Clinical Pathway Improves Extubation Outcomes

A multidisciplinary team designed a clinical pathway that improved institutional practice and quality of care.

Unsuccessful extubation can increase critical care unit and hospital length of stay, hospital costs, the need for tracheostomy, the risk for developing pneumonia, and morbidity and mortality rates.

After noticing high rates of postextubation stridor among patients in the University of Maryland Medical Center's 22-bed neurocritical care unit, an interdisciplinary team of providers at the Baltimore hospital developed and implemented a clinical pathway that led to sustained changes in practice and contributed to improved extubation outcomes for patients in the unit.

"Multidisciplinary input and support was critical at every stage of this initiative," the study's co-author Megan Lange, DNP, ACNP-BC, acute care nurse practitioner in the NCCU, says in a news release. "Our aim was to affect institutional practice and improve the quality of care provided in the NCCU. By working together, we were able to provide more consistent care and improve our rates of successful extubation."

Multiple Factors to Success

The study, "Implementation of a Clinical Pathway to Reduce Rates of Postextubation Stridor," published in the October issue of Critical Care Nurse, gives an overview of the quality improvement project and shares results from the initial 12-week implementation.

Outcomes included a significant reduction in overall rates of postextubation stridor, reintubation, and reintubation due to postextubation stridor.

Changes in practice occurred as well, including:

Regular assessment of patient risk factors
Use of inhaled budesonide in high-risk patients
Consistent use of a single-dose steroid for high-risk patients

The researchers say determining which individual change had the greatest impact or whether confounding variables contributed to the outcomes is difficult.

For example:

Greater attention to extubation criteria may have prevented premature extubation
Use of a single-dose steroid may have contributed to the overall reduction in duration of mechanical ventilation, decreasing the risk for postextubation stridor
Decreased duration of intubation may have decreased the risk for ventilator-associated pneumonia that could require reintubation.

Interdisciplinary Teamwork

The interdisciplinary team consisted of a neurocritical care intensivist, a neuroanesthesiologist, a neurocritical care fellow, a pharmacist, two NPs, and a physician assistant.

The clinical pathway incorporated available research to create consistency in evaluation of patients receiving mechanical ventilation before extubation and to guide decisions regarding care and treatment.

Before implementing the pathway, all prescribing providers in the neurocritical care unit received training on its use. All NPs, PAs, and neurocritical care fellows had additional one-on-one training on the checklist that outlined the clinical pathway.

During morning rounds, the checklist was to be completed for every intubated patient. While all providers participated in decision-making based on the clinical pathway, the NP or PA assigned to each patient was responsible for completing the checklist.

The implementation phase of the study lasted 12 weeks and weekly updates were posted to encourage compliance and reinforce the training.

During the study period, the pathway was completed on all intubated patients daily, with a total of 606 days of mechanical ventilation and an overall compliance rate of 88%. Of the 56 patients extubated during the trial: