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A nurse-led initiative at St. Joseph’s University Medical Center in Paterson, New Jersey, reduced unplanned extubation rates in the hospital’s 28-bed medical intensive care unit (MICU) from a peak of 2.0 per 100 ventilator days in late 2018 to below 0.7 through 2023, according to a study published in Critical Care Nurse.
The five-year improvement was driven by a multidisciplinary strategy that combined risk-based patient assessments, standardized communication, staff education, family engagement, and evidence-based ventilator weaning practices. The findings offer practical guidance for critical care nurses working to improve patient safety and reduce unplanned extubation rates.
Alyson Triolo, MSN, RN, CCRN, ANP-C, an advanced practice nurse, and Jennifer Ricker, MSN, RN, NE-BC, CCRN, nurse manager of the MICU, led the initiative with an interprofessional team that included nurses, respiratory therapists, intensivists, and performance and safety improvement coordinators.
The study outlines a three-level algorithm that identified patients at the highest risk for unplanned extubation and the situations most likely to trigger self-extubation.
“Our three-level algorithm of associated risk factors helped us identify which patients were at the highest risk for unplanned extubation, as well as the high-risk moments that may trigger an attempt to self-extubate,” Triolo said. “We also revised our standards of care for all patients receiving mechanical ventilation to mitigate ongoing risk factors and reinforce prevention.”
Risk Assessment Guided Prevention Efforts
The initiative emphasized consistent communication and education across the care team. Nurses reinforced proper patient positioning, conducted daily nurse leader rounds for mechanically ventilated patients, and placed signs outside patient rooms identifying those at high risk for unplanned extubation. Patients’ risk status was also incorporated into nursing handoffs and interdisciplinary rounds.
The team also developed standardized talking points to help clinicians educate families about what to do if a patient attempted to remove an endotracheal tube. Bedside reminder signs instructed visitors to alert staff immediately if they observed a patient trying to self-extubate.
Ventilator Weaning Supported Better Outcomes
Staff received additional education on evidence-based ventilator weaning, including spontaneous awakening and breathing trials, to help patients come off mechanical ventilation as soon as clinically appropriate.
Between 2018 and 2023, the unit recorded 343 unplanned extubations. Of those patients, 82 (24%) required reintubation, underscoring the importance of timely ventilator liberation.
Unit Data Changed Restraint Practices
A review of unit data prompted the team to increase the use of mitten restraints, either alone or in combination with wrist restraints, when restraints were clinically warranted.
The review also found that 251 unplanned extubations (73.2%) occurred in patients wearing restraints. Only 12 of those events involved patients wearing mitten restraints, with or without wrist restraints. Those findings led the team to increase the use of mitten restraints when restraints were clinically indicated.
A Culture of Continuous Learning
Every unplanned extubation was treated as an opportunity to improve care. The team conducted immediate frontline reviews, post-event huddles with structured feedback, standardized incident reporting, and regularly shared unit performance data to reinforce learning and identify opportunities for improvement.
“The focus on proper patient assessment for unplanned extubation risk has become ingrained in the unit’s culture, and the signs are now a visible part of the environment,” Ricker said. “This initiative integrated evidence-based interventions, communication, teamwork and education to foster a culture of safety throughout the care we provide.”
