Construction of a nursing quality evaluation indicator system for extubation of endotracheal tube in the Postanesthesia care unit in China: A Delphi study

When a patient wakes up from major surgery, the moment they are ready to breathe on their own is a critical turning point. For years, this transition has relied heavily on the skill and judgment of the nurses working in the recovery room, known as the Postanesthesia Care Unit. These professionals monitor patients as they emerge from anesthesia, managing the removal of the breathing tube that was inserted during the operation. While this procedure is routine, it carries significant risks. If the airway closes, if the patient struggles to breathe, or if secretions block the throat, the situation can become dangerous very quickly. In many places, the way nurses handle this specific task has varied from one hospital to another, making it difficult to ensure that every patient receives the same high standard of safety.

To solve this, researchers in China set out to build a clear, standardized map for nursing care during this delicate phase. They did not guess what should be done; instead, they gathered the best available evidence from medical guidelines and expert opinions to create a specific set of rules and checkpoints. This new system acts like a quality control checklist, ensuring that the recovery room is equipped with the right tools, that the staff follows the correct steps, and that the patient leaves the unit without suffering preventable complications. The goal was simple but vital: to turn a high-risk moment into a consistently safe experience for every patient.

The researchers began by digging through a vast amount of medical literature, searching for proven methods and best practices related to breathing tube removal. They looked at guidelines from major medical organizations and summaries of clinical studies to find the most reliable information. From this research, they drafted a preliminary list of things that matter most. This list was organized into three main categories: the setup of the room and equipment, the actions taken by the nurses, and the final results for the patient. They then held interviews with experienced doctors and nurses to refine these ideas, ensuring the list reflected real-world challenges and needs.

Once this initial draft was ready, the team turned to a group of twenty-two experts from across China to test and perfect the system. These experts included anesthesiologists, specialized recovery room nurses, and hospital managers. The researchers used a method called the Delphi technique, which involves asking the same group of experts to review the list multiple times. In the first round, the experts rated how important each item was and offered suggestions for changes. They asked for specific additions, such as including the use of ventilators as a key factor, and they clarified vague terms to make them more precise. For instance, they changed general phrases about "equipment" to specify that the department must have emergency intubation tools and vehicles designed for difficult airways. They also refined instructions about drug preparation, ensuring nurses know exactly which medications to have ready and how to use them safely.

After the experts reviewed the revised list, they participated in a second round of evaluation. This time, they looked at the updated indicators to confirm their importance and ensure everyone agreed on the final version. The response rate for this second round was perfect, with every single expert returning their feedback. The experts showed a very high level of agreement on what mattered most. They confirmed that the system needed to cover three main areas: the structure of the care environment, the process of the care itself, and the outcomes for the patient. The final system they approved contains thirty-eight specific points to check. These points range from whether the hospital has a written plan for emergencies to whether the nurse can correctly assess if a patient is ready to breathe on their own.

The resulting system is a comprehensive guide that covers everything from the physical setup of the recovery room to the detailed actions of the nursing staff. Under the category of structure, the system checks if the unit has the right equipment, such as suction machines and emergency intubation kits, and if there are enough trained staff members on duty. It also verifies that the hospital has written procedures for handling complications. Under the process category, the system focuses on what the nurses actually do. This includes assessing the patient for risks before the tube is removed, preparing the correct medications, managing the ventilator settings, and carefully monitoring the patient's vital signs during and after the tube is pulled. The experts placed a heavy emphasis on the nurse's role in recognizing high-risk factors and communicating them to the doctor before any action is taken.

The final part of the system looks at the results. It tracks whether the patient experienced any problems, such as a spasm of the voice box, low oxygen levels, or damage to the teeth during the procedure. One of the most critical measures is the rate of unplanned extubation, where a tube is removed accidentally before it is safe. The data suggests this happens more often in some regions than others, making it a key target for improvement. By tracking these outcomes, hospitals can see if their care is working and where they need to make changes. The researchers found that the experts were highly confident in this system, with scores indicating that the indicators are both scientifically sound and practically useful.

While the system is now ready for use, the researchers acknowledge that it has not yet been tested in hospitals across the country. The group of experts came from specific regions, which means the findings might need adjustment for different settings in the future. However, the work provides a solid foundation for improving patient safety. By giving nurses and hospitals a clear, agreed-upon standard for care, this study offers a way to reduce the risks associated with waking up from anesthesia. It transforms a complex medical procedure into a series of manageable, checkable steps, ensuring that the moment a patient takes their first breath on their own is a moment of safety rather than uncertainty.