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(Chest. 2001;120:538-542.)
© 2001 American College of Chest Physicians

Factors Associated With Reintubation in Intensive Care*

An Analysis of Causes and Outcomes

Ursula Beckmann, BSc, MD and Donna M. Gillies, RN

* From the Division of Anesthesia, Intensive Care and Pain Management, John Hunter Hospital, Newcastle, Australia.

Correspondence to: Ursula Beckmann, BSc, MD, Division of Anesthesia, Intensive Care and Pain Management, John Hunter Hospital, Locked Bag 1, Newcastle Regional Mail Center, Newcastle N.S.W. 2300, Australia; e-mail: mdub{at}alinga.newcastle.edu.au


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Introduction: Reports on reintubation have focused on patients in whom planned extubation has been unsuccessful or those who have been accidentally extubated. However, reintubation is often required in events not related to accidental extubation. These cases have not been well described previously.

Objectives: To examine the causes, outcomes, and contributing factors associated with patients who required reintubation for events not including accidental extubation.

Methods: Appropriate reintubation incidents were extracted from the Australian Incident Monitoring Study in Intensive Care database and analyzed using descriptive methodology.

Results: One hundred forty-three incidents were identified with prominent precipitating events, including tube malposition (17%), securing/taping problems (17%), pilot tube/cuff problem (16%), blocked/kinked airway (14%), failed extubation (14%), and poor planning for extubation (6%). Narrative description of morbidity included hypoxia in 25% of reports, hypercarbic respiratory failure in 12%, aspiration in 7%, sputum retention in 7%, and cardiac arrhythmias in 6%. The reporter selected "major physiologic complications" and "prolonged hospital stay" as prominent adverse outcomes in 52% and 16% of patients, respectively. Major factors contributing to reintubation involved "error of judgement/problem recognition" (identified in 62% of reports), "high unit activity" (20%), "difficult patient habitus" (26%), and "lack of patient cooperation" (14%). Rechecking patient and equipment, and skilled assistance were prominent factors in limiting the adverse consequences of the incident.

Conclusion: This study indicated that reintubation not related to accidental extubation resulted in major physiologic complications and potentially contributed to increased length of stay. Its findings suggest that the adequate provision of highly qualified, intensive-care-trained staff is essential for the avoidance or minimization of these incidents.

Key Words: adverse effects • incident monitoring • intensive care • intubation, endotracheal • patient safety • quality assurance • reintubation • respiration, artificial • risk factors


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Macewen1 described the first successful use of an artificial airway in 1880. Since then, whether by endotracheal tube, nasal tracheal tube, or tracheostomy, it has become a prominent intervention in the modern ICUs. However, its acceptance and widespread use is not without complications, which have been previously documented.2 3 4 5 6 7

Most recently, reports on airway complications have focused on patients who have had unsuccessful extubations or those who have self-extubated and require reintubation.8 9 10 11 12 13 14 15 16 17 18 These studies have examined results of unplanned reintubations and have tried to determine factors that place the patient at risk for requiring reintubation.

Incidents related to the provision of health care in the intensive-care environment are gathered through the Australian Incident Monitoring Study in Intensive Care (AIMS-ICU) database. An analysis of this database permits identification of actual and latent problems, and further assists in identifying prominent causes, adverse outcomes, and factors that either contributed to or limited the incident.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Following medical and nursing collaboration, the AIMS-ICU study was established in 1993 to provide an anonymous, voluntary incident reporting system for ICUs throughout Australia and New Zealand. The initial development and methodology of this project have been described previously.19 20 More than 90 ICUs were registered with the project at the time of this review.

An incident was defined as any unintended event or outcome that could have, or did, reduce the safety margin for the patient. It may or may not have been preventable, and it may or may not have involved an error on the part of the health-care team. ICU staff members of participating units were invited to report any incident they were involved in, using standardized report forms. The event was to be described by the reporter in detail in the narrative section, including reasons for its occurrence, outcomes, and limiting factors. The reporter was also asked to indicate his/her opinion with regard to contextual information by selecting appropriate choices from multiple tickbox lists. This contextual information related to patient and staff factors, the estimation of the effect of the incident on the patient, and those factors contributing to or limiting the event. Guidelines for the completion of the incident report form were available to the reporter, including definitions of the terms for the different choices.

Reports gathered by a participating ICU were entered onto a central computerized database. A proprietary database program (FoxPro; Fox Software; Perrysburg, OH) was used for data entry, storage, and retrieval. Before being forwarded to the national coordinator, the reports were reviewed at the local unit at staff review sessions to discuss concerns. These reports were then added to the AIMS-ICU national database, and following narrative review, were allocated standardized key words. Many reports described multiple incidents.

