 My name is Lauren Burko, I'm a professor of anesthesiology at the University of Florida and the president of the Society for Airway Management. I'm going to talk to you about the unplanned extubation awareness and prevention initiative, a multi-specialty collaborative. So what do all three of these pictures have in common? Well, they all experienced a preventable death due to complications as a result of unplanned extubation. Naveen Morcos on the left was a 30-year-old female undergoing an appendectomy for presumed appendicitis. During the procedure, her endotracheal tube was dislodged. The anesthesiologist was unable to replace the tube, and the patient required a surgical airway. Unfortunately, she suffered a severe brain injury and cardiac arrest. This case resulted in a $35 million settlement. Mason rushed in Wally at the top, was eight days old. He and his twin were born premature at 28 weeks gestation. While his twin died at birth, Mason survived and was intubated and placed on a ventilator. During repositioning, his breathing tube became dislodged, but it was not recognized. By the time it was recognized, it was too late to save him. Drew Hughes on the right was a healthy teenager who fell while skateboarding, sustaining a head injury. He was taken to the nearest hospital for treatment. That hospital decided that he needed to be transferred to a level one trauma center for further management. Although awake and alert, a decision was made to intubate him for the long transport for airway protection. However, in the ambulance, his tube was accidentally removed. The crew replaced the tube, but did not recognize it was in the esophagus. As his oxygen levels dropped, the crew diverted to the nearest hospital. But by the time they arrived, Drew had suffered an anoxic brain injury. He then passed away. Drew's death inspired a movement started by his family to increase awareness about unplanned extubation. Now these deaths are all tragic, but unfortunately they are not isolated events. Unplanned extubation is both common and costly. Unplanned extubation incidents in adults can range from 0.5 to 35.8%, which adds up to about an average of 120,000 unplanned extubations per year. The incidence in children in neonates is even higher, as high as 80.8%, which averages to about 14,500 unplanned extubations in neonates and about 2,000 unplanned extubations in pediatrics. Unplanned extubation can lead to a variety of complications that increase both morbidity and mortality, as well as costs, such as hypoxia, failed reintubation, injury to the vocal cords, pneumonia, brain injury, or even death. Now the complications of unplanned extubation also double the average ICU length of stay, from nine days to up to 18 days. And the increased hospital costs, as well as the increased morbidity and mortality, add up to $5.5 billion in hospital costs every year. So what is unplanned extubation? Well, it's the unplanned, unintentional, and uncontrolled dislodgement or removal of a patient's life-sustaining breathing tube. This can occur either due to self-extubation or accidental extubation. So when and how does unplanned extubation occur? Well, accidental extubation can occur during patient transport, during tube repositioning, during patient procedures, or during pruning, which is placement in the prone position to facilitate extubation. Pruning is a strategy that's commonly used for patients with severe rare disease due to the recent COVID-19 pandemic. So with this pandemic, the number of patients at risk for unplanned extubation is most likely increasing. Then unplanned extubation can also occur as self-extubation, when the patient's level of consciousness increases enough that they remove the breathing tube themselves. Well, there are several risk factors for unplanned extubation. Inadequate securement of the endotracheal tube increases risk. Inadequate sedation, which can lead to increased patient consciousness. Patient agitation, confusion, or delirium, which may result from their underlying disease. The lack of patient restraints and inadequate staffing ratios are all known risk factors for unplanned extubation. And the COVID pandemic may be contributing to this increased unplanned extubation risk. COVID patients are often placed in the prone position to improve oxygenation and ventilation, and this change in position risks dislodgement of the tube. A high secretion burn in COVID patients has also been reported, and this leads to an increased risk of tube obstruction resulting in the need for urgent replacement of the tube. Agitation, which is a known risk factor, may be present in the setting of hypoxia. And surges may impact optimal care by affecting staffing ratios and the need to use untrained staff in critical care areas. So here are some of the major gaps to addressing this important problem. Many hospitals are not even tracking unplanned extubation, so they may be unaware of the risk and the incidence at their hospital. There's a general lack of awareness and education about the problem. So as a result, few hospitals have instituted protocols or