Early Extubation Best Practices, presented to the COAP Management Committee by Daniel Mumme, MD FACS, May 2017
Background: Early extubation within COAP and STS has been defined as extubation <6 hours after cardiac surgery. The definition of < 6 hours is somewhat arbitrary and early literature defined early extubation with an 8-hour cutoff. Early extubation is an integral part fast-track post-operative cardiac surgery care, designed to help reduce health care resources while preserving optimal patient outcomes. Other aspects of fast-track cardiac surgical care including lower dose, faster-acting opioid based anesthesia, specific vent weaning protocols, and direct admission to a cardiac stepdown ward (no ICU stay) will not be covered in this review.
Currently there are no society guidelines (STS, AATS) or consensus statements surrounding early extubation. Early extubation is not a portion of the STS composite rating nor the star rating system. Currently COAP considers early extubation a level II metric. While early extubation does not have long-term implications such as stroke, renal failure, or mortality, we have felt that it serves as a surrogate for the coordination of post-operative care amongst the entire surgical and ICU teams. There continues to be a wide variation of early extubation rates amongst hospitals in Washington state. The state average for early extubation is 69% (2014—2016).
Summary of Data Behind Early Extubation:
(See Early Extubation Literature for more detail on individual studies)
–There are no society guidelines (STS, AATS) for early extubation.
–Early extubation is safe as there is no difference of mortality or morbidity.
(Silbert, Cheng, Karaman, van Mastright, Wong (Cochrane Review))
–Early extubation reduces ICU LOS.
(Arom, Cheng, van Mastright, Wong (Cochrane Review))
–Early extubation may be cost effective.
(Arom, van Mastright)
–Early extubation probably does not reduce overall LOS.
(Silbert, van Magistright, Wong (Cochrane Review))
–The reintubation rate is low.
(Arom, Cheng, Crawford, Silbert, Wong (Cochrane Review))
–Fast-track cardiac surgery can be safe when applied to select patients.
(van Magistright, Wong (Cochrane Review), Youssefi)
–Dexmedetomidine based sedation may reduce intubation time
— Some data suggests there is a greater morbidity and mortality when extubation extends beyond 12 hours and that there is no difference between extubation <6 hours and <12 hours. (Crawford)
Strength of Data: The Cochrane review of 28 randomized clinical trials gave a low level of evidence to the primary outcome of mortality and the secondary outcome of morbidity. ICU LOS and overall LOS were downgraded to low level of evidence. Some of the initial studies were performed in the 1990s and may be outdated.
Tacoma General Hospital/Pulse Heart Institute experience with improving early extubation:
Prior to 2015, early extubation rate at Tacoma General for CABG only was 47%. In an effort to improve our early extubation times, a CABG collaborative group was created which sought input from all potential responsible parties. This group included cardiothoracic surgery, pulmonary, cardiac anesthesia, nurse manager, data manager, quality manager, IT/EPIC support, respiratory therapy, physician assistant, cardiac care line manager, and organizational effectiveness manager. Input from each member of the group was sought. Retrospective CABG only data of surgeon specific ventilator times as well as anesthesiologist and surgeon narcotic usage was obtained. Prospective data was collected and presented to all cardiac surgeons and all members of the CABG Collaborative group on a bi-weekly basis initially to assess and correct problems as quickly as possible. Since then the meetings have spaced out to quarterly and now bi-annually.
Various actions taken over the next few months included:
–Education of Cardiac ICU nurses of goal of early extubation. Creating a culture of early extubation
–Marking the 6 hour and 24 hour extubation times on a whiteboard in the patient’s ICU room to alert all members of the team
–Respiratory therapy signing out at bedside
–Rewriting the post-operative EPIC order set to include less narcotic use and encourage non-narcotic alternatives
–Creating a 2 hour post-operative “huddle” to decide to proceed with early extubation
–Willingness on all members of the team to extubate patients with IABP in place
–More liberal use of pulmonary consult
–More stringent use of extubation protocol
–Citing which patients did/did not meet extubation mark at nursing sign-out of 07:00 and 19:00.
–ICU nurse to send email to surgeon and nurse manager if patient failed the 6-hour mark.
–Attempt to create real-time data review to understand why patients were failing early extubation
–Weekly vent reports sent out to all cardiac surgeons, RT, nursing manager, quality manager, and cardiac ICU nurses
–Vent data reviewed at monthly Quality meeting and Coronary COE meeting
–Early extubation as one of four metrics used for Pulse cardiac surgery quality bonus
–Early extubation also one of several metrics cited for LEM bonus of Pulse administration.
