Background

Prolonged intubation has been associated with unfavorable outcomes after cardiac surgery. A standardized approach is needed to ensure prompt extubation and shorten intensive care unit stays.

Local Problem

This quality improvement project was designed to evaluate the impact of a fast-track extubation protocol on time to extubation and intensive care unit length of stay.

Methods

The intervention group consisted of 26 adult cardiac surgery patients who underwent the fast-track extubation protocol. A Mann-Whitney test was used to compare time to extubation and intensive care unit length of stay in this group with those of a pair-matched control group of patients from the previous year who did not undergo the fast-track extubation protocol.

Interventions

An evidence-based literature review was used to develop a fast-track extubation protocol involving extubation in less than 6 hours. An educational activity was created to improve intensive care unit staff members’ knowledge of the fast-track extubation protocol, and its effectiveness was measured by a posttest score of 80%.

Results

The percentage of patients with extubation times of less than 6 hours was significantly higher in the fast-track extubation protocol group than in the pair-matched control group (U = 179, P = .003). The mean intensive care unit stay decreased from 2.92 days in the control group to 1.85 days in the fast-track extubation protocol group.

Conclusion

Implementing a fast-track extubation protocol for adult cardiac surgery patients shortened time to extubation and intensive care unit stay, expediting and improving recovery processes in the intensive care unit.

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Fast-Track Extubation for Cardiac Surgery Patients

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Fast-Track Extubation for Cardiac Surgery Patients

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Open-heart surgery remains a necessary treatment for patients with coronary artery disease, valvular heart disease, and heart failure. Because of the complexity of cardiac surgical procedures and existing comorbidities, prolonged ventilation and intensive care unit (ICU) stays remain challenging. Over the last few decades, multiple studies have shown a correlation between longer intubation periods and adverse outcomes following cardiac surgery.13  A Cochrane review by Wong et al4  showed strong and consistent evidence of the effectiveness of fast-track interventions for adult cardiac surgery patients in reducing ICU length of stay and duration of ventilation. Prolonged intubation is 1 of 5 morbidity measures used in composite scores for evaluating performance in cardiac surgery procedures.5,6 

Chan et al7  provided evidence that a standardized approach to fast-track extubation (FTE), applicable to a diverse population of cardiac surgery patients, can safely reduce time to extubation by limiting variations and delays in treatment. Complex pathologies and unique perioperative situations—including systemic anticoagulation, use of cardiopulmonary bypass, hemodynamic variations, extensive volume replacement, postoperative anesthetic requirements, and existing comorbidities—pose obstacles to the implementation of FTE protocols in cardiac surgery.8  Early extubation is defined by the Society of Thoracic Surgeons (STS) as the removal of the endotracheal tube within 6 hours of ICU admission.

Early extubation is defined by the Society of Thoracic Surgeons as the removal of the endotracheal tube within 6 hours of ICU admission.

As the efficacy of an accelerated recovery is highly dependent on provider participation, promoting the use of a pathway can reduce process interruptions. In contrast to the conventional high-dose opioid techniques of the past, our FTE protocol consisted of a step-by-step method for reliably decreasing the overall duration of intubation. This quality improvement (QI) project centered on the development of a local protocol for enhancing care outcomes via the early extubation of cardiac surgery patients.

This QI project was performed at a midsize medical center serving southwestern and central Florida that specializes in cardiac care and heart failure services, including left ventricular assist device procedures and heart transplants. The facility performs approximately 400 adult cardiac operations annually. Twenty beds make up the cardiothoracic intensive care unit (CTICU), which is led by intensivists who collaborate with 4 cardiothoracic surgeons, 5 advanced practice providers, 7 cardiac anesthesia providers including anesthesiologists and certified registered nurse anesthetists (CRNAs), 5 perfusionists, multiple respiratory therapists, and 2 registered nurse (RN) managers.

Over the past 3 years, the chief of cardiothoracic surgery has exponentially expanded the program and consistently increased surgical acuity and improved performance outcomes. The recent addition of the heart failure program has necessitated a more systematic approach, as it has significantly elevated the standard of care. Examination and collaboration with the surgical and pulmonary care teams revealed inconsistencies in the recovery strategies for postsurgical patients. The interprofessional team lacked a uniform approach aligning with perioperative standards and STS quality metric ratings. Early extubation is a quality indicator reported to STS-participating institutions as a morbidity metric and serves as a national benchmark performance measure and quality of care standard. The STS national database is essential for self-monitoring and concentrating quality initiatives on areas of concern. The quality initiatives are used for cardiothoracic surgery research and are reported publicly.2  The implementation of an FTE protocol at this facility offered a new way for improvement of health care quality.

