Study in Critical Care Nurse examines how Duke University Hospital nurse researchers identified barriers to extubation and implemented workable solutions.
A Duke University Hospital cardiothoracic intensive care unit (CTICU) nursing research committee has developed a uniform approach to safely decreasing ventilation times for patients after cardiac surgery.
Extubation within six hours after being admitted to the intensive care unit (ICU) after cardiac surgery is associated with fewer adverse outcomes, shorter ICU stays, and lower costs, but it 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 CTICU led to a new extubation (FTE) protocol and altered patient care processes.
Consequently, 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 consistent approach to advance patients toward extubation, with a goal of early extubation within six hours, according to a press release.
The study appears in June’s issue of Critical Care Nurse.
"Members of the interdisciplinary team were key stakeholders in the redesign of care processes, which allowed us to develop a sustainable and consistent protocol," said co-author Myra Ellis, MSN, RN, CCRN-CSC, a clinical nurse IV in the CTICU and chair of the CTICU nursing research committee at Duke University Hospital, Durham, North Carolina. "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 regarding which patients were deemed eligible for early extubation by the surgical team; lack of a clear plan to initiate the weaning and extubation process; inappropriate use of sedation to lower blood pressure; and inadequate pain management.
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, followed by 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%.
The nursing committee also 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 created healthy competition between peers, generated enthusiasm, and made best practices socially desirable.
“Members of the interdisciplinary team were key stakeholders in the redesign of care processes, which allowed us to develop a sustainable and consistent protocol.”
Myra Ellis, MSN, RN, CCRN-CSC, chair of the CTICU nursing research committee
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.
KEY TAKEAWAYS
High rates of variability in extubation times among cardiac surgery patients led to a new extubation protocol.
Barriers to extubation fell into three groups: process-specific, people-specific, and patient-specific.
Patients extubated within the recommended window improved from 47.5% to 72.5%, without increasing morbidity or mortality.