| Description |
Background: Timely extubation is vital for Cardiovascular Intensive Care Unit (CVICU) patients who undergo coronary artery bypass graft (CABG) surgery because longer durations of time spent intubated are associated with risk for mortality, delirium, and longer length of stay in the ICU. The Society of Thoracic Surgeons established a performance measure for prolonged intubation, with a benchmark set at <12 hours of intubation time. Scoring is based on a star system, where one star is lower than expected, two stars are as expected, and three stars are higher than expected. The University of Utah CVICU has consistently scored 'one star' for the past two years. The purpose of this project was to reduce time-to-extubation in patients who have experienced a CABG by implementing a Postoperative Extubation Protocol. Methods: Social Cognitive Theory was used to guide this quality improvement project. Prior to implementation of the Postoperative Extubation Protocol, current time-to-extubation, nurses' knowledge regarding criteria for extubation, and nurses' perceptions of the current process for extubation were measured. Next, a multidisciplinary postoperative extubation protocol was developed and implemented. After 30 days, the change in time-to-extubation and ‘nurses' perceptions of the protocol, including usability, satisfaction, facilitators, and barriers, were evaluated after implementation were assessed using Wilcoxon signed-rank tests. Results: Nine patients underwent CABG surgery in the two months before the Postoperative Extubation Protocol was initiated, and 18 had CABG surgery after the Postoperative Extubation Protocol. The Pre-intervention group had a mean time intubated of 275 minutes (SD= 298), compared to 164 minutes (SD=191) in the post-intervention group. The difference was not statistically significant but did show a trend toward reduced time spent intubated in the post- intervention group (t(10)=0.94, p=0.36), a clinically significant finding. Fifteen interdisciplinary team members filled out the pre and post-surveys. Results from the pre and post-implementation surveys (Table 1) showed statistically significant differences, including an increase in the timeliness of extubation (W=48, p=0.004), an increase in the nurses' perception that extubation was conducted systematically (W=42, p=0.002), and an increase in timely extubation for patients with obesity (W=21, p <0.001). Responses to qualitative questions indicated that the respondents noted improved teamwork and communication due to the Postoperative Extubation Protocol. Conclusions: The implementation of the Postoperative Extubation Protocol resulted in a trend towards decreased mean time to extubation, a clinically significant finding. Nurses perceived that extubation was more timely and systematic in the post-intervention period. The reduction in time spent intubated is vital because negative consequences of prolonged intubation time include risk for mortality, delirium, and longer length of stay in the ICU. |