This QI project used the plan-do-study-act (PDSA) method to implement the FTE protocol for adult cardiac surgery patients. The PDSA cycle is a key component of lean management and encourages scientific study to ensure quality, allowing for quick assessments and minimal risks.9  The PDSA process and lean management hold everyone accountable to the FTE protocol guidelines to reduce complications in the work process. Using lean work design concepts, patient care procedures were redesigned to eliminate variability and serve as a guideline to facilitate FTE. After the problem was defined and inclusion and exclusion criteria were identified, metrics were chosen based on nationally recognized definitions of FTE. After variability was eliminated, the PDSA process steps were completed.

This QI project consisted of implementing an FTE protocol for adult cardiac surgery patients and then assessing the percentage of patients extubated in less than 6 hours and examining the length of ICU stay. Pair-matched electronic health record (EHR) data from the previous year were obtained for comparison. In addition, we evaluated the effectiveness of an educational activity in improving the FTE protocol knowledge of ICU RNs. The specific aims of the project were as follows: (1) increase the percentage of patients extubated in less than 6 hours as compared with a pair-matched control group from the previous year; (2) reduce the average length of ICU stay as compared with a pair-matched control group from the previous year; and (3) evaluate the effectiveness of an educational activity in improving FTE protocol knowledge of ICU staff members as measured by a posttest score of 80%.

We obtained institutional and institutional review board approval before the start of the project. This evidence-based QI project was conducted over 8 weeks. The project leader educated the CTICU RNs on the necessary FTE protocol guidelines and procedures. The initiative used a convenience sample of RNs who provided patient care in the CTICU. The FTE project was introduced to the CTICU team during the morning huddle. Participants were recruited by inviting CTICU RNs to an educational session on the FTE protocol. We supplied the CTICU breakrooms with recruitment flyers containing a QR code that directed potential participants to the consent form. After a participant gave consent, the project leader provided them with a QR code with a link to the online educational video. At the end of the video, a separate link directed the participant to the postactivity evaluation. The posttest questionnaire assessed the outcome measure FTE protocol knowledge of ICU staff. A descriptive analysis was used to determine if the educational activity had a positive impact on knowledge, as demonstrated by a posttest score of 80 or higher.

The online educational video described the FTE protocol and facilitated performance improvement. Fourteen CTICU RNs completed the educational activity, with a 100% success rate in achieving a score of 80% or higher on the postactivity assessment. In contrast, some obstacles at the project site that challenged the progression of the project included the high turnover rate of the ICU nursing staff, the need to collect data from multiple EHR platforms, and ICU staff burnout and disengagement.10  However, as awareness of improved outcomes and patient-to-nurse ratio increased, so did stakeholder support.

The FTE protocol was developed from an evidence-based literature review and included adult cardiac surgery patients (aged >18 years) admitted for coronary artery bypass grafting, valve repair or replacement, aortic aneurysm repair, or a combination surgery performed in an elective setting (see Figure). Additional criteria included hemodynamic stability, fluency in English, normal renal function, and normal left ventricular ejection fraction. The FTE protocol excluded high-risk cardiac surgery procedures, revision chest operations, and patient history of difficult intubation. In addition, patients with left ventricular ejection fraction less than 40%, uncontrolled diabetes mellitus, end-stage renal disease, hemodynamic instability (systolic blood pressure <90 mm Hg or heart rate >120 beats per minute), use of high-dose inotropes or vasopressors (epinephrine or norepinephrine infusion >0.05 μg/kg/min), risk of postoperative bleeding, and cardiogenic shock were excluded.

An FTE protocol was implemented to promote early extubation in less than 6 hours and timely discharge from the intensive care unit.

The FTE group consisted of a convenience sample of 26 patients admitted for cardiac surgery. Potential participants were identified 2 work days before surgery. The project leader described the planned FTE protocol and anesthesia interventions with the potential participants in person or by televisit. If the patient could not be reached, the information session was performed on the day of surgery. Consent was obtained from all recruited participants who met inclusion criteria and agreed to participate.

