Airway Safety

Failed airway management is as high as 1 in 50-100 in ED and ICU settings and can be even higher prior to arrival at the hospital. Although the goals are airway safety are uniform, applied practice is often fragmented and lacks standardization across the continuum of care, including pre-hospital arrival. Our APSS Blueprints provide healthcare organizations with practical, evidence-based checklists and protocols to establish an airway safety standard across hospital settings.

Patient Stories


It is estimated that 12.5 to 44% of COVID-19 cases were nosocomial – acquired in hospitals by patients who were admitted for other reasons.1,2

Rickman, H. M., Rampling, T., Shaw, K., Martinez-Garcia, G., Hail, L., Coen, P., … & Houlihan, C. F. (2020). Nosocomial transmission of COVID-19: a retrospective study of 66 hospital-acquired cases in a London teaching hospital. Clinical Infectious Diseases.


Carter, B., Collins, J. T., Barlow-Pay, F., Rickard, F., Bruce, E., Verduri, A., … & Stechman, M. J. (2020). Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople). Journal of Hospital Infection106(2), 376-384.

Even for intubations performed by hospital-based transport teams, 70% of neonates required multiple attempts, compared to 30% of the pediatric population3

Smith, K. A., Gothard, M. D., Schwartz, H. P., Giuliano, J. S., Jr., Forbes, M., & Bigham, M. T. (2015). Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport. Prehosp Emerg Care, 19(1), 17-22. doi:10.3109/10903127.2014.964888

In the hospital setting, first attempt intubation success in neonates is <50%4

Sauer, C. W., Kong, J. Y., Vaucher, Y. E., Finer, N., Proudfoot, J. A., Boutin, M. A., & Leone, T. A. (2016). Intubation attempts increase the risk for severe intraventricular hemorrhage in preterm infants—A retrospective cohort study. The Journal of Pediatrics, 177, 108-113. doi:

The incidence of failed intubations in children in out-of-hospital settings, defined by 3 or more unsuccessful attempts, is as high as 58%, and these or other major intubation difficulties are associated with higher odds of cardiac arrest5

Hansen, M., Meckler, G., Lambert, W., Dickinson, C., Dickinson, K., Van Otterloo, J., & Guise, J. M. (2016). Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS. BMJ Open, 6(11), e012259. doi:10.1136/bmjopen-2016-012259

Unplanned Extubations happen in over 7% of patients who undergo mechanical ventilation in the ICU and the complications of unplanned extubations result in over $4 billion in healthcare costs6

da Silva, P. S. L. and Fonseca, M. C. M. (2012). Unplanned Endotracheal Extubations in the Intensive Care Unit. Anesthesia & Analgesia, 114(5), 1003–1014. doi:10.1213/ane.0b013e31824b0296

Failed intubations occur in as high as 38% of patients in non-physician intubator field cases and as high as 22% of patients in physician intubator field cases7

Crewdson, K., Lockey, D.J., Roislien, J., Lossius, H.M., & Rehn, M. (2017). The success of pre-hospital tracheal intubation by different pre-hospital providers: A systematic literature review and meta-analysis. Critical Care, 21(31),

The incidence of failed airways can be as high as 1 in 50-100 in ED and ICU settings and the occurrence of death or brain damage have been reported to be 38-fold (ED) to 58-fold (ICU) higher compared to the operating room setting with anesthesia8

Cook, T. M. and MacDougall-Davis, S. R. (2012). Complications and Failure of Airway Management. British Journal of Anaesthesia, 109(suppl 1), i68–i85. doi:10.1093/bja/aes393

Unplanned extubation occurs in over 7% of patients undergoing mechanical ventilation in the Intensive Care Unit and the complications of unplanned extubations result in over $4 billion healthcare costs.9

da Silva, P. S. L., & Fonseca, M. C. M. (2012). Unplanned endotracheal extubations in the intensive care unit: Systematic review, critical appraisal, and evidence-based recommendations. Anesthesia & Analgesia, 114(5), 1003- 1014.

The incidence of perioperative complications is greater in patients with obstructive sleep apnea (OSA).10

Liao, P., Yegneswaran, B., Vairavanathan, S. et al. Can J Anesth/J Can Anesth (2009) 56: 819. doi:10.1007/s12630-009-9190-y.

Sentinel events from respiratory depression are caused by wrong dosing 47% of the time and improper monitoring 29% of the time.11

Joint Commission. (2012). Sentinel Event Alert Issue 49: Safe use of opioids in hospitals. August 8, 2012.

68% of all failure-to-rescue deaths occur among surgical inpatients with treatable complications, pressure ulcers, post-operative respiratory failure, and post-operative sepsis.12

Reed and May, HealthGrades Patient Safety in American Hospitals Study, March 2011.

Approximately 25,000 potentially life-threatening errors occur daily in hospital intensive care units (ICUs), and up to 10 percent of these adverse events involve unintended incidents in Airway Management; more than half of these errors have been deemed preventable.13

Needham, D. M., Thompson, D. A., Holzmueller, C. G., Dorman, T., Lubomski, L. H., Wu, A. W., … & Pronovost, P. J. (2004). A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Critical Care Medicine, 32(11), 2227-2233.


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