{"id":3142,"date":"2021-03-08T10:24:02","date_gmt":"2021-03-08T18:24:02","guid":{"rendered":"https:\/\/www.qualityhealth.org\/coap\/?page_id=3142"},"modified":"2021-03-08T10:24:02","modified_gmt":"2021-03-08T18:24:02","slug":"best-practices","status":"publish","type":"page","link":"https:\/\/www.qualityhealth.org\/coap\/best-practices\/","title":{"rendered":"Best Practices"},"content":{"rendered":"

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Cardiovascular\u00a0 Surgery<\/strong><\/span><\/h3>\n

Early Extubation Best Practices<\/span>,<\/strong>\u00a0presented to the\u00a0COAP Management Committee by Daniel Mumme, MD FACS,\u00a0May 2017<\/p>\n

Background:<\/b>\u00a0 Early\u00a0extubation\u00a0within COAP and STS has been defined as\u00a0extubation\u00a0<6 hours after cardiac surgery.\u00a0\u00a0 The definition of < 6 hours is somewhat arbitrary and early literature defined\u00a0early\u00a0extubation\u00a0with an 8-hour\u00a0cutoff.\u00a0\u00a0 Early\u00a0extubation\u00a0is an integral part fast-track post-operative cardiac surgery care, designed to help reduce health care resources while preserving optimal patient outcomes.\u00a0 Other aspects of fast-track cardiac surgical care including lower dose, faster-acting\u00a0opioid based\u00a0anesthesia, specific vent weaning protocols, and direct admission to a cardiac stepdown ward (no ICU stay) will not be covered in this review.<\/p>\n

Currently there are no society guidelines (STS, AATS) or consensus statements surrounding early\u00a0extubation.\u00a0\u00a0 Early\u00a0extubation\u00a0is not a portion of the STS composite rating nor the star rating system.\u00a0\u00a0Currently COAP considers early\u00a0extubation\u00a0a level II metric.\u00a0\u00a0\u00a0While early\u00a0extubation\u00a0does 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.\u00a0\u00a0\u00a0 There continues to be a wide variation of early\u00a0extubation\u00a0rates amongst hospitals in Washington state.\u00a0 The state average for early\u00a0extubation\u00a0is 69% (2014\u20142016).<\/p>\n

Summary of Data Behind Early\u00a0Extubation:\u00a0\u00a0<\/b><\/p>\n

(See Early\u00a0Extubation\u00a0Literature for more detail on individual studies)<\/b><\/p>\n

\u2013There are no\u00a0society guidelines (STS, AATS) for early\u00a0extubation.<\/p>\n

\u2013Early\u00a0extubation\u00a0is safe as there is no difference of mortality or morbidity.<\/p>\n

(Silbert, Cheng,\u00a0Karaman,\u00a0\u00a0van\u00a0Mastright,\u00a0Wong\u00a0(Cochrane Review))<\/p>\n

\u2013Early\u00a0extubation\u00a0reduces ICU LOS.<\/p>\n

(Arom, Cheng, van Mastright, Wong (Cochrane Review))<\/p>\n

\u2013Early\u00a0extubation\u00a0may be cost effective.<\/p>\n

(Arom, van Mastright)<\/p>\n

\u2013Early\u00a0extubation\u00a0probably does not reduce overall LOS.<\/p>\n

(Silbert, van Magistright, Wong (Cochrane Review))<\/p>\n

\u2013The reintubation rate is low.<\/p>\n

(Arom, Cheng, Crawford, Silbert, Wong (Cochrane Review))<\/p>\n

\u2013Fast-track cardiac surgery can be safe when applied to select patients.<\/p>\n

(van Magistright, Wong (Cochrane Review), Youssefi)<\/p>\n

\u2013Dexmedetomidine based sedation may reduce intubation time<\/p>\n

(Curtis, Karaman)<\/p>\n

\u2014 Some data\u00a0suggests there is a\u00a0greater morbidity and mortality when\u00a0extubation\u00a0extends beyond 12 hours and that there is no difference between\u00a0extubation\u00a0<6 hours and <12 hours.\u00a0(Crawford)<\/p>\n

Strength of Data<\/b>:\u00a0\u00a0 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.\u00a0 ICU LOS and overall LOS were downgraded to low level of evidence.\u00a0\u00a0 Some of the initial studies were performed in the 1990s and may be outdated.<\/p>\n

Tacoma General\u00a0<\/b>Hospital\/Pulse Heart Institute\u00a0<\/b>experience with improving early\u00a0extubation:<\/b><\/p>\n

