Fast-track Extubation Protocol Reduces Ventilation Time

Duke University Hospital safely decreased ventilation times for patients after cardiac surgery, thanks to a new extubation protocol and more efficient workflow processes.

For cardiac surgery patients, extubation within six hours after being admitted to the intensive care unit (ICU) after surgery is associated with fewer adverse outcomes, shorter ICU stays and lower costs. Early extubation within the six-hour window requires coordination across units and disciplines, with a focus on patient safety, speed and efficiency.

High rates of variability in extubation times among cardiac surgery patients in Duke’s 32-bed, high-volume, high-acuity cardiothoracic intensive care unit (CTICU) led to a new fast-track extubation (FTE) protocol and redesigned patient care processes. As a result, the proportion of patients extubated within the recommended six-hour window improved from 47.5% to 72.5%, without increasing morbidity or mortality.

“Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol” examines how the CTICU nursing research committee developed a uniform approach to advance patients toward extubation, with a goal of early extubation within six hours. The study appears in June’s issue of Critical Care Nurse (CCN).

Co-author Myra Ellis, MSN, RN, CCRN-CSC, is a clinical nurse IV in the CTICU and chair of the CTICU nursing research committee at Duke University Hospital, Durham, North Carolina.

“Members of the interdisciplinary team were key stakeholders in the redesign of care processes, which allowed us to develop a sustainable and consistent protocol,” Ellis said. “We worked together to identify barriers and implement workable solutions.”

Barriers to extubation fell into three groups: process-specific, people-specific and patient-specific.

Process-related issues included a lack of clarity about which patients were deemed eligible for early extubation by the surgical team and lack of a clear plan to initiate the weaning and extubation process. Inappropriate use of sedation to lower blood pressure and inadequate pain management were also considered process-specific barriers.

People-specific issues included interdisciplinary communication, poor patient progression during shift change and an absence of cross-coverage when respiratory therapists were away from the unit transporting patients.

The most common patient-specific barrier was metabolic acidosis, and others included hemodynamic instability, bleeding, respiratory acidosis and altered mental status.

During the study period, people- and process-related barriers for patients in the FTE cohort decreased from 48% to 17%.  Reintubation rates, lengths of stay and 30-day mortality did not differ between the preintervention and FTE patient cohorts.

The final analysis included 312 patients (101 in the preintervention cohort and 211 in the intervention phase). The FTE protocol was implemented Sept. 1, 2017, demonstrating an initial improvement after three months and a sustained effect at the one-year mark.

In addition, the committee used personal, social and structural sources of influence to guide the interventions and encourage sustained behavior change. For example, a colorful racetrack poster in the unit breakroom featured cars with names of the interdisciplinary “pit crews,” whose patients were successfully extubated within the recommended six-hour window. The racetrack generated enthusiasm, created healthy competition between peers and made best practices socially desirable.

As the American Association of Critical-Care Nurses’ (AACN’s) bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The award-winning journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in acute, progressive and critical care settings. CCN enjoys a circulation of more than 130,000 and can be accessed at http://ccn.aacnjournals.org/.

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