Unplanned Extubations in the NICU May Lead to Higher Costs, Lower Quality Measures

Unplanned extubations in preterm infants can lead to worse outcomes and increased hospital costs.1 During mechanical ventilation in the NICU, unplanned extubations are the most common adverse events impacting nearly 1 in 5 patients.2 The global burden of unplanned extubations on 75,000 neonates and infants can generate incremental costs of $550 million each year.3 This  increases the potential for short- and long-term negative patient outcomes. It also leads to longer mechanical ventilation durations as well as increased ICU and general hospital lengths of stay.1

One study found that each unplanned extubation in pediatric patients leads to hospital costs of $36,692 and an increase of more than six days per case.3 For infants that have an unplanned extubation and require reintubation, the costs could be even higher. Quality improvement efforts to reduce unplanned extubations should be encouraged to promote patient safety and improve patient outcomes.3 Reductions in unplanned extubations rates in the NICU may also lower hospital costs.1

Unplanned extubation costs

When reviewing the financial downstream impacts of unplanned extubations, there are a number of potential costs extending up to $50,000 per incident.1 A separate data analysis revealed these variable costs may involve the following departments and subsequent costs per case3:

  •  Pharmacy: $2,748
  •  Respiratory therapy: $4,318
  •  Radiology: $1,086 
  •  Laboratory: $3,142
  •  Blood bank: $593

The U.S. News and World Report also tracks metrics on the number of unplanned extubations in their annual best children’s hospital report.4 A lower ranking due to unplanned extubations could affect overall ranking resulting in potential risks associated with funding, public image, or admittance levels.

While unplanned extubations have the obvious administrative costs associated with these occurrences, there may also be psychological and clinical costs among caregivers at the bedside. When the  ETT migration occurs during an unplanned extubation, the environmental stressors of this adverse event could have unseen costs on the care deliverer. These unintended extubation events can also increase in-hospital morbidity — with immeasurable psychological trauma on the staff involved.3

Impacts of unplanned extubations on NICU quality measures

The Children’s Hospitals Solutions for Patient Safety (SPS) recommends unplanned extubations rates close to zero for every 100 ventilator days with a care bundle implementation.5

Yet today there is little standardization around reduction of unplanned extubations, and some  recommended intervention practices may lead to additional neonatal stress and impact long-term patient development.6 Clinicians believe avoiding unplanned extubations is a high priority, but they must rely on visual checks, auscultation, and chest X-rays to support their patients.6 And introducing neonates to frequent chest X-rays poses yet another health risk including radiation exposure.7 But certain innovative technology — like the SonarMed™ airway monitoring system — may help by providing real-time insights into the neonate’s airway. This potentially lowers the need for daily chest X-rays and exposure to radiation.

Use of SonarMed™ technology may also lower unplanned extubations when combined with other quality measures, including:3,6

  • Augmenting ETT taping methods
  • Decreasing daily ETT movement orders
  • Ensuring appropriate nurse-to-patient ratios
  • Reducing overall patient handling

In addition, studies have shown that remote monitoring systems may reduce the need to check on patient conditions — enabling more time for uninterrupted sleep and development.8

Related: Read more about the impact of unplanned extubations on clinical patient safety

Improving NICU workflow efficiencies with acoustic monitoring technology

Apart from the clinical safety costs surrounding patients, appropriate preventive measures can help reduce the frequency of these events.3 The SonarMed™ airway monitoring system is the only device of its kind that can assist in providing ETT position status in real-time. This can help clinicians make more informed decisions for their patients.9 For example, clinicians that are witnessing a possible desaturation event within their patient may attempt suctioning. Without the ability to see if suctioning is the correct approach, this may cause unintended harm to the patient. Suctioning the ETT in the NICU should only be performed when there are signs of tracheal secretions and to avoid routinely performing the procedure.10

With the SonarMed™ airway monitoring system, clinicians have the ability to optimize NICU suctioning and provision of the appropriate care through better verification of ETT location. Additionally, the system provides timely notifications and specific measurements that promote a coordinated response to address potentially critical events such as tube movement or occlusion. Improving clinician patient assessments in this way may decrease unplanned extubations by guiding clinical decisions towards the right care at the right time.

Related: Discover more benefits with SonarMed™ airway monitoring solution.


†  The SonarMed Airway Monitoring System should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment.

1. Hatch LD 3rd, Scott TA, Slaughter JC, et al. Outcomes, resource use, and financial costs of UEs in preterm infants. Pediatrics. 2020;145(6):e20192819.           

2. Internal analysis of Premier Data, GMA data, third-party consulting and primary research.

3. Roddy DJ, Spaeder MC, Pastor W, Stockwell DC, Klugman D. UEs in Children: Impact on Hospital Cost and Length of Stay. Pediatr Crit Care Med. 2015;16(6):572–575.

4. Olmsted MG, Powell R, Murphy J, Bell D, Stanley M, Sanchez R. Methodology U.S. News & World Report Best Children’s Hospitals 2019–2020. RTI International. 2019; 114.

5. Klugman D, Melton K, Maynord PO, et al. Assessment of an unplanned extubation bundle to reduce UEs in critically ill neonates, infants, and children. JAMA Pediatr. 2020;174(6):e200268.

6. Galiote JP, Ridoré M, Carman J, et al. Reduction in unintended extubations in a level IV neonatal intensive care unit. Pediatrics. May 2019;143(5):e20180897.

7. Scott, M., Fujii, A., Behrman, R. et al. Diagnostic ionizing radiation exposure in premature patients. J Perinatol. 2014;34:392–395.

8. Schiavenato M, Antos SA, Bell FA, et al. Development of a scale for estimating procedural distress in the newborn intensive care unit: the Procedural Load Index. Early Hum Dev. 2013;89(9):615–619.

9. Nacheli GC, Sharma M, Wang X, Gupta A, Guzman JA, Tonelli AR. Novel device (AirWave) to assess endotracheal tube migration: a pilot study. J Crit Care. 2013;28(4):535.e1–535.e5358.

10. Gonçalves RL, Tsuzuki LM, Carvalho MG. Endotracheal suctioning in intubated newborns: an integrative literature review. Rev Bras Ter Intensiva. 2015;27(3):284–292.

About the Author

Laura Lyons, Training Education Consultant for Medtronic and Tom Larkin, Training Education Consultant for Medtronic

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