Over the past two years, early extubation at Tacoma General has improved for all open heart operations. In 2016, the CABG only early extubation rate was 79%. Improvement in blood product usage, another goal of the above collaborative, has also occurred. The results have thus far been sustainable. Attempts to make the data analysis more real-time, actionable, and accountable are felt to have contributed to the improved results. Multi-disciplinary efforts to improve early extubation have created a culture of early extubation.
For further questions, please contact:
Jeannie Collins-Brandon, Program Director COAP; firstname.lastname@example.org
Daniel Mumme, MD FACS Pulse Heart Institute; email@example.com
Reducing Post-CABG 30 Day Readmissions – Best Practices, presented to COAP Management Committee by Ryan Foresman, MD, May 2017
Background: CABG ranked as having the highest potentially preventable readmission rate within 15 days following discharge (13.5%)
- Second highest average Medicare payment per readmission ($8,136)(MedPAC, 2007).
- $151 million: The estimated annual cost to Medicare for potentially preventable CABG readmissions
CMS update 2017
- Penalties for <30 day readmission following CABG
- It is projected that penalties for total readmissions will increase to $528 million in 2017, $108 million more than in 2016.
- HRRP (Hospital Readmission Reduction Program) hospitals with readmission rates that exceed the national average are penalized by a reduction in payments across all of their Medicare admissions—not just those which resulted in readmissions.
Most importantly, the significant cost to the patient both from a financial and emotional perspective cannot be dismissed. Although the cost to the patient is difficult to quantify, it remains undoubtedly significant.
Unfortunately, there is a paucity of literature addressing the issue of post-CABG 30 day readmission.
Harrison Medical Center Post-CABG readmission reduction:
In 2016, Harrison Medical Center (HMC) was able to decrease post-CABG 30 day readmissions to 3.6%. For comparison, National Range: 12-24%, STS: 10% (2016), COAP (WA state) average: 7.9%. Prior to 2017 HMC had post-CABG 30 day readmission rates of 16.3% in 2014 and 8.9% in 2015. In an effort to significantly reduce our readmission rates several key steps were taken. These steps are listed below along with how each step was addressed.
- Identification of patients with greatest risk of readmission
According to STS the most frequent causes of readmission are fluid overload (often presenting as pleural effusion) 23%, infection 20%, and arrhythmia (most commonly atrial fibrillation) 8%.
According to NIH / CIHR Cardiothoracic Surgical Trials Network the patients most at risk for readmission are female gender, diabetes mellitus, COPD, elevated creatinine, low hemoglobin, long duration of surgery (Ann Thorac Surg. 2014 October ; 98(4): 1274–1280.).
Once we understood which patients pose the risk, the following steps were taken; incorporating a full-time heart failure ARNP, direct surgical team involvement with optimizing patients in preoperative acute heart failure, and early establishment of true baseline weight as a goal for discharge.
ICU and PCU nursing education/re-education regarding acute heart failure with focus on signs of fluid overload postoperatively.
Patients were taught the Heart Zone tool.
Beta blocker doses were not increased and ACE inhibitors were held until patients were close to baseline weight.
- Observation vs readmission
Discussions with ER physician director were held to utilize observation status on some “readmissions” especially those that were related to heart failure or stable rhythm changes. This was done to allow for 24 hours of evaluation without admitting the patient. ED physician would then notify the surgeon on call and the surgical team then rounds on the patient the next day.
- Early post-operative follow-up (within 3 days post-discharge)
The single most important change was the implementation of having our Advance Practice Clinicians begin seeing patients in clinic on the 3rd day post-discharge. This allowed for very early recognition of heart failure symptoms, knowledge that the patients were not correctly taking medication, and a lack of patient understanding of their recovery process.
- Ann Thorac Surg. 2014 Oct; 98(4): 1274–1280
- JAMA, 2003 Aug; 290(6): 773-780
- J Thorac Cardiovasc Surg 1999;118:823-32
- J Thorac Cardiovasc Surg. 2001 Aug;122(2):278-86
- January 26, 2016 – Scientific presentation at the 52nd Annual Meeting of
The Society of Thoracic Surgeons. John P. Nabagiez, MD
1,185 patients who received visits from PAs on days 2 and 5 following hospital discharge had a significantly lower rate of readmission (10%) compared to (17%). This represents a 41% reduction in the rate of readmission within the first 30 days following cardiac surgery. It cost $23,500 to make house calls to 363 patients, which saved $977,500 in readmission costs.
This translated to $39 in healthcare savings for every $1 spent.