Implementing Fast-Track Extubation Protocols for Cardiac-Surgical Patients: A Review of the Literature
By Erika Adams
Senior Honors Thesis School of Nursing
University of North Carolina at Chapel Hill April 6, 2018
Abstract
Aim: To investigate the empirical evidence to support the use of early extubation protocols for
the implementation of fast track care in cardiac surgical patients.
Background: Early extubation has continued to serve as a common goal for post-surgical patients
over the past several years, but limited resources outline or define the post-surgical process. Method: A review of the literature was conducting regarding implementing fast-track extubation
protocols for cardiac-surgical patients. A systematic search was done on PubMed, Current Index of Nursing and Allied Health Literature (CINAHL) yielded ten (10) research studies that were included in this review.
Findings: After review of the literature, early extubation protocols are feasible, safe for patients,
Implementing Fast-Track Extubation Protocols for Cardiac-Surgical Patients: A Review of the Literature
Introduction
Early extubation is defined by The Society of Thoracic Surgeons’ national cardiac database, as “removal of breathing tube <6 hours after arrival to cardiovascular ICU” (Camp, 2009)(p.415). Early extubation has continued to serve as a common goal for post-surgical patients over the past several years. Cheng (1998) describes fast track cardiac pathways as a process of care aimed at improving the efficiency of care in cardiac surgical patients. ‘Fast track protocol’ may be used anonymously for ‘early extubation protocol’. The College of Cardiology Foundation/American Heart Association Guideline recommends fast-track extubation for low- to medium-risk patients (Gutsche et al., 2014). But limited resources outline or define the post-surgical process. Hawkes et al. (2010) indicated that there have been few randomized control trials (RCT’s) to demonstrate the success of early extubation protocols in comparison with conventional postoperative ventilation practices. Surgeons strive to implement effective extubation strategies, while maintaining a balance between patient safety and economic restrictions.
In patients undergoing extensive and critical surgery, specifically cardiac surgery, benefits and risks of prolonged ventilation must be weighed. Controversy still remains over how long a patient should remain intubated, and at what point or duration is extubation initiated. Prolonged intubation following cardiac surgery has been associated with negative outcomes and increased risks for complications. Extensive studies have shown, that like other patient
populations, early extubation in cardiac surgical patients is proven to be beneficial and produce better outcomes. Protocols that implement earlier extubation times may be successful in
The purpose of this honors project is to review and summarize early extubation protocols, and analyze the success of those protocols. This literature review describes quality improvement projects that implemented fast-track protocols in cardiac surgical patients, and examines the outcomes associated with the intervention.
Background
Mechanical ventilation is considered when a patient presents with signs that he/she cannot maintain a natural airway or adequate oxygenation. The decision to mechanically ventilate is a standard intervention initiated in surgical patients. Invasive ventilation, via an endotracheal tube, aids in the exchange of oxygen and carbon dioxide to and from the lungs. Most surgical patients do not require mechanical ventilation beyond the operative period. However, it may be continued for patients with chronic respiratory conditions, or those undergoing traumatic and extensive surgical procedures.
In the past, cardiac surgical patients were ventilated overnight following surgery and were given a regimen of high-dose opioid-based anesthesia and postoperative analgesia. Even after routine surgeries, the patient was ventilated overnight for up to 24 hours (Wong, Lai, Chee, & Lee, 2016). Because of the profound physical changes affecting cardiac-surgical patients, surgeons may feel the need to implement unnecessary precautions. Once believed that extra time on the ventilator created a blunt effect to the bodies stress response from surgery, care teams were in no rush to remove intubation tubes. By maintaining sedation and mechanical ventilation, the patient appears to be hemodynamically stable. Prolonged intubation was believed to provide the patient’s body more time to adjust and return to normal (Richey et al., 2017).
becoming surgical candidates. With medical advancements, surgeons are better able to
accommodate patients with pre-existing or comorbid conditions; all leading to a greater amount of needs and competition over limited resources. In attempts to address the expanding needs, health care systems are forced to create new ways to manage cardiac surgical patients. Introduced in the 1990’s, fast-track cardiac anesthesia has evolved as a way to keep up with increasing demands. In attempts to reduce hospital length-of-stay and resources utilization, experts began to propose fast track extubation (FTE) methods to streamline cardiac surgery. Fast track cardiac care involves complex interventions to extubate patients in less time, and decrease recovery time.
Now, fast-track cardiac care recommends that patients be extubated within six (6) hours of heart surgery (Soltis, 2015). Numerous studies have demonstrated the benefits to early extubation, and the risks associated with prolonged intubation. Prolonged ventilation and endotracheal intubation itself may result in unnecessary patient discomfort, increased risks for complications, and increased cost of care (Wong, Lai, Chee, & Lee, 2016). Complications from delayed weaning can include: ventilator-associated pneumonia, tracheal stenosis, pneumothorax, airway trauma, ventilator associated lung injury and more. Esteban et al. (2007) demonstrated that mortality increases with increasing duration of mechanical ventilation. The most effective way to reduce complications of mechanical ventilation is to limit its duration. Once a person no longer requires mechanical ventilation, they can be weaned from the ventilator and extubated.
Benefits to early extubation include: shorter recovery time, decreased lengths-of-stay, reduced post-surgical complications, early mobilization, and overall improved patient outcomes (Marcantuono et al., 2015). There is no evidence of compromised patient safety or major
been reported the same, when compared to conventional extubation practices (Soltis, 2015). Studies show that early extubation or fast track care of cardiac surgical patients lead to a
decrease in intensive care unit and hospital lengths-of-stay, and ultimately a possible reduction in hospital costs. Surgical units are encouraged to follow new guideline suggestions, and implement shorter intubation times.
But despite the overwhelming evidence of patient benefits, post-surgical and intensive care units have failed to successfully implement strategies to achieve shorter intubation times. There are limited incentives in place, to encourage the adoption of suggested changes. An inconsistency in the practice of extubation calls for a standardized protocol (Chan et al., 2018). By implementing a time-directed extubation protocol, variations can be limited and care teams can strive together to achieve the set goal. Clear protocols create detailed guidelines and algorithmic rules that are frequently used to achieve quality care and improvements. Further evaluation is needed to assess the need for multidisciplinary protocols to facilitate safe and expeditious extubation in select populations. The following studies address the benefits of early extubation, and explore the outcomes of implementing a set protocol in cardiac-surgical patients.
