Development of Standardized Extubation Guidelines in a Medical Intensive Care Unit

Oral endotracheal tube (OETT) intubation is a medical intervention for critically ill medical patients who have lost the ability to maintain their airway, suffer respiratory failure, or have deteriorated clinically to the point at which loss of the ability to protect their airway is imminent. For these patients, intubation and mechanical ventilation (MV) is appropriate. Self-extubation (SE) is an event in which an intubated patient receiving mechanical ventilation removes the endotracheal tube before removal is deemed clinically appropriate. Self-extubation disrupts medical treatment and may lead to emergent re-intubation. The Intensive Care Unit (ICU) studied is a 25-bed unit for critically ill medical patients at an academic hospital in urban Utah. The unit recently expanded from 17 to 25 beds. This expansion opened February 2017, and new nursing staff are being trained to accommodate the change. The goal of the unit was 10 or fewer SE events for the previous fiscal year; 17 events occurred. Analyzing incident report data showed that 70% of the patients who self-extubated during the period July 2015-March 2017 did not require reintubation. No standardized process had previously existed for evaluating appropriate patients for extubation. This unit is also designated for teaching medical housestaff. This entails monthly rotations of pulmonary/critical care fellows, residents, interns, and medical students. The objectives for this project were to: 1. create a clinical guideline to promote timely controlled planned extubation; 2. present the guideline to medical directors and nursing administration for possible implementation on the unit; 3. provide education on readiness for controlled extubation to nursing staff; 4. disseminate project findings through presentation at the Snowbird Continuing Medical Education (CME) conference. Relevant topics evaluated in the literature review include timely extubation criteria and recommendations, ventilator weaning parameters, sedation types and methods, and problems with prolonged mechanical ventilation. Implementation of project goals included designing the guideline using incident report data, performing root cause analysis for the events, and using information from the literature review along with feedback from the content experts and project chair. Education for unit nursing staff is also a critical component. The guideline was presented at staff meeting in April. In summary, SE is a disruptive event in which a patient removes his or her OETT prematurely before clinicians have deemed it appropriate to discontinue MV therapy. Although it is disruptive, the majority of patients do not require reintubation. This suggests that a timely extubation guideline of objective clinical criteria is appropriate and needed for an expanding medical critical care unit.