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Critical Care |

Rapid Extubation Following Cardiac Surgery With a Nurse Driven Protocol

Jason Vourlekis*, MD; Lauren Waver, MSN; Linda Halpin, MSN; Linda Henry, PhD; Niv Ad, MD
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Inova Fairfax Hospital, Falls Church, VA


Chest. 2012;142(4_MeetingAbstracts):406A. doi:10.1378/chest.1386369
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Abstract

SESSION TYPE: Post operative ICU issues Posters

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Ventilator management (VM) is a component of the Society for Thoracic Surgery's (STS) coronary artery bypass graft (CABG) quality composite rating for cardiac surgery programs. The two measured principal outcomes are: percent of patients extubated within 6 hours of surgery and prolonged mechanical ventilation avoidance, defined as the percent of CABG patients requiring > 24 hours mechanical ventilation. As VM directly links to ICU and hospital length of stay, we sought to enhance VM as one component of our performance improvement.

METHODS: We revised our nurse driven extubation protocol in late 2009 and implemented the new protocol in 2010. Key changes included earlier administration of neostigmine and glycopyrrolate at 35° C patient temperature instead of 36° C; more rapid titration of FiO2 and sedation when appropriate; allowing extubation over broader pH range (7.30 - 7.45 instead of 7.35 - 7.45), and intensivist oversight of extubation. Protocol changes were reinforced with nursing education.

RESULTS: In 2009 for isolated CABG patients, 45.3% (220 of 486) were extubated in less than 6 hours; the median ventilator time was 6.4 hours, and 6.4% required prolonged ventilation. For 2010, 57.0% (253 of 444) were extubated within 6 hours and improved further to 62.6% (264 of 422) for January - September 2011. Median ventilator hours declined to 5.2 and 4.8 respectively. Percent prolonged ventilation remained stable over this period ( 8.1% in 2010; 6.0% in 2011). Over the same period, the percent of patients transferring from the ICU to the stepdown unit on day of surgery increased from 6.2% in 2009 to 21.0% in 2010 to 21.7% in 2011 while patient acuity as judged by STS risk score and Euroscore remained stable.

CONCLUSIONS: Nurse driven extubation protocols with intensivist oversight allows for superior results to like programs based on STS database comparisons.

CLINICAL IMPLICATIONS: Improvements in VM performance are eminently achievable and allow for more rapid transition of patients from the ICU to stepdown status.

DISCLOSURE: The following authors have nothing to disclose: Jason Vourlekis, Lauren Waver, Linda Halpin, Linda Henry, Niv Ad

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Inova Fairfax Hospital, Falls Church, VA

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