An FTE protocol was implemented to promote early extubation in less than 6 hours and timely discharge from the ICU. At the conclusion of surgery, the cardiac surgeon and the anesthesia team decided by consensus which patients to include and exclude from the FTE protocol based on possible intraoperative changes. Reasons for exclusion included unanticipated intraoperative bleeding, hemodynamic instability, and having undergone longer procedures. The unique relationship between the cardiac anesthesia providers and the chief of cardiothoracic surgery fostered a productive operational environment, allowing them to collaborate to achieve positive outcomes for each patient. The long-term partnership of the cardiac team fostered seamless communication between the various providers. The successful execution of the project was also facilitated by the collaboration between the CRNAs and the ICU nurses, which allowed achievement of time-sensitive objectives and the removal of obstacles to communication encountered in prior approaches. Previous techniques depended on physician communication, which was limited by insufficient participation and availability of providers. Anesthesia handoff sheets were created for the CTICU RNs to record the extubation times and ICU length of stay. Previously, there was no anesthesia handoff or report system, which hindered the continuity of care between providers. The CRNAs gave the FTE protocol report to the CTICU RNs upon their arrival at the unit. After collaboration with the CTICU team, the RNs executed the protocol and followed up with the anesthesia providers for additional input. The anesthesia and ICU teams convened with the project leader weekly to assess and evaluate protocol interventions and project concerns.

Anesthesia management included a preoperative medication regimen of acetaminophen and gabapentin. Intra-operative medications included midazolam, fentanyl, and vecuronium infusions at the discretion of the anesthesia provider. Patients were intubated with transesophageal echo probe monitoring and central venous access. Anesthesia was maintained with isoflurane, ketamine, dexmedetomidine, and a low-dose propofol infusion. All patients received insulin, as well as inotropic and vasoactive medication, as needed. Ultrasound-guided interfascial plane blocks were administered before incision for intraoperative and postoperative pain management.14 

When the CTICU RN arrived at the unit, they received a postoperative anesthesia handoff sheet from the CRNA. At the 2-hour mark, the ICU nurse conferred with the CRNA to discuss the patient’s recovery progression. This ease of communication helped achieve the extubation objectives. In addition, the proficiency of the ICU nurses in following the extubation guidelines contributed to the success of the project. The ICU nurses implemented specific interventions that included assessing hemodynamic stability, respiratory status, neurologic status, chest tube drainage, pain control, postoperative glycemic control, and patient temperature. The ICU nurses then notified the anesthesia provider of the results to obtain agreement regarding extubation criteria. Extubation times and ICU length of stay were recorded and the documentation secured in a locked box at the CTICU nurses’ station.5,12 

Data were collected on all cardiac surgery patients undergoing FTE protocols who met inclusion criteria and provided written consent. The outcome metric time to extubation (in hours) was calculated for each patient as the time from arrival at the ICU to the time of extubation. The outcome metric length of ICU stay was calculated in days. Cardiac anesthesia handoff sheets were placed in each patient’s medical record and labeled “FTE.” The handoff sheets included intraoperative anesthetic interventions and time slots for extubation and discharge from the ICU. Data were collected from the EHR and anesthesia handoff sheets. We analyzed a pair-matched control group of patients from the previous year who did not receive the FTE protocol using descriptive and quantitative statistics and compared it with the intervention group. We used a nonparametric test to determine whether there were statistically significant differences in outcome measures between the 2 groups.

The final analysis included 26 recruited patients in the FTE protocol group and 26 pair-matched control group patients. Patient procedures included coronary artery bypass grafting both on and off pump, mitral valve replacement or repair, aortic valve replacement, repair of ascending aorta, tricuspid valve repair, and a combination approach. Eleven patients (6 in the control group and 5 in the FTE group) had combined procedures. The 2 groups had similar baseline demographic characteristics. The sample population ranged in age from 28 to 77 years of age, with a mean age of 63.5 years. Both groups consisted mainly of White men (see Table). All patients underwent elective surgery (n = 52). Two of the patients in the intervention group were reintubated within 4 hours of extubation. Because of the relatively small sample sizes and nonnormal distributions of the 2 groups, analysis was performed using the Mann-Whitney test. The results showed that the FTE protocol group had a significantly higher percentage of patients extubated within the recommended 6-hour window than the pair-matched control group (85% vs 50%; U = 179, P = .003). After the intervention, the mean length of intubation was reduced by 3 hours. The results for ICU length of stay demonstrated a 37% reduction in the FTE protocol group compared with the control group, although the difference was not statistically significant, with mean values of 2.92 days in the control group and 1.85 days in the intervention group (U = 314, P = .62).

The results of this QI project demonstrated that an FTE protocol with a interprofessional approach could effectively increase the proportion of patients extubated within the STS-recommended 6-hour window. In addition, the results showed that an FTE protocol led to a 37% reduction in ICU length of stay. The production of an online educational video for the CTICU RNs and the participation of the interprofessional team members were additional factors that contributed to the success of the project. The instructional video provided comprehensive details about the FTE procedure, encompassing the perioperative phase as well as intraoperative anesthesia management. The CTICU nurses demonstrated knowledge of extubation criteria for fast-tracking patients and intraoperative anesthetics. The initiative was favorably received and helped improve the standard of postoperative cardiac care.

The passion and confidence of the ICU nursing staff laid the ground-work for improved processes and protocol-driven care.

Contributing to the project’s strength were the continuity of anesthesia providers and cardiothoracic surgeons for both patient population samples, the convenience of access to the population samples, and the availability of data via the EHR system. This QI initiative was distinguished from previous projects by its analysis of the impact of intraoperative anesthesia management on extubation times and ICU length of stay. In contrast to previous approaches, the combination of a multimodal opioid-sparing analgesia technique and intraoperative chest wall nerve blocks enabled a unique method of evaluating the early recovery processes of cardiac surgical patients. Another component of project success was the engagement of ICU nursing staff members and the project leader (a CRNA) in the dissemination of information promoting early extubation and decreased ICU stays. The team agreed that the ease of communication between the CRNAs and ICU nurses contributed to the positive results. In previous approaches, communication was hindered by its limitation to physicians. As evidenced by an increase in available ICU bed space and a reduction in operating room holds, this QI initiative contributed to an overall improvement in the quality of care and may reduce hospital costs.

The implementation of the FTE protocol generated an abundance of enthusiasm for change among staff members, including the chief of cardiothoracic surgery. Because of the nature of the surgery and the high-risk patient population, the anesthesia provider and ICU nurses’ level of experience was crucial to achieving positive outcomes. Differing patient characteristics, unanticipated intraoperative hemodynamic changes, varying skill level of practitioners performing regional nerve blocks, and challenges encountered postoperatively limit institutions’ ability to adhere to FTE protocols.

The project leader reviewed each case before the scheduled surgery. At the beginning of the day, the project leader provided the anesthesia team, cardiac operating room staff, and ICU nursing staff with instructions regarding patient selection. All questions were directed to the project leader. After conclusion of the procedure, the project leader discussed the extubation plan with the ICU team (nurses, physicians, and respiratory therapists) and followed up to ensure that the plan was executed. The data were validated daily using the EHR and the anesthesia handoff sheet. The ICU nursing staff acquired expertise in extubation protocols. Moreover, given the communication between CRNAs and ICU nurses, the ICU intensivists were able to relinquish a portion of their practice autonomy. Consequently, the passion and confidence of the ICU nursing staff laid the groundwork for improved processes and protocol-driven care. The use of highly skilled and proficient staff members improved the efficacy of this QI project. In a systematic review conducted by Agüero-Martínez et al,15  mastery of FTE methods depended on the health care provider’s expertise. The findings of this QI project align with those of Chan et al7  in demonstrating that an FTE protocol reduced overall intubation times and increased the rate of early extubation. This QI project yielded results comparable to those of Wong et al4  in their Cochrane review, which demonstrated the use of an FTE protocol to reduce time to extubation and ICU length of stay. In addition, Ellis et al5  and Hefner et al11  used an FTE protocol to reduce intubation times and reported a sustained reduction over 1 and 4 years, respectively.

This QI project was limited in several ways. The most significant obstacle was the 8-week allotted time for implementation. Two patients in the intervention group required reintubation as a result of unanticipated events postoperatively. This multimodal approach makes it difficult to determine which countermeasures may have had the most effect in achieving FTE success. Other limitations included the performance of the project at a single institution, small sample sizes, a shortage of ICU nurses, and the use of a convenience sampling methodology. Because cardiac surgery patients can vary in terms of the severity of their diagnoses and the complexity of their procedures, this patient population is challenging to treat with a protocol-based approach. Consequently, ongoing communication, continuity of care, and education across departments are essential for effective implementation of a long-term QI strategy.

This QI initiative provided the clinical site with guidance for incorporating the FTE protocol into the cardiac program by integrating metrics within the anesthesia and ICU QI departments. Integrating the FTE protocol into the perioperative cardiac surgical care workflow and establishing key performance indicators to evaluate its sustained performance will increase the success of the cardiac surgical program as a whole. Strong rapport and facilitated collaboration between the CRNAs and the ICU nurses contributed to the enhanced recovery of the cardiac surgical patients. The improvements realized may reduce the facility’s use of resources and help contain costs. This small-scale QI project may be used to evaluate the applicability of the FTE methodology to other institutions with more extensive cardiac programs.

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Footnotes

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].

 

Financial Disclosures

None reported.

 

See Also

To learn more about cardiac surgery patients, read “Dexmedetomidine in Adult Patients in Cardiac Surgery Critical Care: An Evidence-Based Review” by Brock in AACN Advanced Critical Care, 2019;30(3): 259–268. https://doi.org/10.4037/aacnacc2019888. Available at www.aacnacconline.org.