In healthcare, a significant threat to ventilated patient safety is Unplanned Extubation, which occurs when a patient pulls their breathing tube out of their airway (self-extubation) or an external force causes the breathing tube to be pulled out of the airway (accidental extubation).
Drew Hughes’ story is why we are passionate about raising the awareness of unplanned extubation and working to prevent any further harms or deaths.
A 2012 review of the adult literature published in Anesthesia and Analgesia found that 7.3% of intubated adult ICU patients, undergo the unintentional, self or accidental removal of their endotracheal tube. A 2013 review of the neonatal literature published in Respiratory Care found that 18.2% of intubated patients in the NICU undergo an unintended extubation.
download unplanned extubation fact sheet
THE ANNUAL IMPACT OF Unplanned Extubation (1,2,4,6,8,9)
annual intubated ICU patients
preventable unplanned extubation events
ICU length of stay
additional ICU VAP’s
average increase in ICU costs per event
in wasteful healthcare spending
Unplanned extubation leads to an increased incidence of pneumonia and increased the length of hospital stay, which leads to increased healthcare costs.
of pneumonia (%)
increased length of
icu stay (days)
download the Complications of
Unplanned Extubation Recognition & Prevention Paper
factors that increase incidents of UE (#)
Inadequate breathing tube stabilization
Patient restlessness and agitation (1,2)
Inadequate sedation (2,3)
Use of physical restraints (2)
Absence of clear policies and procedures related to weaning (2)
Factors related to nursing staff (inexperienced, night shift, inadequate staffing) (1)
Use of Midazolam to decrease agitation and delirium (4)
fighting unplanned extubation
The ABCDEF Bundle is the evidence-based execution plan outlining the relationship between sedation, prolonged ventilation, and prolonged bed rest with poor ICU outcomes. When healthcare providers adopt this guideline, their outcomes have been pretty impressive. Here are a few of those numbers:
Increased daily awakening assessments
34.8% reduction in daily benzodiazepine dosage
Increased RASS scores (meaning the patient was less sedated)
33% reduction in delirium
17.6 reduction in duration of mechanical ventilation
12.4% reduction in ICU LOS
14% reduction in hospital LOS
No change in mortality, VAP, or discharge status
we can’t solve what we can’t track
Extubation may occur as a planned or unplanned event. All extubations, planned and unplanned must be tracked in order to better define those events that are unintended and uncontrolled.
Data is best collected through electronic capture of data fields from electronic patient care reports. This requires having an 'Electronic Health Record System' that includes the following Patient Safety Movement Foundation Core Data Set for Unplanned Extubation.
1. Lucas da Silva, et al. Unplanned Endotracheal Extubations in the Intensive Care Unit. Anesth Analg 2012;114:1003–14
2. DeLassence A, et al. Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in intensive care unit: a propective multicenter study. Anesthesiology. 2002; 97(1):148-56.
3. DeGroot RI, et al. Risk factors and outcomes after unplanned extubation in the ICU: A case control study. Critical Care, 2011, 15:R19
4. Dasta, et al. Daily Cost of an ICU Day. Crit Care Med 2005 June 33(6) 1266-71
5. Fisher, D.F., et al., Comparison of commercial and noncommercial endotracheal tube securing devices. Respir. Care, 2014. 59(9): p. 1315-23.
6. Medicine, S.f.C.C. Critical Care Statistics. 2017; Available from: http://www.sccm.org/Communications/Pages/CriticalCareStats.aspx.
7. Moons, P., et al., Development of a risk assessment tool for deliberate self-extubation in intensive care patients. Intensive Care Med, 2004. 30(7): p. 1348-55.
8. Needham, D.M. and P.J. Pronovost, The importance of understanding the costs of critical care and mechanical ventilation. Crit Care Med, 2005. 33(6): p. 1434-5.
9. Wunsch, H., et al., ICU occupancy and mechanical ventilator use in the United States. Crit Care Med, 2013. 41(12): p. 2712-9.
1. Barr, J., et al., Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med, 2013. 41(1): p. 263-306.
2. Barr, J., Liberating ICU Patients from Deep Sedation and Mechanical Ventilation-- an Overview of Best Practices, in ICU Liberation: The Power of Pain Control, Minimal Sedation, and Early Mobility, C.T. Balas M, Hargett K, Editor. 2015, Society for Critical Care Medicine.
3. Sneyers, B., et al., Predictors of clinicians' underuse of daily sedation interruption and sedation scales. J Crit Care, 2017. 38: p. 182-189.
4. Sneyers, B., et al., What stops us from following sedation recommendations in intensive care units? A multicentric qualitative study. J Crit Care, 2014. 29(2): p. 291-7.
5. Sneyers, B., et al., Current practices and barriers impairing physicians' and nurses' adherence to analgo-sedation recommendations in the intensive care unit--a national survey. Crit Care, 2014. 18(6): p. 655.
6. Tanios, M.A., et al., Perceived barriers to the use of sedation protocols and daily sedation interruption: A multidisciplinary survey. Journal of Critical Care. 24(1): p. 66-73.
7. Rubin, E. 2018.
8. Dale, C.R., et al., Improved Analgesia, Sedation, and Delirium Protocol Associated with Decreased Duration of Delirium and Mechanical Ventilation. Annals of the American Thoracic Society, 2014. 11(3): p. 367-374.
FACTORS THAT INCREASE INCIDENTS OF UE
1. da Silva PS, Fonseca MC. Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg. 2012; 114(5): 103-1014.
2. McNett M, Kerber K. Unplanned extubations in the ICU: Risk factors and strategies for reducing adverse events. J Clin Outcomes Manag. 2015;22(7): 303-311.
3. Aydigan S, Nurten K. The Assessment of the Risk of Unplanned Extubation in an Adult Intensive Care Unit. Dimens Crit Care Nurs. 2017;36(1):14/21.
4. de Groot RI, Dekkers OM, Herold IH, et al. Risk factors and outcomes after unplanned extubations on the ICU: a case-control study. Crit Care. 2011:15(1):R19