About Unplanned Extubations (UEs)
Unplanned Extubation: the unintentional and uncontrolled removal of an intubated patient's endotracheal tube (ventilator/breathing tube) due to self-extubation, nursing care, or movement of the patient. UEs, are one of the most underreported safety events, especially when reporting associated morbidities or death.
- PreCOVID data of underreported values present averages of 7.4 - 12% occurrence with ranges of .5%-36% (sm-lrg ICUs).
- We performed 173 provider interviews from (med-lrg) ICUs finding averages of 5% from shared administrative reports, and up to 17% from provider statements.
- Each year, 1.65 million adult ICU patients are intubated. Of these patients, ~200,000 experience unplanned extubations.
- Over 50,000 ICU patients die as a result of unplanned extubations each year.
- The associated costs per UEs can vary widely, with costs averaging $41,000.
- Annually, adult unplanned extubations collectively cost hospitals $8.14 billion. Including neonatal and pediatric ICU, this annual cost is around $11.34 billion.
Increased mortality rate; more than 50,000 deaths annually in the U.S.
Increased risk of vocal cord injury; affecting the ability to speak and swallow.
Increased risk for hypoxemia (lack of oxygen), resulting in:
Brain damage, cardiac arrest, respiratory failure, hemodynamic instability, and aspiration pneumonia.
|Safety events eliminate incentives for group payment models.|
|Disrupt clinical workflow|
|Provider Post Traumatic Stress Disorder (PTSD) and Burn Out Syndrome (BOS)|
|Risk of Malpractice Lawsuit|
Pre-COVID Annual Trends
UEs are highly under-recognized and under-reported. Our interviews show an average report rate of 12% in med-lrg hospitals.
These numbers reflect the median of available data, ranging from 0.5% - 35.8%