Description of the Best Practice
Our Lady of Lourdes Medical Center is a major provider of cardiac services to
southern New Jersey. In 1997, nearly 1,300 open heart surgery procedures were
performed by a team consisting of 15 cardiothoracic surgeons and supported by
over 80 board certified cardiologists. Members of the cardiac team
participated in the Institute for Healthcare Improvement Cardiac Surgery
Collaborative and utilized the Plan-Do-Study-Act Rapid Cycle Improvement
Concept to reduce the amount of time that a patient remained intubated
following open heart surgery. Usual practice at this institution resulted in
patients remaining intubated for approximately 12 hours post-op. Because of
complications and discomfort associated with intubation, an attempt was made to
achieve extubation of at least 80% of our patients within six hours of arrival
in the intensive care unit following open heart surgery.
Implementation
A Task Force consisting of representatives from the nursing staff,
cardiothoracic surgery, anesthesiology, cardiology, pulmonology, respiratory
therapy, and hospital administration was assembled to address the objectives.
The overall task was immediately divided into sections, including the
development of a modified anesthesia protocol that would reduce the amount of
anesthetic agents used during the operation, a modification of the CVU protocol
for monitoring respiratory status and for performing extubation, and the
establishment of pre-printed orders and changes in intensive care unit policies
that would be required to streamline and facilitate the changes in patient
care. Also a part of this process was the development of a mechanism for
tracking results on a concurrent basis.
Time Frame
The members of the team met for the first time on 10/31/96. Within one week, a
re-written anesthesia protocol, draft versions of the new unit policies, and a
draft version of the pre-printed orders were available for review and
modification. It was agreed that a small group of anesthesiologists and a
selected group of surgeons would pilot the project, focusing on low risk
first-time routine coronary bypass surgery patients to insure that patient's
safety would not be jeopardized and to demonstrate early success in the
process. Meetings of the team were held on a weekly basis thereafter for the
next two months. During that time, progressive increases in the number of
anesthesiologists and surgeons, and increasing levels of patient's severity
were incorporated into the protocol. By January, 1997 all members of the CT
surgery staff, all anesthesiologists, and all patients were participating in
the rapid extubation protocol. Nursing familiarity with the process increased
during that time and the results of the project were posted in a conspicuous
location in the intensive care unit.
Financial Profile
Establishing the costs associated with a patient being on a ventilator, the
cost of monitoring such patients, and the costs of caring for complications
arising from the patient being ventilated for an extended period of time were
considered to be inordinately difficult. As the primary objective was to
improve patient comfort and to emulate models that had been demonstrated to be
cost effective in other institutions, it was felt unnecessary as a part of this
project to specifically define the financial gains associated with rapid
extubation. It is clear however, that there was a significant reduction in the
number of laboratory tests performed on these patients as a result of their
early extubation. Most conspicuous was the reduction in the use of blood gases.
In addition, a reduction in the average amount of time that a patient remained
in the intensive care unit was noted. Our tracking system did not allow us to
identify specific gains associated with reduction in pulmonary complications,
however. Patient satisfaction was assessed by use of a survey. Patients felt no
significant change in discomfort as a result of rapid extubation and in many
cases strongly applauded the opportunity to be extubated at an earlier time
than usual.
Outcome
Average time of intubation was reduced from 13 hours (1995) to 4.56 hours
(11/96-2/97). 78% of all patients were extubated within six hours of arrival in
the intensive care unit. Length of stay in the intensive care unit for
uncomplicated cases dropped by 6.5% for coronary bypass patients and by 19% for
patients undergoing uncomplicated valve surgery. Subsequently, three additional
surveillance studies demonstrated that this gain had been maintained, with 78%
of patients being extubated within six hours on the most recent of these
surveillance evaluations.
Best Practice Narrative is limited to a one page summary.
Supporting data is limited to one page.
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