The key word "reintubation" was assigned to a report in which a patient required reintubation to maintain adequate airway protection and/or ventilation. These incidents included situations in which the reintubation was related to accidental extubation and those that were not. Accidental extubation included self-extubation and other events leading to the accidental dislodgment of the artificial airway. For this review, only reintubations not related to accidental extubation were included, and their contextual information was analyzed using descriptive methodology.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Since 1993, 93 units had progressively enrolled in the AIMS-ICU study. By December 1999, these units had contributed 7,525 reports describing > 11,000 incidents. These incidents fall into five major categories: (1) airway and ventilation (n = 1,829), (2) drugs and therapeutics (n = 2,744), (3) procedures, lines, and equipment (n = 2,687), (4) patient management and environment (n = 2,267), and (5) unit management (n = 1,572). Reintubation incidents are included in the first category; 241 reintubation incidents were identified, 98 being related to accidental extubation, and the remaining 143 requiring reintubation for events not related to accidental extubation. This article examines the latter, of which 114 incidents involved an oral endotracheal tube, 20 involved a nasal endotracheal tube, and 9 involved a tracheostomy.

Eighty-four of the incidents (59%) occurred during the weekday day shift (7 AM to 7 PM), 47 incidents (33%) occurred during the weekday night shift, and a further 12 incidents (8%) occurred on weekends or during a public holiday. All incidents, with one exception, occurred in the ICU: 122 incidents (85%) during ongoing care, 11 incidents (7.5%) during a hospital admission intervention, and a further 8 incidents (5.5%) during an emergency intervention. (Information was not provided in one incident report.)

Of the 143 patients involved in this report, 5 patients were aged < 28 days old, 10 patients were between 28 days and 1 year of age, 10 patients were between 1 year and 14 years of age, and 118 patients were > 14 years. Table 1 shows the main events precipitating reintubation for pediatric vs adult patients, which are categorized into six primary causes.


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  		Table 1.. Prominent Events Precipitating Reintubation Not Related to Accidental Extubation *

 
Staff members who precipitated the incident included 61 nurses, 29 doctors, and 5 other professionals. In 49 reports, no individual staff member precipitated the event. Nursing staff detected the incident in 114 reports, medical staff detected 23, and other professionals detected it in 6 reports. To the prompting "was the staff member ICU trained?" the reporters answered in an affirmative manner for 30% of staff precipitating the incident, compared to 89% of those detecting the incident. The remaining 11% of staff detecting the incident were trained in another specialty, eg, anesthesiology.

Reporter selections for estimated patient outcomes due to the reintubation are identified in Table 2 . They chose "major physiologic complications" in 52% of incidents and "prolonged hospitalization" in 16%. Reporters description in the narrative of morbidities associated with the incidents included hypoxia in 25% of incidents, hypercarbic respiration failure in 12%, aspiration in 7%, sputum retention in 7%, and cardiac arrhythmias in 6%.


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  		Table 2.. Reporter Estimation of the Adverse Effect of Reintubation *

 
Of the multiple contributing factors selected (Table 3 ), "error of judgment or problem recognition" was chosen most prominently by the reporter. For each incident, the reporter could choose multiple selections of factors serving to limit the adverse effect of the incident. Prominent factors included rechecking the patient (n = 80; 56%), skilled assistance (n = 72; 50%), prior experience (n = 41; 29%), rechecking the equipment (n = 34; 24%), and use of correct protocol (n = 22; 15%).


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  		Table 3.. Reporter Estimation of Common Factors Contributing to Reintubation Incidents *

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Quality has become a major issue in health-care provision by both nursing and medical staff in the intensive-care environment. The need for measurement of quality based on patient outcomes and complications remains a complex problem. Incident reporting is well established in Australia and New Zealand ICUs through the AIMS-ICU study. This study provides reporting of incidents, which permit the identification of active and latent errors. The reporters of incidents are health professionals involved with the event and are thus ideally placed to provide crucial contextual information not captured elsewhere. The power of this system is further increased by the collation of large numbers of reports to a central database.

A number of possible disadvantages may be encountered when utilizing anonymous incident monitoring. The information gathered does not provide a numerator or denominator, so that the true incidence of problems cannot be assessed. It is likely that only a small fraction of all incidents are reported. Selected contributing factors represent the opinion of the reporter and do not necessarily prove a cause-and-effect relationship. Also, the possibility of volunteer bias or selection bias needs to be considered for both the ICUs electing to join the study as well as for individual staff members choosing to participate.19 20 Despite these possible disadvantages, incident monitoring provides important information not found in prospective and retrospective studies.

A wide range of problems occurring during the care of patients in the intensive-care environment has been reported to the AIMS-ICU national database. Unplanned reintubation is a commonly reported problem involving most ICUs.

Control of the airway with an artificial airway is an accepted standard practice in modern ICUs. However, its acceptance and widespread use is not without complications. Following successful placement of the artificial airway, complications such as laryngeal injury, tracheal injury, malposition, nasal or soft-tissue injury, and cuff leakage may occur and have all been documented.2 3 4 5 6 7

Reports on airway complications have focused on patients who have undergone unsuccessful extubation and require reintubation or patients who have accidentally self-extubated and require reintubation.8 9 10 11 12 13 14 15 16 17 18 Although small in size, the results of these studies suggest an increased number of complications and higher mortality for patients who required reintubation. Some of these studies13 17 18 have tried to identify variables that predict patients at risk for reintubation but have been inconclusive. To our knowledge, only one case control study has examined other reasons for reintubation.16 This study by Torres et al16 focused on the increased risk of pneumonia for patients requiring reintubation when compared to patients who did not. The prominent reasons for reintubation in their 40 patients included cuff leakage (n = 9), tube obstruction (n = 3), self-extubation (n = 6), and failed extubation (n = 12). Other contextual factors were not elicited in their report. Although these causes were also prominent in our findings, their frequency was distributed more evenly in our study. For our pediatric patients, reintubation was more prominently linked to tube blocking or kinking and inadequate securing.