quality improvement activities to combat this problem, despite the fact that there are several proven quality improvement methods that can reduce this risk. So how can we prevent unplanned extubation? Well, the most important first step is better education and awareness of providers taking care of these patients. We also need improved communication and better security devices. And the use of standardized protocols can also reduce risk, including protocols for sedation and weaning, protocols for how to secure the tube and what devices to use, standardization of procedures such as turning patients or pruning patients, and tracking of events. Now our Society for Airway Management has several special project committees, and three years ago we formed one to address unplanned extubation. In our initial meetings, we discussed the possibility of collecting data on unplanned extubation and perhaps even sending out a survey. But as these discussions continued, we recognized that many hospitals were not even tracking unplanned extubation, and they weren't even aware of the problem. So our committee changed tactics, and instead we first decided to focus on activities to increase awareness and prevention of this problem. So first we partnered with the Patient Safety Movement Foundation to help them update their actionable patient safety statements, AA on airway safety and 8B on adult unplanned extubation. And we also recognized that AA and 8B didn't really address pediatrics or neonates at all. So we helped them create new apps, 8C on neonatal and pediatric airway safety, and 8D on neonatal and pediatric unplanned extubation. And we collaborated to create tools and core data sets to help hospitals track their data. And our committee recognized that we needed help to get the message out. So we reached out to other medical societies and patient safety groups, as well as quality improvement organizations to help us increase awareness. And we now have 20 members in this collaborating that partners with our committee. Here are some of the societies and organizations that have joined our collaborative to date. In addition to the Society for Airway Management, several other medical societies, including the American Academy of Pediatrics, the American Association of Nurses and Essetists, the American Society for Anesthesiologists, the American College of Emergency Physicians, and several others have all joined this collaborative. And other organizations such as the Patient Safety Movement, the Anesthesia Patient Safety Foundation, CMS, and the Children's Hospital Solutions for Patient Safety have also joined our movement. And here are some of the collaborative achievements to date. We've worked with the Patient Safety Movement every year to update apps 8A and 8B. We also created 8C and 8D, which are now available. And we're currently working with the Patient Safety Movement to create a new app that addresses respiratory diseases such as the COVID-19 pandemic, and that app should be coming out soon. We've published several publications over the past two years to increase awareness, and we've given several presentations at both national and international meetings. As you can see by this list, we've published many articles both online and in print across many different specialties, as many as 19 publications. And the collaborative participated in the Do It for Drew social media campaign to increase awareness, and that reached over 300,000 people this past year. And we've given several presentations at both national and international meetings on unplanned extubation and the work of the collaborative, including the Society for Airway Management Annual Meeting in Boston in 2018, the IHI Safety Congress in 2019, and the World Airway Management Meeting that was held last year in Amsterdam. And that included two abstract presentations, as well as an innovation presentation. So what is our message and our recommendations to you? Well, we still need to further increase awareness, which will hopefully then spur hospitals to take action, and we need hospitals to educate their providers about unplanned extubation. And then it needs to be tracked so you can identify the scope of the problem at your institution. Then you can apply proven best practice quality improvement methodologies to eliminate preventable death and harm from unplanned extubation. So what are the next steps of the coalition? Well, we continue to push unplanned extubation awareness and prevention through dissemination and demonstration of evidence-based best practices, research, and education. And that can also include the use of the actionable patient safety statements, 8B, 8D. The collaborative has also applied for an AHRQ grant to help further our research and our efforts. We've also formed an adult hospital solution for airway safety network, which will be discussed in more detail in another session. And we encourage all providers that teach airway management to include unplanned extubation education in all of their difficult airway courses so you can continue to spread the message. Thank you very much.