Unplanned Extubations

Decreasing rates of the most common serious patient harms is a strategic priority for SPS.

A pediatric unplanned extubation (UE) is the inadvertent dislodgement of an endotracheal tube in a pediatric patient setting. Historically, many providers have considered unplanned extubations an expected consequence of care delivery in children’s hospitals because of various difficult challenges, including sedation of a child, length of the neonatal/pediatric airway and inability to predict extubation readiness. Multiple single-center studies have shown that quality improvement initiatives can reduce unplanned extubations.

To further quantify prevention methods, the SPS UE Pioneer Cohort was launched in January 2016. They have since achieved significant improvement and identified prevention bundle elements using data and analysis obtained from the UE Pioneer Cohort. The UE Pioneer Cohort has identified the initial bundle elements that are highly likely to result in decreased harm to hospitalized children when reliably implemented. The network strategy has been successful, with a 48% reduction in unplanned extubations across the network as of March 2022, and the UE Pioneer Cohort continues to test interventions to further reduce UE rates.