Prior to 2015, early\u00a0extubation\u00a0rate at Tacoma General for CABG only was 47%.\u00a0\u00a0In an effort to\u00a0improve our early\u00a0extubation\u00a0times, a CABG collaborative group was created which sought\u00a0input\u00a0from all potential responsible parties.\u00a0 This group included cardiothoracic surgery, pulmonary, cardiac anesthesia, nurse manager, data manager,\u00a0quality manager,\u00a0IT\/EPIC support, respiratory therapy, physician assistant, cardiac\u00a0care line\u00a0manager, and organizational effectiveness manager.\u00a0\u00a0\u00a0\u00a0Input\u00a0from each member of the group was sought.\u00a0 Retrospective\u00a0CABG only\u00a0data of surgeon specific ventilator times as well as anesthesiologist\u00a0and surgeon narcotic usage was obtained.\u00a0 Prospective data was collected and presented to\u00a0all\u00a0cardiac surgeons and all members of the CABG Collaborative group on a\u00a0bi-weekly basis\u00a0initially\u00a0to assess and correct problems as quickly as possible.\u00a0\u00a0Since then the meetings have spaced out to quarterly and now bi-annually.<\/p>\n

Various actions taken over the next few months included:<\/p>\n

Nursing\/RT efforts:<\/p>\n

\u2013Education of\u00a0Cardiac ICU\u00a0nurses of goal of early\u00a0extubation.\u00a0 Creating\u00a0a\u00a0culture of early\u00a0extubation<\/p>\n

\u2013Marking the 6 hour and\u00a024 hour\u00a0extubation\u00a0times on a whiteboard in the patient\u2019s ICU room to alert all members of the team<\/p>\n

\u2013Respiratory therapy signing out at bedside<\/p>\n

\u2013Rewriting the post-operative EPIC order set to include less narcotic use and encourage non-narcotic alternatives<\/p>\n

\u2013Creating a\u00a02 hour\u00a0post-operative \u201chuddle\u201d to decide to proceed with early\u00a0extubation<\/p>\n

\u2013Willingness on all members of the team to extubate patients with IABP in place<\/p>\n

\u2013More liberal use of pulmonary consult<\/p>\n

\u2013More stringent use of\u00a0extubation\u00a0protocol<\/p>\n

\u2013Citing which\u00a0patients did\/did not meet\u00a0extubation\u00a0mark at nursing\u00a0sign-out\u00a0of 07:00 and 19:00.<\/p>\n

\u2013ICU nurse to send email to surgeon and nurse manager if patient\u00a0failed the\u00a06-hour\u00a0mark.<\/p>\n

Data efforts:<\/p>\n

\u2013Attempt to create real-time data review to understand why patients were failing early\u00a0extubation<\/p>\n

\u2013Weekly vent reports sent out to all cardiac\u00a0surgeons, RT, nursing manager, quality manager, and cardiac ICU nurses<\/p>\n

\u2013Vent data reviewed at monthly Quality meeting and Coronary COE meeting<\/p>\n

Compensation efforts:<\/p>\n

\u2013Early\u00a0extubation\u00a0as one of\u00a0four metrics used for Pulse cardiac surgery quality bonus<\/p>\n

\u2013Early\u00a0extubation\u00a0also one of several metrics cited for LEM bonus of\u00a0Pulse administration.<\/p>\n

Over the past two years, early\u00a0extubation\u00a0at Tacoma General has improved for all\u00a0open heart\u00a0operations.\u00a0 In 2016, the CABG only early\u00a0extubation\u00a0rate was 79%.\u00a0\u00a0 Improvement in blood product usage,\u00a0another goal of the above collaborative, has also occurred.\u00a0\u00a0 The results have thus far been sustainable.\u00a0\u00a0\u00a0Attempts\u00a0to make the data analysis more real-time, actionable,\u00a0and accountable are felt to have\u00a0contributed to the improved results.\u00a0\u00a0\u00a0Multi-disciplinary efforts to improve\u00a0early\u00a0extubation\u00a0have created a\u00a0culture of early\u00a0extubation.<\/p>\n

For further questions, please contact:<\/p>\n

Jeannie Collins-Brandon, Program Director COAP;\u00a0jcollinsbrndon@qualityhealth.org<\/a><\/p>\n

Daniel Mumme, MD FACS Pulse Heart Institute;\u00a0daniel.mumme@multicare.org<\/a><\/p>\n

 <\/p>\n

Reducing Post-CABG 30 Day Readmissions \u2013 Best Practices,\u00a0<\/b><\/span>presented to\u00a0COAP Management Committee by\u00a0Ryan Foresman, MD, May 2017<\/p>\n

Background<\/b>:\u00a0\u00a0CABG ranked as having the highest potentially preventable readmission rate within 15 days following discharge (13.5%)<\/p>\n