Actionable Patient Safety Solutions (APSS)

Unplanned-Extubation
Unplanned Extubation

The Unplanned Extubation APSS Blueprint outlines actionable steps healthcare organizations should take to successfully implement and sustain improvements in order to reduce morbidity and mortality pertaining to Unplanned Extubation. Actionable steps to improve Unplanned Extubation in patients and summaries of available evidence-based practice protocols are included:

  • Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
  • Performance improvement plan to follow if improvements are necessary
  • Clinical workflow from Unplanned Extubating to discharge including an inpatient Unplanned Extubation and action tool worksheet
  • Knowledge base on treatment for Unplanned Extubation
  • How to educate patients and family members about different aspects of Unplanned Extubation
  • Unplanned Extubating resource guide
  • Guidance on how to measure outcomes

The Blueprint is revised annually and is available free of charge on our website.

Hospitals who make a formal commitment to improve Unplanned Extubation and share their successes on the PSMF website have access to an additional level of consulting services.

Executive summary

The Problem
Unplanned extubation (UE) is the unintentional removal of a patient’s life-sustaining breathing tube which occurs when a patient removes their tube (self extubation) or when the tube is dislodged by an external force (accidental extubation). It can also occur when the endotracheal tube malfunctions (i.e. balloon failure) requiring replacement of the tube (device malfunction). While preventable with stepwise, simple measures, UE is a major cause of harm and death both in the hospital and in the emergency medical service (EMS) sector. Of the 1.65 million intubated ICU patients in the US annually, 121,000 are estimated to experience an unplanned extubation (da Silva & Fonseca, 2012).

The Cost
UE is estimated to cause 36,000 annual ventilator-associated pneumonia cases, to increase ICU costs by $41,000 per UE event, and to double length of stay, ultimately culminating in $4.9 billion in wasted healthcare costs (De Groot et al., 2011; Dasta, McLaughlin, Mody & Piech, 2005). Most importantly, it is associated with 33,000 ICU deaths in the US yearly.

The Solution
Many healthcare organizations have successfully implemented and sustained improvements and reduced harm and death UEs. These organizations have focused on projects that included implementing an UE prevention “bundle”, with the additional effects of increasing patient satisfaction, improving clinician engagement, and growing the financial bottom line.

This document provides a blueprint that outlines the actionable steps organizations should take to successfully reduce UEs and is targeted toward adult unplanned extubation. Pediatric and neonatal unplanned extubation is addressed in APSS 8D.
This document is revised annually and is always available free of charge on our website. Hospitals who make a formal commitment to improve UE and share their successes on the PSMF website have access to an additional level of consulting services.

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