Unplanned Extubations

SPS recognizes the critical need to reduce Unplanned Extubations (UE) in pediatric patients and is committed to advancing UE prevention efforts as part of the Network’s broader patient safety improvement portfolio.

A small cohort of SPS Network hospitals began UE reduction efforts in 2016, followed by the release of an evidence-based prevention bundle in 2018. By 2022, the Network had achieved a 51% reduction in UE ICU events. While this progress was significant, we recognized an opportunity for continued improvement.

In 2024, informed by data analysis and expert guidance, SPS launched a new UE-NICU improvement cohort focused on Proactive Safety Huddles. By integrating Proactive Safety Huddles into routine practice, hospitals can proactively identify and mitigate UE risks before events occur, develop individualized safety plans for higher-risk patients, strengthen frontline engagement, and deepen leadership insight into UE prevention efforts. Since its launch, the NICU UE Proactive Safety Huddle cohort demonstrated a nearly 20% reduction in the cohort rate.

Since we started in 2016, the Network has achieved a 61% reduction in the UE ICU rate, and we are determined to continue this progress. SPS continues to explore new and innovative strategies to further prevent UEs.