Unplanned Extubation
Common. Costly. Preventable.

In health care, a significant threat to ventilated patient safety is Unplanned Extubation, which occurs when a patient or other external force pulls an inadequately stabilized breathing tube out of the airway.7,11,41,42

Every year, unplanned extubation impacts more than 121,000 patients, causes over 36,000 cases of ventilator-associated pneumonia, leads to more than 33,000 preventable deaths, and adds more than $4.9 billion in wasteful healthcare costs. The median incidence rate of Unplanned Extubation is 7.3% in all ventilated ICU patients.7,11,41,42 As the current standard of care, this is unacceptable.

Securement Practices

Unplanned extubation can only occur when an endotracheal tube is inadequately secured, allowing either deliberate or accidental forces to pull the tube out of the trachea.20,21 Current securement practices fall into two broad categories.

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Category 1

Manual Securement

The first is “manual” and utilizes either twill or a variety of adhesive tape to secure the tube. Typically twill tape is cinched around the tube and then wrapped and tied behind the neck to secure the cinch point at the mouth. Adhesive tape is usually wrapped around the tube and then taped to the cheek and neck or pulled together behind the neck, again with the purpose of securing the point where the tape goes around the tube at the mouth.

 
 
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Category 2

Commercial Device Securement

The second category incorporates “commercial devices” specifically designed to secure endotracheal tubes. These devices wrap behind the neck and connect to the endotracheal tube by either a cloth or plastic strip that surrounds the tube, a screw that squeezes the tube, or a channel that the tube goes through. Some commercial devices also utilize adhesive to secure the device to the patient’s face. Device effectiveness is typically measured by the amount of force required to displace the device, ability to hold the endotracheal tube in place, ease of application, degree of pressure damage the device causes to oral mucosa, lips, and facial skin, and patient satisfaction or pain.20,22

 
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Unplanned Extubation increases with the following factors:

  • Patient restlessness/agitation (7)

  • Inadequate sedation (10,37)

  • Use of physical restraints (37)

  • Absence of clear policies and procedures related to weaning (10)

  • Factors related to nursing staffing such as night shift, inexperienced ICU nurses, or unit characteristics that prevent adequate nursing observation (7)

 
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The Annual Cost of Unplanned Extubation


1,650,000
annually intubated ICU patients57,58


121,000
preventable unplanned extubation events7


$100,198
average ICU cost per each occurrence with complications41,42


$4,900,000,000
wasted health care dollars7,11,41,42

 

The Significant Clinical Burden

A comprehensive guided review of the literature reported that unplanned extubation occurs in 7.3% (median) of all adult ICU intubated patients.7 Other studies have found adult ICU occurrence rates from 2.0% to 10%.6,11,12 The clear majority (62.8%-96.4%) of unplanned extubations in adult intensive care units are the result of patient self-extubation.3,5,11,13 Data from outside the anesthesia and ICU settings are scant, but two studies suggest the unplanned extubation rate in the emergency medical services (EMS) setting is approximately 3%, but it is likely higher since these studies relied solely on voluntary self-reporting.14,15

Unplanned extubation is the fourth most common adverse event in the Neonatal Intensive Care Unit (NICU).16 Incidence in the NICU is between 1-4.8 unplanned extubations per 100 ventilated days.16,17 In a prospective study in a combined pediatric/neonatal ICU da Silva and colleagues found the unplanned extubation rate to be 18.7%.18 Self-extubation is the most frequent cause of unplanned extubation in neonates (60%); accidental extubation during retaping of the tube, suctioning, weighing, or ventilator circuit changes make up the remainder.19

 
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Drew’s Story

Drew Hughes was an active, vibrant 13-year-old boy from North Carolina. In June of 2013, Drew was out skateboarding with his friends and fell backward, striking his head on the pavement. After visiting the local emergency department, the decision was made to transport Drew to the Level I Trauma Center. He was alert and conscious in the Emergency Department, but as a safety precaution the medical staff recommended Drew be sedated and a life sustaining breathing tube be placed in his airway for the long transport. En route to Vidant Medical Center in Greenville, Drew woke up in the ambulance and removed the breathing tube from his airway–an event called unplanned extubation. The paramedics responded by injecting Drew with a medication to paralyze him so they could replace the breathing tube before continuing the transport. Over the next 30 minutes, Drew’s oxygen levels fell dramatically because his breathing tube had been improperly positioned in his esophagus rather than his trachea. As a result, Drew lost his life. If Drew’s breathing tube had been adequately stabilized, this preventable tragedy would never had occurred.

We believe one death is too many. That’s why Securisyn Medical is partnering with The Do It For Drew Foundation, Airway Safety Movement, and the Patient Safety Movement Foundation to raise awareness and eliminate preventable deaths from unplanned extubation.

Unfortunately, Drew’s story isn’t unique. Unplanned Extubation is affecting patients and hospitals around the country every day. And sometimes, UE even makes headlines.

 
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Unplanned Extubation is Preventable

Prevention of unplanned premature extubation begins with securement. As noted above multiple authors have described the absence of an optimal endotracheal tube stabilizer for patients of any age.15,20-22,24-26,28,30,34,54-56

Attributes of the optimal securement device include: 20,22,31,33,57

  • Easy to apply and maintain
  • Adequate stabilization of the tube against external forces that risk dislodgement
  • Prevention of tube movement >3.5 cm
  • Security is not compromised when the device is exposed to blood, saliva, or other fluids
  • Secures the endotracheal tube without compressing the tube and decreasing the internal diameter
  • Enables movement of the tube in the mouth for oral care and ulceration prevention without jeopardizing the position of the distal tip
  • Facilitates suctioning of the tube and oropharynx without risk of tube movement
  • Allows good visualization of the oral cavity
  • Requires infrequent adjustment or change

Learn how you can get involved in tracking, preventing, and eliminating Unplanned Extubation.