Methodology
criteria includes publications written before 2007, published in non-scholarly journals, written outside of the United States, and studies that focused on information regarding extubation time itself. No limitations were made on the type of study design. The initial search yielded 388 articles, but was narrowed down to ten (10) articles based on the exclusion criteria. Many were discarded because they did not address or relate to the effectiveness of standardized protocols in decreasing extubation times in cardiac patients. Articles geared toward discussion or education of benefits and risks factors of early extubation were not used in this review. Additional discards included writings that were responses to original studies or texts that were not scholarly articles.
Findings
The literature search yielded several articles that addressed the efficacy and safety of early extubation protocols compared to the institution’s conventional approach. Each of the studies outlined the details of their protocol, and the strategies taken to implement the intervention. The literature review matrix (Appendix A) provides additional details on each case study, and the related outcomes for each intervention.
Ender et al. (2008) implemented a plan to admit patients directly to a post anesthesia care unit (PACU) following cardiac surgery. By sending elective cardiac-surgical patients to the PACU, a team of anesthesiologist’s was waiting and ready to begin the weaning process
compared to fast-track patients for differing outcomes. The conventional treatment control group was admitted directly to the ICU following cardiac surgery, and then extubated under direction of the unit staff. Outcomes measured included intubation duration, postoperative lengths-of-stay, number of readmission, morbidity and mortality rates. Fast-track patients had shorter intubation times, and shorter lengths-of-stay. Patients who were extubated in less than 6 hours were also found to have lower incidence of post-operation complications and problems, and lower mortality rates. The authors concluded that the protocol was safe for the patient population implemented on, and remained an effective way to expedite extubation (Ender et al, 2008).
Camp (2009) conducted a quality improvement project on coronary artery bypass (CABG) or isolated valve surgical patients. The project aimed to extubate patients in less time, while also decreasing pulmonary complications and the use of resources. The project implemented several practical measures into practice, such as: communication tools, hand-off goal sheets, DVT bundles, best pulmonary practice bundles, and multidisciplinary rounds. The entire staff was included in the guideline changes, and educated on their role in the implication process. Following implication of the intervention, the duration of patient intubation dropped
significantly. Early extubation rates increased by approximately 50 percent. The large study sample (2211 patients) provided ample evidence to make accurate inferences. The authors also found lower rates of pneumonia, sepsis, pulmonary complications, and lengths-of-stay. Specific guidelines and a standardized approach can be attributed to the overall success of this quality improvement project (Camp, 2009).
the cardiac surgical ICU to extubation. The study was completed over a 2-year time frame. The first year of data was collected retrospectively, as the sample of patients receiving conventional ventilation practices. 266 patients were randomly selected to follow the new extubation
guideline. Patients included were undergoing first coronary artery bypass and elective coronary artery bypass graft operations. Patients with significant pre-existing lung disease or
co-morbidities were excluded; due to previous evidence cited that preoperative lung function variables related to poor lung function were associated with longer ventilation times. Clinicians and doctors were not included in the implementation of the protocol. Nurses had sole
responsibility for leading the extubation process. Unlike any of the other articles described, the ITS results showed no statistical difference in patient outcomes between the pre- and post-intervention groups. The early extubation guideline did not lead to an overall reduction in time to extubation or patient length-of-stay (Hawkes, Foxcroft, & Yerrell, 2010).
Fitch et al (2014) describes the effectiveness of a standardized early extubation protocol implemented to decrease intubation time to less than six (6) hours. The study includes data from three (3) separate time periods. Patients in the first time period follow conventional ventilation practices. Patients in period two (2) followed ventilation instructions developed by a
extubation, until determined that ventilation is no longer necessary. The percentage of patients extubated within six (6) hours of surgery increased from 12 percent (period one (1) to 38 percent by period three (3). Median initial postoperative ventilation decreased from 11.0 hours (period one (1) to 7.1 hours. Results reflect that the early extubation protocol was successful and made a difference in patient outcomes (Fitch et al., 2014).
Gutsche et al. (2014) predicted that by defining a clear extubation process and implementing a fast-track protocol, the percentage of patient’s extubated within 6 hours of leaving the operating room would increase. Prior to the project there was no existing protocol in place for post-surgical patients. Key stakeholders from varying disciplines were identified and recruited to contribute to the project process. The project improvement (PI) team worked
together to develop a protocol that incorporated multidisciplinary involvement. Patients included in the study were having surgery for an aortic valve replacement (AVR), mitral valve
replacement (MVR), or coronary artery bypass grafting. The PI team identified 4 patient barriers to early extubation, and then implemented measures to address those factors in the new protocol. Surgical ICU care teams were educated and trained on the importance of early extubation how to properly implement the protocol into practice. Goals related to the early extubation were
typically related to oversedation, equipment delay, or failure to follow new protocol guidelines. Team members were initially concerned that that a fast-track protocol may create an ethical concern and increase the risk for reintubation. None of the patients that met inclusion criteria for the study required reintubation. The protocol was successful in increasing the number of
patient’s extubated early (Gutsche et al., 2014).
extubation protocols did have better outcomes. Length of stay in the post-operative area and ICU were shortened, and direct costs were reduced. However, 50 percent of fast-track patients did require additional health care services following discharge from the hospital. The costs acquired during post-discharge care are not calculated into the patient cost of care (Marcantuono et al., 2015).
In a study published in the American Association of Critical-Care Nurses (AACN), the researchers focused on the role of clinical nurse specialists (CNS’s) in improving patient outcomes and patient safety (Soltis, 2015). The study used CNS’s to facilitate a fast track protocol and ensure best practice standards through early extubation. The clinical nurse specialists support staff nurses to ensure that appropriate resources are available to use, while improving system processes. A multidisciplinary team from the cardio-thoracic intensive care unit initiated the quality improvement project, led by the CNS’s and nurse manager. Potential risk factors for prolonged intubation were researched, to identify at risk patient groups. The protocol was discussed and sent for approval among collaborating surgeons, intensivists,
improved patent management, collaboration, and team communication. Outcomes positively reflected the use of the protocol. The percentage of patient’s extubated early increased from 14.4 percent to 48 percent. Mean ventilation time, readmissions to the ICU, and prolonged
intubations also decreased. There were no failed extubations recorded. Based on the reduction in length-of-stay, the hospital reported a reduction in cost greater than $2 million (Soltis, 2015).
