A, Level of harm associated with UE categorized by reintubation within 1 hour, no reintubation within 1 hour, and cardiovascular collapse and rate over time. B, Statistical process control chart of cardiovascular collapse associated with UE. There was an absolute reduction of 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days. Centerline shift was determined by the Shewhart rule of 8 or more points below the centerline. The centerline shift began in November 2016.