing procedures should require restraining a patient's hands at least 20 em away from treatment tubes (Carrion el a!., 2000). Of the UEE patients, 60.7% were lying on their backs with their heads elevated. This result was similar to the findings of Grap et a!. (1995). The head up position allowed the patient to pull out the tube by moving his head toward his hands even when they were in wrist restraints.
Nursing staff members need to be mindful that intubation and restraints can cause considerable patient stress, a contributing factor in self-extubation (Betbese et al., 1998; Boulain, 1998; Chevron et al., 1998). Medina et al. (1993) and Young et al. (2000) recom mended that all patients who are intubated should have a clear order for adequate sedation to prevent UEE. Nurses should assess the condition of patients with this in mind and appropriately restrain and sedate patients at risk for self-extubation (Boulain, 1998; Chen et al., 2002; Tung et al., 2001).
When we studied the communication abilities of patients, we found that only 9% could not communicate with nurses, and 91 % could nod, write or gesture to communicate. Usually, the nursing staff received in formation from patients via nodding and gestures and made nursing care judgments based on their clinical experience. Nursing staff who had limited experience may have misunderstood patients. Therefore. auxiliary tools such as a drawing board, reading board or picture cards should be applied in an lCU setting. Nurscs should make a special effort to communicate with these patients and to relate their findings and observations in every shift report.
We found, as did Grap et al. (1995), that patients extubated themselves because they were experiencing pain (71 % in our study), felt unable to breathe, wanted to breathe on their own, were confused and worried, or wanted·to talk. Some patients did not understand the risks of self-extubation or know alternative ways to communicate. Grap et al. (1995) found that only 36.9% of subjects had been informed about the intubation. We believe that obtaining the feelings and perceptions of intubated patients should be made a nursing priority. The nursing staff should repeatedly inform patients about the importance of intubation, alleviate their pain and discomfort as much as possible and re-assure them in order to decrease the rate of self-extubation.
Mean number of days of intubation before UEE was 6 days in our study. However, 44.1 % of UEEs occurred within 2 days, similar to previous studies (Chen et al., 2002; Coppolo and May, 1990). This suggests that nurses should pay particular attention to the physical and psychological needs of these patients in the first 2 :lays of intubation.
Re-intubation after accidental extubation was neces ,ary in 86.4%. This figure for re-intubation following
UEE incidents is significantly highcr than 44.9% following all extubations and 41.2% following self extubation. Our results are similar to those of Betbese ct al. (1998) and Christie et al. (1996) who found the need for re-intubation after accidental extubation ranged from 76.9% to 80% and the over-all nced for re-intubation after UEE ranged from 45.8% to 48%. Nursing staff reported various reasons for accidental extubation. Ten incidents (45.5%) occurred when nurses were performing routine care of the mouth or tube, when they were re-adjusting the tube bandage or when they were changing the position of the patient and not adequately supporting the tube. Ten other incidcnts (45.5%) occurred when patients coughed or when the tube was ejected by the patient's tongue. Because almost half the accidental extubations were elosely related to nursing care, we have the opportunity to reduce their incidence of UEEs by educating the nursing staff.
Betbese et al. (\998) proposcd three nursing care protocol changes. First, nursing staff should effectively secure the endotracheal tube and occasionally re-check the cuff. Second, when changing the tape or doing routine oral care, the attending nurse should request assistance. Third, when changing the position of a patient, the attending nurse should appropriately sup port the tube.
Over half of our UEE patients did not need reintubation. This indicates that prolonged intubation may be unnecessary and could be eliminated to save medical resources.
Thcre are advantages to early tracheostomy. such as comfort and security that might help minimize the incidence of unplanned extubation (Saffle et al., 2002). Better secretion removal, less laryngeal damage and better ability to eat and speak have been also recognized (Jaegor et al., 2002). Rapid weaning from ventilatory support (Brook et al., 2000; Rodriguez et al., 1990) and reduced incidence of tracheobronchial colonization by multiple pathogens (Teoh et al., 2001) are also bcneficial effects. In our subjects, the mean duration of intubation before unplanned extubation was 6 days. However, 10% (26/259) of the subjects were intubated over 14 days before unplanned extubation. Certain patients under prolonged intubation may need daily evaluation for early tracheostomy to reduce the incidence of unplanned extubation. Further studies to examine the relationships among the early tracheostomy, timing for weaning program, and the incidence of unplanned extubation are necessary.
We also evaluated the level of the consciousness in our patients before and after UEE. Overall, 78.2% were conscious before and 81.9% were conscious after DEE. Following accidental extubation, percentage of coma tose patients rose from 13.6% to 27.3%. It is evident that after accidental extubation, there is not only a greater need for re-intubation but also an increase in
261
S-H Yell el a1. I Inlerllalionai Journal
morbidity relating to level of consciousness. In this study, 8.3% were accidental extubation. Betbese et al. (1998), Chevron et al. (1998) and Christie et al. (1996) found the frequency of seIf-extubations to range from 77.9% to 87%, and the frequency of the accidental extubations to range from 13% to 22.1 %. Betbese et al. (1998), Chevron et al. (1998) and Christie et al. (1996) have indicated that accidental extubation is a predictive factor for re-intubation. Because serious complications such as tachypnea, airway trauma and arrhythmia are more likely to occur after accidental extubation, nurses should be especially vigilant of patients at risk.
6. Conclusions and implications
In our study, UEE incidents frequently occurred when patients became restless and agitated because of pain, discomfort, inability to communicate and lack of sedation. When nurses did not adequately restrain patients and were not at bedside, UEEs were especially likely to take place. Because of the serious consequences that may follow UEE, nurses often felt responsible and were blamed by patients' families and administrators. Nevertheless, UEE incidents were sometimes beyond the control of nursing staff. Nurses with less experience did not manage the care of these patients as well as nurses with more experience. Continuing education, tramlOg and updating standard procedures for the care of intubated patients may help prevent UEE.
How UEE relates to restlessness, restraints and sedation has not been thoroughly studied. Whether restless patients should be restrained or given sedatives to prevent UEE has not been confirmed by these studies. Moreover, dosage and type of sedatives, as well as the time at which they should be administered, needs further evaluation. The use of restraint is a controversial issue and :their use is often not recommended. More studies should be done to address alleviating the pain and discomfort of intubation, to evaluate timing for weaning off a respirator, to propose better methods for securing the tube and to improve communication between nurses and patients.
7. Limitations
The incidents of UEE were collected in the leU of one medical center. Our sample may not completely represent all cases of UEE. Although we instructed nurses on how to answer the questionnaire and the head nurses double-checked completed forms, we did not study interrater reliability of answers provided by nurses. This should be examined in future. Another limitation is the measurement of dependency with respect to other lCU patients that were not included in
Nursing Studies 41 (2004) 2)5-262
this study. Dependency should be given more priority in futurc study to clarify its effect on prevalence of UEE in developing countries as Taiwan.
Acknowledgements
The authors gratefully acknowledge the assistance from Professor Kuender Yang, Professor James Steed, chief Ling-Nu Hsu and Ms. Wen-Hui Hsu in prepara tion of this manuscript. Appreciation is extended to all the participating administrators, staff and patients, whose cooperation made this study possible.
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