Mahle et al. (2016) wrote an article on a guideline initiated to promote early extubation practices in pediatric patients. The study took a collaborative learning approach to design and implement a fast-track protocol for congenital cardiac surgical patients in the pediatric
population. Ten hospitals, in the Pediatric Heart Network were chosen to participate in the study. Five of the hospitals served as active sites. The other five hospitals were not directly involved in the protocol, but contributed data by serving as a “control site”. One of the active sites became the “model site”; while the remaining institutes modified their existing practices to best match the example. Two operations were chosen to implement the protocol on: repair of tetralogy of fallot (TOF) and repair of isolated coarctation of the aorta. Intubation was measured as the duration of time between leaving the OR and removal of the endotracheal tube. Outcomes were measured one (1) year prior to implementation of the protocol, and 1 year following
discontinuation of all continuous IV analgesics, cumulative dose of opioids and benzodiazepines, the proportion of subjects receiving dexmedetomidine, and mean FLACC score. The mean FLACC score did increase from 1.3 to 2.1 – an interesting observation. Overall, clinical
outcomes reflected an increase in patient’s extubated early, while reintubation rates and hospital length-of-stay remained the same (Mahle et al., 2016).
A group of researchers at the University of Kansas Medical Center designed a multidisciplinary early extubation protocol as a quality improvement project in the
within 6 hours. An association can be seen between early extubation and longer ICU stay. Richey et al, states that the increase in ICU care despite a decrease in ventilation times happened because “extubation is not the driving force behind readiness to leave the ICU” (2017). Patient’s extubated early had higher rates of renal failure; it is believed that care teams were weaning the patient too quickly and withheld fluids or administered diuretics at a time when the renal system was vulnerable. Patients extubated after 12 hours, continued to have longer ICU length-of-stays and higher mortality rates. Sufficient evidence does not demonstrate if patients in the 6-12 hour intubation group have significantly worse patient outcomes than the less than 6 hours of
intubation group. The authors feel that the study demonstrated that there is no observable benefit to extubating within the 6-hour time frame. The protocol led to an increase in the number of patients’ extubated early, but reflected negative patient outcomes. It is concluded that parameters should be considered on a case-by-case study, and extubation performed based on individual readiness (Richey et al., 2017).
methods. 1581 patients were included in the study. Patients with medical comorbidities were not contraindicated, and still included in the process towards early extubation. If the patient did not meet 6-hour timeframe, steps were still followed until safe extubation could be achieved. Patient’s extubated past 6 hours had similar factors: demographically older, prevalence of hemodialysis, history of prior myocardial infarction, and representation of emergent cases with longer procedural times. A significant decreased was observed in extubation times following implementation of the protocol. The number of early extubation patients increased from 43.7 percent to 64.1 percent. Reintubation rates and mortality rates remained consistent. Hospital length-of-stay was not affected by the protocol (Chan et al., 2018).
Discussion
This literature review was motivated by the search for evidence and influence of an early extubation time-directed protocol on patient outcomes in cardiac surgical patients. Early
extubation has been shown to improve patient outcomes. By implementing clear guidelines to direct the ventilation process, patient care teams are able to better collaborate and support a common goal of improved patient outcomes. The reviewed studies attempted to adopt and implement the new standards, based on evidenced based care. Each of the articles created an intervention with a time-sensitive approach. By using six (6) hours as the cutoff for early
was already proven to be associated with the highest level of negative patent outcomes. The study by Hawkes, Foxcroft, and Yerrell (2010) was the only study to exhibit no change in patient intubation times. Lengths-of-stay in the hospital or intensive care unit was shown to decrease in multiple studies. Mahle et al. (2016) reported no change in hospital lengths-of-stay. Data from Richey et al.’s (2017) study showed an increase in early extubation, also associated with an increase in ICU length-of-stay.
Many of the studies utilized a multidisciplinary approach and showed how important it is to have a team approach to patient care. Several articles discussed the use of various disciplines to develop and initiate the protocol. By allowing other professions to contribute, multiple
perspectives are covered throughout the implementation process. If the entire care team is aware of the changes in standard of care, the more likely the patient is to progress towards early
extubation. Investment of multiple professions creates a common goal to strive for in the
patient’s overall outcomes. Open communication may also be encouraged if the entire care team is on the same page. The studies that did not use a multidisciplinary approach appeared to put an overwhelming responsibility on the nursing staff. Without the contribution of multiple
stakeholders, the protocol was less likely to succeed; other disciplines were in no way affected if the fast-track guideline was not followed. A sense of accountability was also created when different specialties were involved in the implementation process. Nurses were able to carry out their role, while being held accountable for their contribution to the overall goal of early
extubation.
surgery, and did not require a change in practice from other parts of the care team (Ender et al., 2008). Camp et al. (2009) describes a process initiated and terminated by physician order – incorporating nursing care for the physician-led plan. “Weaning from mechanical ventilation can often be prolonged when each step in the process requires a physician order and therapist
intervention” (p. 419). Fitch (2014) was the first to publish a nurse-led protocol. Nurses and respiratory therapists followed a strict algorithm to meet extubation criteria. The physician was notified for approval of extubation once the patient was considered ‘ready’. Many of the articles published after Fitch (2014), began using nurses more at the forefront of the quality
improvement project. Nurses are leaders and well positioned to implement changes in patient practice and care, while still conforming to the scope of practice. There are increasing
opportunities for nurses to get involved in quality improvement projects.
Two different categories regarding subject criteria appeared in the results section – studies that identified patient’s pre-intervention for early extubation, and studies that
implemented early extubation on all post-surgical patients. Both perspectives are important and aid in the evaluation of time-directed protocols. However, the inconsistencies provide limited ability for comparison. Soltis (2015), Richey et al. (2017), and Chan et al. (2018) all
varying populations. The nature of the study is changed when the protocol was only applied to a specific subgroup of candidates.
The patient profile eligible for surgery is constantly changing – cardiac surgical patients of today are older and possess more complex health conditions. These patients are at higher risk for postoperative complications and morbidities, including: renal failure, vasogenic and
cardiogenic shock (Richey et al., 2017), and sepsis (Camp et al., 2009). Postoperative complications, such as these, could increase length-of-stays despite the practice of early
extubation (Richey et al., 2017). Recommendations address evidence of better patient outcomes with a relatively healthy patient. Results may reflect a range of outcomes, depending on the pool of candidates included. Future research could analyze effects of protocol initiation on each specific aspect of hospital stay with consideration of comorbidities.
The study that showed no change in patient outcomes post-intervention was the outlier (Hawkes, Foxcroft, & Yerrell, 2010). It is interesting to note that resistance to change was reported as a barrier to implementation of the protocol. Novice nurses felt that the new guidelines were easier to adopt, while seasoned nurses were less likely to modify their plan of care. The protocol did not appear to be embraced as welcoming change. The authors explain that the protocol was assumed to be further documentation of existing practices, and did not require integration. Individual interpretation was used to facilitate implementation (Hawkes, Foxcroft, & Yerrell, 2010). Outcomes may have been different if nurses were incorporated into a
implementing evidenced based care, nurses are able to see first hand benefits and improve overall patient care. The outcomes likely would have reflected an increase in early extubation, if the protocol had been consistently enforced.
Conclusion
References
Alía, I., & Esteban, A. (2000). Weaning from mechanical ventilation. Critical Care, 4(2), 72– 80.
Camp, S. L., Stamou, S. C, Stiegel, R. M., Reames, M. K., Skipper, E. R., Madjarov, J.,… Lobdell, K. W. (2009). Quality Improvement Program Increases Early Tracheal
Extubation Rate and Decreases Pulmonary Complications and Resource Utilization After Cardiac Surgery. Journal of Cardiac Surgery, 24, 414-423.
Chan, J. L., Miller, J.G., Murphy, M., Greenberg, A., Iraola, P., & Horvath, K. (2018). A Multidisciplinary Protocol-Driver Approach to Improve Extubation Times Following Cardiac Surgery. The Annals of Thoracic Surgery.
Cheng, D. C. H. (1995). Early Extubation after Cardiac Surgery Decreases Intensive Care Unit Stay and Cost. Journal of Cardiothoracic and Vascular Anesthesia, 9(4), 460-464. Cheng, D. C. H. (1998). Fast Track Cardiac Surgery Pathways: Early Extubation, Process of
Care, and Cost Containment. The Journal of the American Society of Anesthesiologists, 88(6), 1429-1433.
Ender, J., Borger, M., Scholz, M., Funkat, A., Anwar, N., Sommer, M., & ... Fassl, J. (2008). Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept. Anesthesiology, 109(1), 61-66.
Esteban, A., Ferguson, N. D., Meade, M. O., Frutos-Vivar, F., Apezteguia, C., Brochard, L.,… Anzueto, A. (2007). Evolution of Mechanical Ventilation in Response to Clinical
Fitch, Z. W., Debesa, O., Ohkuma, R., Duquaine, D., Steppan, J., Schneider, E. B., & Whitman, G, J. R. (2014). A protocol-driven approach to early extubation after heart surgery. The Journal of Thoracic and Cardiovascular Surgery, 147(4), 1344-1350.
Gutsche, J. T., Erickson, L., Ghadimi, K., Augoustides, J. G., Dimartino, J., Szeto, W. Y., Ochroch, E. A. (2014). Advancing extubation time for cardiac surgery patients using lean work design. Journal of Cardiothoracic and Vascular Anesthesia, 28(6), 1490-1496. Hawkes, C., Foxcroft, D.R., & Yerrell, P. (2010). Clinical guideline for nurse-led early
extubation after coronary artery bypass: an evaluation. Journal of Advanced Nursing, 66(9), 2038-2049.
Jiricka, M. K. (2006). Ask the Experts. Critical Care Nurse, 26(3), 70-72
Mahle, W. T. Nicolson, S. C., Hollenbeck-Pringle, D., Gaise, M. G., Witte, M. K., Lee, E. K.,… Shekerdemian, L. S. (2016). Utilizing a collaborative learning model to promote early extubation following infant heart surgery. Pediatric Critical Care Medicine Journal, 17, 939-947.
Marcantuono, R., Gutsche, J., Burke-Julien, M., Anwaruddin, S., Augoustides, J. G., Jones, D., … Herrmann, H. C. (2015). Rational, Development, Implementation, and Initial Results of a Fast Track Protocol for Transfemoral Transcatheter Aortic Valve Replacement (TAVR). Catherization and Cardiovascular Interventions, 85, 648-654.
Richey, M., Mann, A., He, J., Daon, E., Wirtz, K., Dalton, A., & Flynn, B. C. (2017).
Soltis, L. M. (2015). Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery. AACN Advanced Critical Care, 26(1), 35-42.
Appendix A Literature Review Matrix
Citation Purpose,
Sample, & Setting
Design / Methodology Findings Implications
Ender, J., Borger, M., Scholz, M., Funkat, A., Anwar, N., Sommer, M., & ... Fassl, J. (2008). Cardiac surgery fast-track treatment in a
postanesthetic care unit: six-month results of the Leipzig fast-track
concept. Anesthesiology, 109(1) , 61-66.
Purpose: To compare the safety and efficacy of a fast-track protocol
implemented by anesthesiologist s with direct admission from the OR to the PACU. Sample: 421 Setting: University of Leipzig, Germany
The research team hypothesized that ICU admission for post-surgical cardiac patients may be avoided, by implementing a fast-track protocol with direct admission from the OR to the PACU.
The study would compare outcomes pre- and post-intervention
retrospectively. Data from the pre-intervention patients were collected during a 6-month period, and would serve as the control group. Control patients were admitted to the ICU from the operating room. Weaning and extubation was performed under direction of the ICU staff and nurses.
The intervention/protocol required the team to create a 3-bed cardiac anesthesia PACU adjacent to the OR.
Events of interest to be measured were: extubation times, postoperative length-of-stays, number of readmissions, morbidity and mortality.
421 patients were treated under the new protocol guidelines. No significant
differences regarding patient population were found in between the pre- and post- intervention groups. Fast-track patients had shorter intubation times, and shorter postoperative lengths-of-stay in the
PACU/ICU,
intermediate care unit, and hospital.
Control: Median time to extubation = 860
This intervention was implemented only for elect cardiac-surgical patients.
The direct admit PACU made it easier to implement the
intervention, and keep the patient safe. The team utilized
The PACU was staffed with anesthesiologists and nurse anesthetist to
facilitate the weaning process. 421 fast-track patients (elective cardiac-surgical patients only) were retrospectively matched 1:1 and compared to patients undergoing cardiac surgery prior to the protocol implementation. Fast-track patients were admitted to the PACU once they were determined to be hemodynamically stable, without excessive bleeding, and have a core temperature of at least 36 degrees.
Both groups of patients were sent to intermediate care and then to the regular nursing ward before being discharged.
mins, median length-of-stay in PACU/ICU = 20 hours, median length-of-stay in intermediate care = 26 hours, median length-of-stay in the hospital = 11 days.
Fast Track: Median time to extubation = 75 mins, median length-of-stay in PACU/ICU = 4 hours, median length-of-stay in intermediate care = 21 hours, median length-of-stay in the hospital = 10 days. Readmission rates were similar between the groups.
Fast-track patients had a significantly lower incidence of low cardiac output syndrome (0%) and mortality (1%).
mortality rates in the intervention group. Lower intubation times may be associated with less ventilator-related infections and sepsis. The authors concluded that fast-track protocols are safe for cardiac surgical patients.
Camp, S. L., Stamou, S. C, Stiegel, R. M., Reames, M. K., Skipper, E. R., Madjarov, J.,… Lobdell, K. W.
(2009). Quality Improvement Program Increases Early
Purpose: To evaluate the impact of a quality improvement project on early
The institute’s database was used to identify patients who had a CABG, isolate valve surgery, or combination of the two at Carolinas Medical Center
Data was collected between 2002 and 2006. The QIP was put into effect in 2004. Outcomes were measured between the
The protocol and algorithm are clearly outlined and stated in the study. It can be repeated and
Tracheal Extubation Rate and Decreases Pulmonary
Complications and Resource Utilization After Cardiac Surgery. Journal of Cardiac Surgery, 24, 414-423.
extubation, pulmonary complications, and the use of resources following cardiac surgery using a “risk-adjusted methodology” Sample: 2211 Setting: Carolinas Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC
between 2002 and 2006. The team implemented a quality improvement project to extubate patients early, and improve
cardiac/pulmonary
outcomes. A protocol was developed that “establishes physician-ordered
mechanical ventilation weaning algorithm for the cardiovascular recovery unit (CVRU). Staff were given specific guidelines and parameters to report back hourly on each patient.
Multidisciplinary rounds were implemented and included: a cardiac intensivist, attending cardiac surgeon, cardiac fellow, NP, staff nurse, charge nurse, respiratory therapist, and pharmacist.
intervention group and conventional group. 980 subjects were extubated in less than 6 hours following surgery (intervention group). 1231 were extubated in more than 6 hours following surgery (conventional group).
Conventional group patients were more likely “to have hypertension, chronic renal insufficiency, previous cerebrovascular accident, chronic obstructive pulmonary disease (COPD), unstable angina, depressed left ventricular ejection fraction, multi-vessel coronary artery
disease, be elderly. and have urgent or
emergent operations compared to early extubation patients.” Conventional patients also had higher rates
trials/studies. Providers and
respiratory therapists lead the protocol. Nurses are notified when weaning will begin. Nurse’s role is not at the forefront of the project.
The authors believe decreased pulmonary complications can be attributed to improved clearance of secretions, earlier mobilization, and improved cardiac performance. Decreased pneumonia may be attributed to improve respiratory dynamics, coughing, earlier ambulation, return of ciliary function, and adherence to pulmonary bundle strategies. Patients unable to follow early extubation protocols may have an underlying disease process contributing to prolonged intubation times.
of operative mortality, stroke, sepsis, renal failure, atrial fibrillation, hemodialysis and additional complications. Conventional groups had higher rates of readmission, reintubation, and lengths-of-stay. Early extubation rates increased
post-intervention, by approximately 50%. Early extubation could be associated with lesser rates of pneumonia, sepsis, additional pulmonary complications, and shorter lengths-of-stay.
extubation increased. Specific guidelines and time-restrictive protocol led to more early extubations. “Our QIP improved early
extubation rates and pulmonary outcomes, which we attribute to a systematic,
standardized approach along with improved communication”
Hawkes, C., Foxcroft, D.R., & Yerrell, P. (2010). Clinical guideline for nurse-led early extubation after coronary artery bypass: an evaluation. Journal of Advanced Nursing, 66(9), 2038-2049. Purpose: An investigation of the development, implementation, and outcomes of a clinical guideline of early extubation in adult
Mixed methods evaluation. Data was collected between 2001 and 2003. Nurses at the study site created and implemented an early extubation guideline for cardiac surgical patients, as a quality improvement project. The protocol was
Primary outcomes measured time to extubation as time of arrival to the cardiac surgical intensive care unit (SCICU) to extubation. Additional measured outcomes included: length-of-stay in the ICU,
No change was found. Individual interpretation of the guideline by different nurses could have led to variations in protocol
coronary artery bypass graft patients. Sample: 567 Setting: single UK cardiac surgery center
put into effect in 2002. The team analyzed the impact of the guideline by quantifying patient
outcomes, and comparing the implementation process.
Data was collected retrospectively for pre-intervention comparison. Random samples of 30 patients were designated at time points, occurring monthly throughout the study. 301 patients were selected in year 1 for comparison prior to implementation of the guideline. And 266 patients were selected in year 2, following
implementation of the guideline. All patients were adults having first-time coronary artery bypass grafts. Exclusion criteria included: patients with previous coronary bypass or heart valve procedures, pre-existing lung disease requiring treatment, inpatien referrals, patients with
length-of-stay in the hospital, and time to patient being self-ventilated on 40% oxygen with
saturations greater than 95%.
Collected data included interviews with staff and reflections from researchers. Staff was asked to comment on the structure of the guideline and their views on the effectiveness of the implementation process. Interview data revealed that learning extubation skills was an important key to changing culture in the unit. The guideline was reported to be a useful learning tool. It was also noted that novice nurses tended to follow the guideline more consciously, in comparison to more experienced nurses. Nurses also felt that
poor left ventricular function, cardiopulmonary bypass time of more than 2 hours, and patients with pulmonary hypertension.
there was also resistance to change, and opportunities for flexibility and individual
interpretation of the guideline.
The ITS analysis concluded that there was no statistical evidence to show significant differences in outcomes pre- and post-intervention. Implementation of the guideline did not change patient outcomes. Fitch, Z. W., Debesa, O.,
Ohkuma, R., Duquaine, D., Steppan, J., Schneider, E. B., & Whitman, G, J. R. (2014). A protocol-driven approach to early extubation after heart surgery. The Journal of Thoracic and Cardiovascular Surgery, 147(4), 1344-1350.
Purpose: To assess standardized protocols in decreasing extubation times to <6 hours in postoperative CABG patients. Sample: 2061 Setting: John Hopkins Hospital
IRB experimental study. Data was collected on 2061 patients undergoing CABG between 2005 and 2012. The study includes specific and detailed protocol guidelines to improve extubation performance. Extubation times were determined by admission times to the ICU. The study was conducted in 3 parts, each with additional provisions to the type of protocol
The proportion of patient’s extubated in less than 6 hours was calculated for each time period.
Period 1: 12% Period 2: 24% Period 3: 38% The percentage of postoperative patients extubated in less than 6 hours more than doubled. Compared to period 1, patients in period 3 were more
The study is population specific to cardiac patients receiving CABG. All
postoperative CABG patients received the same ventilation care and followed the same protocol for early extubation.
