Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol

2021 ◽  
Vol 41 (3) ◽  
pp. 14-24
Author(s):  
Myra F. Ellis ◽  
Heather Pena ◽  
Allen Cadavero ◽  
Debra Farrell ◽  
Mollie Kettle ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Fast Track ◽  
Early Extubation ◽  
Control Approach ◽  
Prolonged Intubation ◽  
Care Processes ◽  
Provider Practice ◽  
The Impact

Background Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient’s baseline physiological condition, workflow processes, and provider practice patterns. Local Problem Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. Methods This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. Results In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. Conclusions The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

Readmission to the Intensive Care Unit after Fast-Track Cardiac Surgery: An Analysis of Risk Factors and Outcome according to the Type of Operation

2010 ◽  
Vol 13 (4) ◽  
pp. E212-E217 ◽  
Author(s):  
Fevzi Toraman ◽  
Sahin Senay ◽  
Umit Gullu ◽  
Hasan Karabulut ◽  
Cem Alhan
Keyword(s):  
Risk Factors ◽  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Fast Track

scholarly journals Effect of motor subtypes of delirium in the intensive care unit on fast-track failure after cardiac surgery

2018 ◽  
Vol 155 (1) ◽  
pp. 268-275.e1 ◽  
Author(s):  
Anna Lee ◽  
Jing Lan Mu ◽  
Chun Hung Chiu ◽  
Tony Gin ◽  
Malcolm John Underwood ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Fast Track

One-Week versus 2-Day Ventilator Circuit Change in Neonates with Prolonged Ventilation: Cost-Effectiveness and Impact on Ventilator-Associated Pneumonia

2014 ◽  
Vol 36 (3) ◽  
pp. 287-293 ◽  
Author(s):  
Shih-Ming Chu ◽  
Mei-Chin Yang ◽  
Hsiu-Feng Hsiao ◽  
Jen-Fu Hsu ◽  
Reyin Lien ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Cost Effectiveness ◽  
Neonatal Intensive Care Unit ◽  
Neonatal Intensive Care ◽  
Ventilator Associated Pneumonia ◽  
Ventilator Circuit ◽  
Mechanical Ventilators ◽  
Prolonged Intubation ◽  
The Impact

ObjectiveTo investigate the impact of 1-week ventilator circuit change on ventilator-associated pneumonia and its cost-effectiveness compared with a 2-day change.DesignAn observational cohort study.SettingA tertiary level neonatal intensive care unit in a university-affiliated teaching hospital in Taiwan.PatientsAll neonates in the neonatal intensive care unit receiving invasive intubation for more than 1 week from July 1, 2011, through December 31, 2013.InterventionWe investigated the impact of 2 ventilator circuit change regimens, either every 2 days or 7 days, on ventilator-associated pneumonia of our cohort.Measurements and Main ResultsA total of 361 patients were maintained on mechanical ventilators for 13,981 days. The 2 groups did not differ significantly in any demographic characteristics. The rate of ventilator-associated pneumonia was comparable between the 2-day group and the 7-day group (8.2 vs 9.5 per 1,000 ventilator-days, P=.439). The durations of mechanical ventilation and hospital stay, and rates of bloodstream infection and mortality, were also comparable between the 2 groups. Switching from a 2-day to a 7-day change policy would save our neonatal intensive care unit a yearly sum of US $29,350 and 525 working hours.ConclusionDecreasing the frequency of ventilator circuit changes from every 2 days to once per week is safe and cost-effective in neonates requiring prolonged intubation for more than 1 week.Infect Control Hosp Epidemiol 2014;00(0): 1–7

scholarly journals Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons

2021 ◽  
Vol 10 (19) ◽  
pp. 4288
Author(s):  
Alessandro Affronti ◽  
Elena Sandoval ◽  
Anna Muro ◽  
Jose Hernández-Campo ◽  
Eduard Quintana ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Primary Outcome ◽  
Kidney Injury ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Deep Sternal Wound Infection ◽  
Major Morbidity ