Early Extubation After Cardiac Surgery: An Evidence-Based, Nurse-Driven Protocol

Prolonged mechanical ventilation in cardiac surgery patients has been associated with increased hospital stay, increased intensive care unit (ICU) length of stay, higher health care costs, and higher morbidity from atelectasis, intrapulmonary shunting and pneumonia. Early extubation is defined as the removal of the endotracheal tube within six hours of end anesthesia time. Early extubation of post-operative cardiac surgery patients has been associated with shorter ICU and overall hospital stays, reduced mortality, decreased resource use, and is safe and effective in elderly patients with no increased risk of reintubation. Therefore, a nurse-driven protocol outlines evidence-based actions and places the decision-making responsibility for the determination of extubation readiness into the hands of the bedside nurse. As such, the question arises in intubated post-operative cardiac surgery patients, how does a nurse-driven extubation protocol compared to no standardized protocol affect extubation rates within six hours post-operative? The search for best evidence began by considering the elements of the PICOT question. Critically appraising the evidence ensures relevance and transferability of the evidence to the specific population for whom the clinician provides care. In critically appraising the body of evidence on nurse-driven protocols and extubation in cardiac surgery patients, synthesis tables were created for type of evidence, major variables and outcomes of early extubation and interventions present in the evidence. Per evidence synthesis, the recommendation was to develop and implement a nurse-driven multidisciplinary protocol to facilitate standardized early extubation (i.e, within six hours post-operative) in cardiac surgery patients. The Iowa Model helped to craft the implementation plan that was extracted from the evidence, with a clear outline from the synthesis to intervention, outcomes and process. The theoretical framework was based on the AACN Synergy Model of Patient Care. The data was analyzed in several ways. Data was collected on six cardiac surgery procedures; coronary artery bypass graft (CAB), aortic valve replacement (AVR), AVR/CAB, mitral valve repair (MVR), MVR/CAB, and mitral valve replacement. Numbers of those extubated under six hours, as well as the surgeon, procedure, admission temperature, utilization of fluid warmers, and any factors important for extubation such as intra-aortic balloon pump and need for ongoing sedation are recorded. Length of stay for the intensive care unit and length of stay for the overall hospital visit was collected in both hours and days. Because the Society of Thoracic Surgeons (STS) records their benchmark in percentage for extubation in less than six hours post-operative, all numbers were also expressed as percentage. The percentage of patients extubated in less than six hours went from 10.4 to 39.8 for AVR; 6.9 to 29.1 for AVR/CAB; 21.7 to 38.1 for CAB; 7.7 to 50.4 for MVRepair; 0 to 13.8 for MVRepair/CAB; 23.8 to 50 for MVReplace. In 2016 the average percentage for cardiac surgery patients extubated less than six hours post-operative was 11.7. For the data February through August 2018, the average percentage for cardiac surgery patients extubated less than six hours post-operative was 36.9; an increase of 25.2%. Prior to implementation, 2016 had approximately 105 patients extubated in less than six hours post-operative. With an average length of ICU stay of approximately 1.9 days, an average of $5166 per patient per ICU day, for 332 patients extubated less than six hours post-operative, is $3.3 million dollars. Our baseline data was 105 patients at 1.0 million dollars. The implementation of this project therefore has a difference of 227 patients extubated within six hours, a cost savings of 2.2 million dollars. The project plan was grounded in planning for sustainability. All process makers and data collection were selected to move early extubation from project to standard of care.