Chest
Volume 112, Issue 5, November 1997, Pages 1317-1323
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Clinical Investigations in Critical Care
Characteristics and Outcomes of Patients Who Self-Extubate From Ventilatory Support: A Case-Control Study

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Objective

To identify factors associated with the occurrence of deliberate self-extubation and to describe associated patient outcomes.

Design

Case-control study.

Setting

ICUs of a national referral, tertiary medical center.

Participants

Fifty adult, intubated patients who had self-extubated from mechanical ventilatory support. Two control subjects who had not self-extubated were matched to each case based on age, gender, primary discharge diagnosis, and time hospitalized (within same quarter).

Measurements

Standardized coding of medical record information, including demographic characteristics, clinical information, intubation and mechanical ventilation characteristics, medications, and selected laboratory indexes.

Results

As compared to the control subjects, patients who self-extubated were more likely to be medical than surgical patients (p<0.001) and have a current history of smoking (p>0.05). Prior to the self-extubation, patients had a greater likelihood of hospital-acquired infections (p<0.001) or other hospital-acquired adverse events (p>0.001), abnormal (< 10, >50 mg/dL) BUN (p>0.05), and abnormal (>20, >50 mm Hg) PaCO2 (p>0.05); they also were more likely to be restless or agitated (p>0.001), and more likely to be physically restrained (p>0.001). A logistic regression model demonstrated that presence of restlessness or agitation and presence of a hospital-acquired adverse event were independently associated with self-extubation from mechanical ventilatory support. In examining outcomes, as compared to the control subjects, those who self-extubated had longer lengths of stay in ICU and hospital, were more likely to need reintubation, and were more likely to suffer complications from intubation. However, none of the cases died within 48 h of self-extubation.

Conclusion

The results underscore the need for clinical guidelines for weaning and for monitoring patients at risk of self-extubation.

Section snippets

Setting and Sample

The study took place at the Cleveland Clinic Foundation, a 1,000-bed national referral center. Cleveland Clinic Foundation has nine adult ICUs (n = 100 beds) with >3,000 patients a year receiving mechanical ventilation.

The cases consisted of all adult patients with occurrences of purposeful SE from mechanical ventilation who were reported by nursing staff to the nursing quality management office during 1993. We defined SE as purposeful patient removal of the ET as witnessed by the nursing

RESULTS

One hundred fifty patients comprised the study sample; 50 who were SE each matched to two patients who were NSE. Results from the univariate analyses are displayed in Table 2, Table 3, Table 4. Table 2 displays the hospital variables for each group. Marginally more of the NSE group returned to home, had a lower rate of discharge to a long-term care setting, and a lower rate of death compared to those in the SE group. Significantly more of the NSE group had a surgical procedure (75%; vs 48%;,

DISCUSSION

SE from mechanical ventilation is a major concern for health-care professionals in the care of ventilated patients. Only a few studies have examined patient factors associated with outcomes of SE.1,5 This retrospective case-control study was conducted to further extend previous work in this area. We found that cases compared to control patients were more often restless or agitated and had more hospital-acquired complications. Furthermore, 25%; of the SE patients did not require reintubation,

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Presented in part at the 1996 annual meetings of the American Geriatrics Society/American Federation of Aging Research, Chicago

Reprint requests: Lorraine Mion, PhD, RN, Dept of Nursing Research, P32, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195

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