Episode #89 Unplanned Extubation Events: Prevention

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Last week, we discussed the incidence, risk factors, and financial cost of unplanned extubation events. We also reviewed an extubation classification tool that can help to track unplanned extubation events and evaluate if a problem exists. Do you use an extubation classification tool at your institution for every extubation event. Today, we are going further into the article to talk about prevention of unplanned extubation events and future directions.

Before we dive into the episode today, we’d like to recognize GE Healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, GE Healthcare – we wouldn’t be able to do all that we do without you!”

Before we get back into the article, we have a segment on Recent Events. This event was produced by the Multicenter Handoff Collaborative which is a special interest group of the Anesthesia Patient Safety Foundation. I will include a link in the show notes for more information. The event was the Handoffs Effectiveness Research in the perioperative environment or HERO Design Studio held on February 15-16^th which yielded 18 design solutions over the course of the 2-day workshop. Funding for this event came from the Agency for Healthcare Quality and Research. There were more than 100 participants from 17 institutions, 10 medical, nursing, and scientific societies, 5 patient safety organizations, 6 industrial partners, and 2 regulatory agencies all represented at the workshop and working together to improve perioperative handoffs and patient safety. One of the comments from a participant in the workshop comes from Steven Greenberg. I’m going to read it now.”

“Excellent job! You have appropriately energized our team to meet next week with key administrators to see if we can develop technologies that might allow us to perform a multidisciplinary handoff between multiple hospital providers in different hospitals.”

This is an important event with patient safety stakeholders working together to improve teamwork and communication surrounding patient handoffs and we are looking forward to hearing more from the Multicenter Handoff Collaborative in the future.

Now, let’s shift gears and get back to our featured article.

[Car Shifting Gear Sound]

Our featured article today is from the February 2022 APSF Newsletter called, “Unplanned Extubation in the Perioperative Environment” by Lauren Berkow and Arthur Kanowitz. To follow along with us, head over to APSF.org and click on the Newsletter heading, then click on the current issue, February 2022, and scroll down until you see our featured article. I will include a link in the show notes as well.

We left off last week talking about prevention for unplanned extubation events which would go a long way to improving patient safety and minimizing excess hospital costs. The first step towards prevention is tracking every extubation event in order to identify any unplanned extubation events and the details surrounding these critical events. One option for tracking is an Extubation Classification Tool that is described in the article. Another important step towards prevention is identifying risk factors and then providing education for  clinicians to be able to identify patients at risk for an unplanned extubation and then taking steps to minimize this risk.

One option for this for pediatric patients may be to use an airway risk assessment scoring tool to identify high risk patients as described by Vats and colleagues published in 2017 in their paper called, “An airway risk assessment score for unplanned extubation in intensive care pediatric patients.” The risk assessment tool included points for the following categories:

• anatomical risk including difficult airway or anatomy
• agitation/sedation holiday
• excessive oral secretion
• multiple procedures or transport
• planned extubation with extubation protocol in place
• prone positioning
• requires frequent re-taping
• history of unplanned extubation

Based on the number of points accumulated, patients were classified as low, moderate, high, and extreme risk. The authors found that patients with higher risk assessments had increased occurrences of unplanned extubations in their study. I will include the citation for this paper in the show notes for more information.

The authors share another great option to help prevent unplanned extubation events: Having a pre-induction huddle to discuss options for securing the endotracheal tube, how the endotracheal tube may be manipulated during the case, and the location and availability of airway equipment if needed for urgent re-intubation if an unplanned extubation occurs. This type of huddle may not be needed for every surgical procedure. If the case is identified as being high risk for unplanned extubation such as procedures that require a shared airway or positioning the patient far away from the anesthesia professional and during cases that require planned extubation and re-intubation, then it is important to have a discussion prior to induction and intubation.

Other strategies to help prevent unplanned extubation events include the following:

• Protocols for bedside tube manipulation and patient transfers
• Bedside reminders with visual cues
• Standardization of tube securement methods
• Optimized securement of the endotracheal tube
• Communication and teamwork especially during high-risk procedures which may include suctioning, turning, and patient transport
• Assigning one team member to be responsible for managing the endotracheal tube during high-risk procedures and preventing unplanned extubation.

