The Performance Gap

Unplanned Extubation (UE) is the unintentional removal of a patients breathing tube, either by self-removal (Self Extubation) or accidental removal due to an external force (Accidental Extubation) causing the tube to become dislodged.
Unplanned extubation, both in the field and in the hospital, is a common and costly problem. Unplanned extubation occurs in approximately 7% (range: 0.5% - 35.8%) of patients undergoing mechanical ventilation in the Intensive Care Unit \cite{da_Silva_2012}, results in over 12,000 deaths \cite{de_Groot_2011}, increases the incidence of pneumonia from 14% to 28% , increases the average ICU length of stay from 9 to 22 days3, and the complications of unplanned extubation result in over $4 Billion in unnecessary healthcare costs \cite{Dasta_2005,Needham_2005}.
Although the incidence of unplanned extubation is likely higher in EMS settings due to the difficulties of transporting critically ill patients in a chaotic environment, unplanned extubation is not tracked in most EMS systems. Similarly, most hospitals do not track unplanned extubation. If we are going to get an accurate measure of the commonness and costliness of unplanned extubation, both in the hospital and in the field, we must develop widespread systems to accurately track all incidences.
Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, practice, and technology plans, examples of which are delineated below for utilization or reference. This is provided to assist hospitals in prioritizing their efforts at designing and implementing evidence-based bundles for reduction of unplanned extubation.

Leadership Plan

Practice Plan

Use current evidence-based guidelines and known best practices during airway management of the intubated, mechanically ventilated patient to eliminate incidences of unplanned extubation.
  • inadequate stabilization of the endotracheal tube
  • inadequate sedation (chemical restraint)
  • inadequate physical restraint

Technology Plan

(Note: A study completed at the University of Colorado, Department of Biomedical Engineering, compared seven methods of endotracheal tube restraint systems and found one device to restrain against significantly higher forces compared to the other systems tested . This restraint system is currently undergoing final stages of research and development and the manufacturer expects market clearance by the FDA in mid-2018.)

Metrics

Topic

Unplanned Extubation in Mechanically Ventilated Patients
Rate of unplanned extubation for patients undergoing mechanical ventilation via endotracheal tube

Outcome Measure Formula

Numerator:  Number of incidences of unplanned extubation in patients mechanically ventilated via an endotracheal tube
Denominator:  Total number of mechanical ventilation days
*Rate of unplanned extubation is expressed in terms of: Number of unplanned extubation incidences per 100 mechanical ventilation days

Metric Recommendations

Direct Impact:  All patients undergoing mechanical ventilation via endotracheal tube
Lives Spared Harm:
\(Lives\ =\ \left(Unplanned\ Extubation\ Rate_{baseline}\ -\ Unplanned\ Extubation_{measurement}\right)\times \ Vent\ Days^*\ _{baseline}\)
* Vent Days is the Outcome Measure Formula Denominator: (Total Number of Mechanical Ventilation Days)
Data Collection: