Table. Unplanned Extubation (UE) Quality Improvement Bundle Factors and Definitions.

Factor	Definition
Standard elements
Standardized anatomic reference points and securement methods	Two licensed clinicians are present for securing, repositioning, and/or manipulating endotracheal tubes Hospitals will select one of the following as an anatomic landmark: gum, teeth, or nare; if unable, use lips Each unit selects a standardized securement method (or a house-wide standardized securement method)
Protocol for high-risk situations	Repositioning occurs with 2 licensed clinicians (having 1 dedicated to hold the tube during movement and repositioning) during high-risk situations, including: Bedside imaging procedures Bedside invasive procedures Kangaroo care/parent holding Routine repositioning Switching beds Early mobility
Recommended elements
Multidisciplinary ACA	A multidisciplinary ACA event form should be completed for each event on the current shift by all clinical witnesses ACA should be used to Pareto institutional-specific causes of UE to identify areas for improvement

Abbreviation: ACA, apparent cause analysis.