What are the options for securing the endotracheal tube? And does it matter how we secure the endotracheal tube? There is no method for securing the tube that is superior, there are important characteristics of optimal securement in the literature and by the Patient Safety Movement Foundation in their Patient Safety Solutions.

Check out Table 3 for a list of suggested characteristics of an optimal endotracheal tube securement device. Plus, we are going to run through them now.

• Provides good stabilization against external forces that may dislodge the tube
• Prevents tube movement that can cause mal-positioning
• Prevents tube movements that can lead to fluid getting past the balloon
• Facilitates suctioning without dislodgement
• Requires infrequent changing or adjustment
• Well tolerated in ICU patients meaning it is comfortable for the patient with minimal risk for pressure injuries

For more information and resources, check out table 4 in the article with helpful links. Important resources include Patient Safety Movement Actionable Patient Safety Solutions for Unplanned Extubation, Airway Safety Movement UE Resources, Children’s’ Hospitals Solutions for Patient Safety Network, and the Patient Safety Movement.

Another important consideration is what to do after a planned and unplanned extubation to keep patients safe during this critical time in the operating room and ICU and prevent the need for re-intubation. The use of high-flow nasal cannula oxygenation, CPAP, or BiPAP may be options to maximize oxygen delivery, prevent hypoxemia, and delay or prevent the need for emergent re-intubation. For patients who are unable to maintain adequate oxygenation and ventilation, it is important to proceed with re-intubation without delay.

What does the future look like for unplanned extubation events? With increased awareness and greater use of mitigation strategies to prevent unplanned extubation events, we can help to identify patients at risk and keep patients safe. Gathering data to track this problem may be improved with increased use of extubation classification tools and the use of core data sets in the electronic medical record as well as quality improvement initiatives related to unplanned extubation events. There are excellent resources available through the Patient Safety Movement Foundation which has a focus on unplanned extubation events as an important step towards achieving a culture of safety. All members of the perioperative healthcare team can check out the Patient Safety Movement Foundation’s Blueprints for Actionable Patient Safety Solutions for educational, evidence-based resources as well as a coaching program for hospitals to work towards a culture of safety, develop quality improvement programs, track unplanned extubation events, and decrease unplanned extubation events at the institution.

Another critical resources is the Society for Airway Management which is dedicated to improving airway safety and has developed a special projects committee to focus on decreasing unplanned extubation events. The work of this committee includes bringing together 20 medical societies and patient safety organizations into a coalition that has published more than 30 articles on unplanned extubation, and creating a toolkit with checklists and core data sets that can be used by hospitals to track unplanned extubation events. As soon as you are done listening to this podcast, head over to airwaysafetymovement.org and patientsafetymovement.org for more information to help tackle the problem of unplanned extubation events in the adult, pediatric, and neonatal population.

The coalition has made a big step towards zero unplanned extubation events in the future with the new patient safety networks which share quality improvement methods and best practices. These include The Children’s Hospitals’ Solutions for Patient Safety Network and The Adult Hospital Solutions for Airway Safety Network. We are excited for this collaboration and teamwork to lead to decreased unplanned extubation events in the future.

[Bechtel]  Before we wrap up for today, we are going to hear from Berkow again. I asked her, what do you hope to see going forward? Here is her response.

[Berkow] I hope that this article will increase the awareness of the readers and that it will spur more hospitals to start tracking unplanned extubation as well as educating their providers on strategies to mitigate risk so that eventually this will reduce the incidence of unplanned extubation going forward and will make our patients safer.

[Bechtel] Thank you so much to Berkow for contributing to the show today.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

You may have seen our look alike vials tweets, but have you checked out the newest page on the APSF website? It is the Look-alike Drug Vials: Latest Stories and Gallery. I will include a link in the show notes and we hope that you will head over there to read about the latest alerts, check out the gallery of look-alike vials, read the related APSF articles, listen to the related podcasts, and consider submitting your own look-alike drug alert. You can help to share information and keep patients safe.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation