CHARACTERIZATION OF CASES OF ACCIDENTAL EXTUBATION IN PATIENTS ATTENDED AT FEDERAL UNIVERSITY HOSPITALS

Abstract

Introduction: The unplanned extubation (UE) is the withdrawal, unplanned and unintentional use of the ventilatory device during the patient’s hospitalizations period. Aim: To characterize cases of UE in a network of Federal University Hospitals (FUH).  Methodology: Cross-sectional, retrospective, quantitative study conducted in a FUH network. A total of 404 UE notifications were analyzed in a period from January 1 to December 31, 2016. We analyzed: classifications of notifications; age; sex; race/color; intubations pathway; locations of the incident; types of manifestations; possible causes; concurrent procedures; damage caused; shift of occurrence; training of notifiers and conduct adopted. The data is placed in Microsoft Excel worksheet for analysis and interpretation.Results: In 2016 there were 404 notifications concerning UE. 65% were not classified as Urgent or Alert. Characteristics of the patients: 53% aged less than 1 year old, 57% male and 46% White. Characteristics of the incidents: 99% of the intubation routes were orotracheal; occurred predominantly in the Adult ICU (53%); in 62% there was displacement of the tube; the most cited cause was the age less than 1-year-old (37%). In 80% of notifications, there were no concomitant procedure; 72% were considered non-serious and 44% were on the night shift. Notifiers 76% were nurses. Conduct: the main conduct adopted was the reintubations of the patient.Conclusion: The study characterized the cases of UE reported in the FUH network, emphasizing the importance of investing in preventive actions to avoid the occurrence of these incidentes.