June 29 marked the sixth anniversary of Drew Hughes’ death – the 13-year-old who lost his life when his life-sustaining breathing tube was unintentionally removed. His tragic death and patient safety event –known as unplanned extubation – inspired a movement, and a coalition of 19 medical professional societies, patient safety and quality improvement organizations are working together to raise awareness about unplanned extubation (UE) and increase prevention efforts by getting hospitals on board with tracking and implementing quality measures.
“Though research and literature clearly points to UE as a common and costly issue, it is not being addressed for the grave risk it presents to patients,” said Dr. Art Kanowitz, co-chair of the SAM Special Projects II Committee and founder of the Airway Safety Movement, in a press statement. “As part of the ‘Campaign to Zero,’ we’re working to raise awareness and get patient safety and quality improvement managers to make UE a key performance measure and deploy the quality measures and processes that are appropriate for improving a key performance measure. But it’s not just patient safety managers, it is going to require the commitment of multiple stakeholders – healthcare executives, providers, patients and patient advocates, and electronic health record (EHR) companies. This is a call to action to those groups to become champions of UE best practices.”
The goal is to get hospitals to commit to supporting this effort. Unplanned extubation is the unplanned, uncontrolled removal of a patient’s life-sustaining breathing tube. There are more than 121,000 unplanned extubation events among adults annually in U.S. intensive care units alone, which are associated with:
· 33,000 preventable deaths every year
· 36,000 cases of ventilator-associated pneumonia
· $4.9 billion in unnecessary healthcare costs
· 2x the ICU length of stay
· $41,000 additional cost per unplanned extubation
In 2018, the Coalition for Unplanned Extubation Awareness and Prevention approved the Patient Safety Movement Foundations’ Actionable Patient Safety Solutions (APSS) #8B as a guide for creating and sustaining safe practices for unplanned extubation in medical facilities. The APSS #8B includes checklists, leadership, action and technology plans, protocols, as well as a core data set to track and reduce UE incidents.
Now, the Coalition is calling on patient safety and quality improvement departments to track intubated patient data; providers to become cheerleaders of UE best practices and data tracking; healthcare executives to provide the resources to allow quality improvement and safety officers to eliminate UE-related deaths; and EHR companies to add the unplanned extubation core data set to their software.
To get involved with the “Campaign to Zero” or Airway Safety Movement, visit airwaysafetymovement.org.