Outcome measurements from studies with a known denominator8 9 10 11 12 13 14 15 16 17 18 provide useful information regarding the occurrence of reintubation, focusing on specific population groups such as trauma or surgical patients. While our study did not provide a denominator, it did provide a rich background of information.

Our report has examined unplanned reintubation not associated with accidental or self-extubation. It is reasonable to suspect that accidental extubation requiring reintubation might comprise a different set of incidents compared to reintubation for events not related to accidental extubation, with their own specific causes and contributing factors. It is planned to report on accidental extubation incidents reported to the AIMS-ICU database separately. Incidents related to malpositioning of the artificial airway were included in this report, as complete accidental extubation had not occurred. One could argue that this group could be analyses as a subgroup of incidents where reintubation is related to accidental extubation.

In some of the incident reports, the events precipitating reintubation or those contributing to it overlapped. In several reports relating to tube securing problems, for example, the final event precipitating reintubation was malpositioning of the artificial airway. A similar overlap was seen in reports in which the contributing factor "uncooperative patient" had been selected. Here, reintubation was necessary when these patients deformed or perforated the artificial airway or pilot tube by biting on it or when tongue movement caused malpositioning of the tube.

Various studies9 11 related to unplanned reintubation have concluded that patients who require reintubation have an increased risk of major physiologic complications. The most frequently reported complications are of respiratory and cardiac nature. Data from our report support this, as the reporters selected the option of adverse effect called "major physiologic complications" in 52% of incidents. These findings highlight the seriousness of events leading to reintubation and the need to identify prominent contributing factors.

Prolonged hospital stay, specifically intensive care stay, is a recognized sequel of reintubation.9 11 Here in 23 patients (16%), the reporter estimated that the event would lead to a longer length of stay. AIMS-ICU reports were usually completed at the time of the incident. Thus, underreporting of the effect on duration of stay is likely.

Grouping the timing of incidence occurrence may be useful when assessing staffing and unit activity levels. Our higher weekday daytime occurrence of incidents may have been due to increased patient and unit activity during that time period. The time for reintubation occurrence was not examined by other studies dealing with reintubation.8 9 10 11 16 Some studies13 17 18 21 of accidental extubation have addressed this issue. Christie et al13 and Tindol et al21 identified a correlation between periods of high activity and the incidence of accidental extubation, while others17 18 failed to do so.

A number of studies21 22 23 have shown that there is a clear relationship between trained intensive-care staff and quality of patient treatment. In our study, the quality of staff also appears to be a very important factor. In the opinions of the staff reporting the incident, more than half of the staff responsible for precipitation of the incident had no or inadequate intensive-care training, compared to 89% of those detecting the incident. The guidelines for completion of the incident form did not give a formal definition of the choice "ICU trained." However, a review of narratives indicated these selections included staff inexperienced in ICU or currently in training. Staff contributing factors may be expected to improve with training.

An important strength of incident monitoring is its ability to elicit factors contributing to the incident. Although individual units may be able to express contributing factors associated with their incidents, the use of a central database has allowed the investigators to assess this information across varied intensive-care settings. Common contributing factors could be grouped into those related to patient, staff, and unit factors. The factors in the latter two groups were linked in some settings. "High unit activity" and "staff busy elsewhere" were major contributing factors in 20% and 19% of reports, respectively. In an earlier article outlining the incidents associated with insufficient nursing staff, Beckmann et al24 commented that during high unit activity, staffing levels are often stretched resulting in incorrect matching of staff to patient and inadequate overall experience level within the unit. As a consequence, errors in judgment and poor treatment decisions may result in suboptimal care. Results from our study support this notion, identifying errors of judgment, problem recognition, and errors of treatment decisions as important staff-related contributing factors. Patient factors including "difficult body habitus" and "uncooperative patient" formed other important contributing factors. No reference to contributing factors listed could be found in other studies.

Other important contextual information gathered through incident monitoring include those factors limiting the adverse effects of the incident. Here, early detection through checking the patient and equipment highlights the importance of close observation. Skilled assistance and prior experience also played an important role in limiting the effects of the incident. This also supports the requirement to maintain a workforce of educated and skilled staff.

In conclusion, this report suggests that reintubation not related to accidental extubation resulted in major physiologic complications and an increased length of hospital stay. Its findings indicate that the adequate provision of highly qualified, intensive care trained staff is essential for the avoidance or minimization of these incidents.


   Footnotes
 
Abbreviation: AIMS-ICU = Australian Incident Monitoring Study in Intensive Care

Received for publication June 7, 2000. Accepted for publication December 18, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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