John Muir Health, Concord Medical Center, USA
Title: Benefits of early extubation after cardiovascular surgery
Biography: Zenaida Carbon
To decrease the length of stay for patients who are extubated within 3 hours following cardiovascular surgery. To sustain above United States of America national benchmark extubation time. To improve early mobilization of patients after cardiovascular surgery.
Endotracheal intubation and mechanical ventilation are required treatment modalities during major surgical procedures, and are maintained in the early post-operative period until the patient is able to support his own respiration. While they are essential forms of treatment, they pose risk for iatrogenic complications and must be discontinued as soon as possible to prevent barotrauma, ventilator-associated respiratory infection, and discomfort.
Early extubation following cardiovascular surgery has been a goal for almost two decades, although the time for extubation changed many times through the years. In the 1990’s, mechanical ventilation was continued through the night and patients were extubated early on the morning of post-op day 1. Soon after, the Society of Thoracic Surgeons encouraged clinicians to discard concerns about extubating patients in the middle of the night, and recommended a more aggressive goal of extubation within 12 hours. More recently the extubation goal has been reduced to the current standard of 6 hours.
The Cardiovascular Surgery Performance Improvement Committee meets monthly to evaluate clinical practices and improve outcomes for patients undergoing cardiac surgery. The interprofessional group is comprised of surgeons, anesthesiologists, clinical nurses, nurse leaders, respiratory therapists (RT), case managers, cardiac educators and quality management nurses. During informal discussions between a thoracic surgeon and the clinical nurse charge nurses in the Cardiovascular ICU (CVICU), they decided to focus their efforts on practice changes that would enable some patients to reach an even more aggressive goal: extubation within 3 hours post-surgery.
Extubating early has tremendous benefits to our patients.John Muir Health CVICU has a routine of having the patient dangle at the bedside 3 hours after extubation as tolerated.
The following morning, all patients with no activity restrictions are out of bed in bedside chair starting at six am. The CVICU staff in collaboration of the lift team gets every one up in bedside chair for at least 1-2 hours as tolerated.
Activity is then tailored to get out of bed around meal times 3x per day even if patients are not eating as of yet.
Early mobility has the benefits of: facilitating chest drainage out into the chest tubes thereby decreasing the amount of time the chest tubes are left in the chest cavity, thereby decreasing the discomfort of the patient.
RN and assistance of physical therapists, patients are ambulated in the hallways using cardiac walker while still in the CVICU ; decreasing the overall length of stay.
Strategy and Implementation:
July, 2017 – Initial practice changes
- Education of staff - The unit Charge Nurses lead daily quality and safety “shift huddles” with the staff, and used these huddles to educate staff about the new goal, solicit input for alterations in practice that would assist with earlier extubation, and to share their experience when practice changes were tried.
- Feedback to anesthesiologist – The anesthesiologist’s phone numbers were distributed to the clinical nurses. If the patient is unable to be extubated within 3 hours, the clinical nurse sends a text to the anesthesiologist to inform him/her of the reason for the inability to extubate. In this way the anesthesiologist receives timely feedback about the patient’s ability to be extubated.
- Data tracking by clinical nurses – Nurses tracked information about each patient: name, medical record number, date of procedure, surgeon, anesthesiologist, nurse and respiratory therapist, and extubation time. Space was provided for the clinical nurse to add comments about the reasons the patient could not meet the 3 hour extubation goal.
- Communication of anticipated extubation time to all staff – Upon arrival to the room, the patient’s nurse or the RT writes the anticipated extubation time on the patient’s white board. This alerts all care providers to the target time, and encourages everyone on the team to work toward the same goal.
August, 2017 – Additional practice changes initiated
- Extubation kits stocked – Previously, when staff determined that a patient was ready for extubation, the RT would need to leave the room to collect three simple items: a chux, 10cc syringe for balloon deflation, and a nasal cannula. In practice, extubation was often delayed because the RT who left the room was side-tracked and asked to perform another task elsewhere in the unit. The team remedied this by changing the room preparation process, and placing these items in the room when it was prepped to accept the patient from surgery. This small change ensured that the items necessary for extubation were present when needed, allowing extubation to proceed without any delay.
- Medications – The group encouraged the use of intravenous Acetaminophen for management of pain. This drug is quite effective in relieving pain and is advantageous in this population because it does not cause the drowsiness or respiratory depression that is characteristic of an opiate.
- Acquisition of two cardiac walkers – To make walking a post op cardiac surgery patient and maintain sternotomy precautions; CVICU manager and director were asked to purchase cardiac walkers for the unit. Cardiac walkers are equipped with padded arms adjustable to patient’s’ height.
The graph below demonstrates the success of this unit-level project that was initiated and led by the three charge nurses in the CVICU.The daily discussions they held during huddles provided opportunity for repetitive reinforcement of best practices and facilitated participation by all staff, which produced sustained and steady improvement. The early extubation project, with leadership by the charge nurses and participation by nursing, respiratory therapy and physicians represents an improved outcome associated with an interprofessional quality improvement activity, led (or co-led) by a clinical nurse.
As of December 2018, out of 245 patients were extubated below three hour target time. We are below the national benchmark of 6 hours.
Patients have an average of 4-5 days stay for their cardiac surgery instead of 7-10 days.
Implications for Practice:
These practice changes can be adopted by any critical care unit to increase the percentage of patients who can be extubated earlier, reducing patient discomfort and reducing the risk for complications associated with mechanical ventilation.
Patients are ambulating in the CVICU instead of waiting to get to step down increasing early mobilization of post cardiac surgery patients, decreasing the overall hospital stay from 7-10 days to 4-5days.