Drew Hughes was only 13 years old when he died after his endotracheal tube was accidentally dislodged during transport to a level I trauma center following a skateboarding accident. The transport team (which included a respiratory therapist) accidentally reintubated Drew in his esophagus and did not recognize the malposition as they did not carry an end-tidal CO2 detector with them.
Drew’s oxygen levels fell, and his heart rate slowed. The transport crew quickly diverted to the nearest hospital. But it was too late. Drew had already suffered from anoxic brain injury and eventually died.
The Society for Airway Management and the Patient Safety Movement Foundation are leading a multi-organization effort aimed at spreading the word about the best practices that are needed to make deaths like Drew’s a thing of the past. The AARC is a key member of the Coalition for Unplanned Extubation Awareness & Prevention.
June 29 is the sixth anniversary of Drew’s untimely death, and the Association is urging respiratory therapists everywhere to read Drew’s story and take proactive measures in their facilities to prevent unplanned extubations from occurring.
Here are the points Drew’s Movement would like every therapist to consider –
- Unplanned extubation (UE) is very common, occurring in more than 200,000 patients in the U.S. every year and resulting in 50,000 deaths.
- UE is costly, increasing ICU length of stay by 9-18 days and adding $4.9 billion in unnecessary costs to the U.S. health system for adults; and increasing ICU length of stay by 9-51 days and adding $2.9 billion to the U.S. health system for neonates.
- Hospitals need to assess their rate of UE and set goals for improvement.
- Support of C-Suite executives is critical for success.
- A quality improvement initiative using the Model for Improvement UE Core Dataset available from the Airway Safety Movement should be implemented.
Drew’s untimely death is inspiring the health care community to take measures needed to ensure no other child or adult falls victim to the complications that can arise from an unplanned extubation. Please share his story with your hospital leadership so they can take the proactive measures needed to make unplanned extubations a thing of the past.