Improved extubation times are associated with clearer and defined protocol
used. The first period included patients weaned at baseline, according to the preferences of
surgeons or providers. In period 2, patients followed a standardized protocol developed by a
multidisciplinary team. Each patient received the same ventilator settings, and paralysis was reversed at 36°C bladder
temperature. There was no fast-track anesthesia protocol for anticipated early extubation patients. Bedside nurses and respiratory therapists led the process to early extubation. Providers were called in for evaluation after nurses and RT’s judged the patient ‘extubation ready’. In period 3, the same protocol was followed with some minor changes – paralysis was reversed at 35.5°C bladder
temperature, and 36°C body temperature, and a “highly visible” pink
than 5x more likely to be extubated in less than 6 hours. Median initial postoperative ventilation times decreased from 11.0 hours (period 1) to 8.8 hours (period 2) to 7.1 hours (period 3). Women in any period were less likely to be extubated in less than 6 hours. Patients with peripheral vascular disease, urgent surgical status, emergent surgical status, COPD, CHF, and recent MI had lower likelihood of early extubation. Patients older in age were also less likely to be extubated early. The proportion of overall patients who required reintubation did not differ between the 3 time periods. No patients selected for FTE were reintubated in the
post-intervention group.
implementing a standard protocol, the entire care team (including providers, respiratory therapists, and nurses) has a better understanding of the patient’s plan of care and goals/expected outcomes. The entire care team is striving for the same thing. Nurses and respiratory
therapists drive the extubation process. Measurable outcomes can be used to
determine when the patient is extubation ready. The provisions implemented between period 2 and period 3 included easy and cost-effective changes that could improve
extubation sheet was placed in each patient’s room as a reminder of extubation goals. Gutsche, J. T., Erickson, L.,
Ghadimi, K., Augoustides, J. G., Dimartino, J., Szeto, W. Y., Ochroch, E. A. (2014).
Advancing extubation time for cardiac surgery patients using lean work design. Journal of Cardiothoracic and Vascular Anesthesia, 28(6), 1490-1496.
Purpose: To redesign a FTE protocol that would remove barriers and increase the percentage of patient’s extubated within 6 hours. Sample: 404 Setting: Surgical Intensive Care Unit (SICU) at an academic, university-affiliated community hospital Quality-improvement study. Then IRB study with retrospective portion to review patient records. There was no existing protocol to address intubation times at this institute, prior to this study.
The SICU created a multidisciplinary ‘process improvement’ (PI) team to analyze and assess barriers to FTE. The PI team identified eligible patients, and outlined an
intervention process. Inclusion criteria were patients having surgery for an AVR, MVR, or CABG. Extubation time was measured from the time the patient entered the SICU. 6 hours was determined the cut-off time for FTE; this time was chosen so that collected data could be directly compared to other
Prior to the creation and implementation of the project, there was no extubation protocol. The percentage of patient’s extubated in less than 6 hours was calculated for a pre- and post-intervention group of patients. Pre-intervention: 27.1%
Post-intervention: 50.2%
The pre-intervention group included 195 patients. The post-intervention group included 171 patients. There were no
differences in demographic predictors between pre- and post-groups. Results also varied by surgery type
performed on the patient.
The FTE showed an
This study is population specific to cardiac patients receiving a CABG, AVR, or MVR. An association can be made between
institutes and guidelines recommended by the Society of Thoracic Surgeons. The PI team identified 4 issues that were leading to delayed extubation: prolonged patient stabilization and delay in rewarming, complicated ventilator weaning process and excessive abg draws, oversedation related to opioid and benzodiazepine overuse, and extubation equipment delays. The final protocol was developed while
addressing each of the 4 problem areas. The guideline was given to the SICU team and the
patient’s admission nurse. Patients were identified as a FTE patient in the OR by attending surgeon or anesthesiologist, based on defined selection criteria. A sign was posted on the patient’s bed with the goal extubation time. Each day, the nurse manager
reviewed the extubation
increase in number of patients successfully extubated in less than 6 hours.
times for the SICU. Marcantuono, R., Gutsche, J.,
Burke-Julien, M., Anwaruddin, S., Augoustides, J. G., Jones, D.,… Herrmann, H. C. (2015). Rational, Development, Implementation, and Initial Results of a Fast Track Protocol for Transfemoral Transcatheter Aortic Valve Replacement (TAVR). Catherization and Cardiovascular Interventions, 85, 648-654. Purpose: To develop and implement a protocol for fast track extubation in patients undergoing transfemoral (TF) TAVR, and assess the success of the protocol by comparing hospital length of stay and direct costs. Sample: 99 Setting: 2 institutes through the University of Pennsylvania Health System. Site A = large academic tertiary care hospital. Site B = moderate sized academic community
Two institutes within the Pennsylvania Health System were assigned the task of developing and implementing a fast track protocol for TAVR patients. Both sites created inclusion criteria, through the consensus of a
multidisciplinary team – including physicians, cardiac surgeons, anesthesiologists,
advanced practice nurses, and research coordinators. Each site had differing exclusion criteria. Site A implemented an
‘organized pathway approach’. The protocol included extubation in the OR following successful TAVR deployment, and transfer to the PACU by the anesthesia team. The patient was monitored for 2 hours and then
transferred to a cardiac intermediate step-down unit. Site B implemented an ‘inclusive systematic pathway’ approach. The
Of the 99 patients considered for the FT protocol, only 39 patients were
considered eligible. 28 of the 39 patients (72%) successfully followed through with the protocol. The remaining 11 patients deviated from the implemented protocol and required ICU care. Site A had high rates of success (94%) than Site B (57%). One fast-track patient from Site A was readmitted for pericardial effusion post pacemaker implantation. 50% of patients also required additional subsequent services or care – including home health services, assisted living, inpatient rehab, and skilled nursing. Patients that followed the fast-track protocol had shorter length of stay in the ICU,
By design of the protocol, the patients were similar in age, but with very few
comorbidities. The excluded patients may have had pre-existing conditions that would already lead to prolonged intubation. For this study, patients were categorized eligible vs ineligible prior to the surgery. The authors felt that it is feasible to develop inclusion factors and identify patients for a fast-track protocol. It is unclear if there are set guidelines for
extubation in patients not following the fast-track protocol.
hospital patient was extubated in the OR following successful TAVR. The patient was transferred to the CTICU for up to 4 hours, during which they were evaluated and monitored for
hemodynamic instability and complications. Once deemed stable by cardiac anesthesia intensivist, the patient was transferred to a floor bed with telemetry monitoring. Patients ineligible to continue with the fast-track protocol were deemed ‘FT deviations’.
Data was collected from each institute and
retrospectively compared.
shorten postoperative length-of-stay, and incurred lower direct costs. Data showed a reduction in direct costs by more than $10,000. And a
reduced length-of-stay by 3-4 days. Fast-track success patients were also shown to have shorter length of stay and lower costs, when compared to fast-track deviation patients. There was no evidence that the care of patients who deviated, were compromised in any way.
70-80% of patients who successfully completed the protocol were doing well at 30 days.
fewer deviations from the protocol. Site A also utilized a PACU, compared to care received in an ICU setting. This could likely be associated with higher costs. The cost benefit may be hard to accurately display, considering 50% of fast-track patients required post-discharge care.
Soltis, L. M. (2015). Role of the Clinical Nurse Specialist in Improving Patient Outcomes After Cardiac Surgery. AACN Advanced Critical Care, 26(1), 35-42. Purpose: A process improvement project to improve early extubation rates and decrease number of Quality improvement project.
A CTICU interdisciplinary team initiated a process improvement (PI) team. The PI team was led by the CNS and nurse manager from the CTICU. The
Modifications were made to existing treatment protocols and postoperative orders. The CNS, bedside staff nurses, and PI team members created a
The study is specific to cardiac surgical
patients. This PI project successfully
demonstrated a
decreased in extubation times in cardiac
readmissions to the CTICU. Sample:
Setting: 12-bed CTICU and 40-bed PCU in a “large medical center in the southeastern United States”
group focused on improving care, and created a goal to increase extubation times of less than 6 hours to 40% by July 2013.
From April 2012-June 2012, the PI project team meet biweekly to analyze barriers and discuss interventions for faster extubation times. The team proposed protocol changes to the surgeons and doctors, and worked to clear any discrepancies in the plan of care. The CNS and nurse manager created an evaluation form for bedside nurses to use when a patient could not be extubated in less than 6 hours. The CNS and PI reviewed the forms to identify additional barriers to extubation. Actions were taken to modify the extubation protocol, based on factors identified by the evaluation process. Data was collected weekly by the CNS and nurse manager.
tool/algorithm for the PCU. The tools were created to outline a step-by-step process when potential
problems/factors arose in the extubation process (similar to a flow-chart or critical thinking map). The algorithms were continuously
emphasized and taught to the nursing team. The nurses reported familiarization with the algorithms, and did not require reference to the plan. The algorithms were implemented into their daily routine and plan of care Nurses also reported improved critical thinking and focus of prevention of complications.
Improved
communication was reported between disciplines and members of the care team.
The early extubation led to improved patient outcomes, decreased hospital length of stay, and decreased hospital costs. A decrease in readmissions to the CTICU was also demonstrated in the project.
The team identified barriers to success, and made improvisations to pre-existing protocols. The CNS and clinical nurses led the
extubation algorithms / protocols, and kept a focused mind on prevention of complications. By preventing
A subgroup of the PI team focused on care
management post-cardiac surgery. The goal was to decrease the number of patients who were
readmitted from the PCU back to the CTICU from 10% to 5% by July 2013. A similar evaluation tool was used to analyze barriers to care for patients readmitted to the CTICU. The PI team also created a rounding nurse role. The role was assigned to a specific CTICU nurse, who then rounded with patients who had been transferred to the PCU in the past 24 hours.
Daily ‘huddle’ team meetings were held on each cardiac surgery patient in the PCU. The RCP’s, CTICU charge nurse, PCU charge nurse, CNS, and advanced care provider were included in the huddle’s.
Daily ‘huddle’ team meetings were held on each cardiac surgery
Outcomes:
# of patients extubated in less than 6 hours: increased from a baseline of 14.4% to 48% to 70%
# of patients intubated for more than 24 hours: decreased from15.7% to 7% Mean initial ventilation hours decreased from 22.8 to 11.1 hours.
There were no failed extubations that required emergent reintubation.
Readmission to the CTICU: decreased from7.4% to 2.6% Patients with pulmonary
complications in the postoperative period decreased from 21.2% to 11%.
Hospital length of stay decreased by 2.2 days. This equated to a reduction of more than $2 million.
assured that the nurses were well aware of the system.
patient in the PCU. The RCP’s, CTICU charge nurse, PCU charge nurse, CNS, and advanced care provider were included in the huddle’s.
The PI team collected data each week. Weekly updates were then sent to the entire nursing,
respiratory, and leadership teams to communicate progress.
Mahle, W. T. Nicolson, S. C., Hollenbeck-Pringle, D., Gaise, M. G., Witte, M. K., Lee, E. K., … Shekerdemian, L. S. (2016). Utilizing a collaborative
learning model to promote early extubation following infant heart surgery. Pediatric Critical Care Medicine Journal, 17, 939-947.
Purpose: to determine if a “collaborative learning strategy-derived clinical practice guideline” can reduce intubation times in infants following cardiac surgery. Sample: 499 Setting: implemented in ten children hospitals across the US Collaborative learning model was used to lead the design of the study. A clinical practice guide was developed by….
10 children hospitals were chosen to participate in the study. 5 of the hospitals were “active sites”, where the clinical practice guideline was
implemented as a new protocol. [One of the active sites already had a protocol being
implemented that was used to develop the CPG. This site was used as the ‘model site’]
5 of the hospitals were not
When comparing the active sites and control sites, the proportion of subjects that that were extubated in less than 6 hours in the pre-intervention phase, was nearly identical. Following
implementation of the CPG, the active sites achieved a
significantly higher rate of early
extubation. Increased from 11.8% to 66.9%. A positive trend is shown in early extubation rates over the 12-month
The specificity of inclusion criteria allowed subjects to be compared to patients at the control sites.
The protocol was implemented on all patients having the index operation, and under 365 days old. There were no other limitations. All subjects were included in analysis of outcomes, regardless if they were able to successfully complete
directly participating in the study, and used as “control sites”.
The CPG focused on decreasing post operation intubation times, and how to implement the protocol. Prior to implementation, intubation times varied widely between the 5 hospitals. Subjects included patients undergoing repair for tetralogy of fallot (TOF) and repair of isolated coarction of the aorta. Subjects enrolled in the CPG, were given
parameter to guide early extubation following surgery.
All outcomes were
collected and measured for 12 months prior to the intervention, and 12 months following
intervention. There was an 8-week phase during the implementation process, where data and outcomes were not measured or collected. This allowed time for trouble-shooting
measurement period. The median duration of intubation among the ‘active sites’ (minus the model site) decreased from 21.2 hours to 4.5 hours following
implementation of the CPG.
Total hospital length of stay did not
significantly decrease following
implementation of the CPG.
Time (median) to introduction of enteral feeds following surgery decreased from 30.7 hours to 19.2 hours.
Time (median) to discontinue all continuous IV analgesics decreased from 43.6 hours to 19.3 hours.
Subjects receiving dexmedetomidine increased from 42.0% to 75.2%.
FLACC pain score
postoperative care after treatment of a
congenital heart defect is “complex” and “many aspects are not standardized”. There are key milestones in the “progression” of a postoperative patient. Variations in success rates were found among the different surgical cohorts. Infants undergoing repair for TOF had higher success rates, compared to the coarctation cohort. However, the
coaractation patients were usually younger – many less than 28 days old.
The authors
of the process.
240 subjects enrolled at the active site, were compared to 259 subjects at the control site (120 in pre-implementation and 139 in post-interventions).
increased after
implementation of the CPG from 1.3 to 2.1. The extubation rates remained essentially unchanged in the ‘control group’ – 11.7% to 13.7%. There was also no significant change in median intubation times in the ‘control group’.
streamlined approach without in-person meetings and site visits may have given the same results.
Richey, M., Mann, A., He, J., Daon, E., Wirtz, K., Dalton, A., & Flynn, B. C. (2017).
Implementation of an Early Extubation Protocol in Cardiac Surgical Patients Decreased Ventilator Time But Not Intensive Care Unit or Hospital Length of Stay. Journal of Cardiothoracic and Vascular Anesthesia, 32(2), 739-744.
Purpose: To analyze the success of intervention and effects on ICU and hospital length of stay, after
implementing a protocol in postoperative patients to extubate in less than 6 hours. Sample: 459 Setting: University of Kansas Medical Center, Kansas
A protocol for
postoperative cardiac surgical ICU patient was created by a
multidisciplinary quality improvement team, with the goal of extubating patients in less than 6 hours. The protocol was designed by a group of caregivers, who met monthly to create and modify elements until implementation. Included in the intervention was: education to all care team members, attainment of ABGs, sedation and paralytic guidelines, placement of reminder signs on patient door,
Baseline
characteristics were similar between pre- and post-intervention groups. The mean ventilation times decreased from 7.4 hours
(pre-intervention) to 5.73 hours
(post-intervention). Before the protocol, only 36% of patients were extubated within 6 hours. Following implementation, 55% of patients met the 6-hour mark. There was little change in the percentage of people extubated in over 12
The patient population was similar between both groups.
The implementation of a protocol resulted in more people being extubated in less than 6 hours. The average number of people extubated in more than 12 hours stayed
relatively the same. Goals to extubate in less time are achievable with inexpensive modifications and implementation of a clear protocol.
City, KS progression toward spontaneous breathing trials, encouragement of huddles to address
weaning progression, and documentation of
circumstances. The
protocol was implemented and later analyzed. The success of the intervention was measured, including the effects on ICU and hospital length of stay, and other morbidities.
IRB approval was obtained to review the data. Data was collected on 246 cardiac surgery patients prior to the protocol. And on 213 cardiac patients after the intervention.
Patients characteristics, ventilation times, and outcomes were compared pre- and post-intervention.
hours.
Median ICU length of stay did increase for all patients – from 49.4 hours
(pre-intervention) to 54.2 hours
(post-intervention). When analyzing times by ventilation groups, the patients that were extubated in less than 6 hours were the patients who required more time in the ICU. Mortality rates
remained low in patients overall extubated in less than 12 hours.
Patients extubated in less than 6 hours were also associated with increased renal failure.
by a median of 5 hours. This is different than the findings often found in other studies.
“Possible reasons for this study
demonstrating an increase in ICU stay despite a decrease in ventilation times is that extubation is not the driving force behind readiness to leave the ICU”
benefit patients. Chan, J. L., Miller, J.G.,
Murphy, M., Greenberg, A., Iraola, P., & Horvath, K. (2018). A Multidisciplinary Protocol-Driver Approach to Improve Extubation Times Following Cardiac Surgery. The Annals of Thoracic Surgery. Purpose: A protocol was implemented on all cardiac surgical patients by bed-side providers over an 8-year period and then retrospectively analyzed for safe and expeditious outcomes. Sample:1581 Setting: Institutes of Health, Bethesda, Maryland
A fast-track extubation protocol was implemented and driven by bedside providers for all postoperative cardiac surgery patients. A retrospective study was completed on 1581 patients over an 8-year period. A protocol outlined the discontinuation of mechanical ventilation, driven by bedside
providers, rather than the conventional approach driver by physician management. Prior to the intervention, patients were managed by the intensive care unit attending. A multidisciplinary team of cardiac surgeons, cardiac ICU attending’s, nursing staff, and respiratory therapists developed the FTE protocol. The
protocol integrated ‘check points’, as a designated time to evaluate patient safety and progression. All staff was required to attend education/orientation on
807 patients were compared in the study, before the
implementation of the fast track extubation protocol. 774 patients were treated under the fast track protocol. No significant differences were found in between the pre- and post- intervention groups. Comparable risk factors, comorbidities, diagnoses, and prior cardiac surgeries, existed between the cohorts.
Median extubation times decreased from 385 mins
(pre-intervention) to 295 mins
(post-intervention). Overall time to extubation was decreased by 20%. The percentage of patient’s extubated in less than 6 hours increased from 43.7%
(pre-intervention) to 64.1% (post-intervention).
The protocol was implemented for all cardiac surgical patients. Patients were not individually chosen based on inclusion criteria, prior to surgery.
The researchers believed that greater utilization of staff resources would minimize interruptions in the protocol process. Emphasis was put on the use of involvement of multiple parts of the care team. Nurses and respiratory therapists primarily directed the protocol. The decision to extubate could be made independent of the intensivist, when following the protocol guidelines.
the protocol, and
compliance was observed for.
Clear protocol guidelines are outlined in the
manuscript – including ventilation settings. Adjustments to ventilation settings were made based on ABG measurements. Once a patient was ruled hemodynamically stable, a spontaneous breathing CPAP trail was initiated. Patients who tolerated the trial were extubated by the respiratory therapist. Outcomes, including overall time to extubation, rate of reintubation, ICU readmission, and lengths-of-stay were measured to evaluate the success and impact of the protocol.
The rate of prolonged intubation (>24 hours) was reduced from 7.3%
(pre-intervention) to 4.9% (post-intervention). There were no significant changes noted in rate of reintubation, in-hospital mortality, or 30-day survival.
Patients extubated later were demographically older, had higher prevalence of hemodialysis, and a history of prior
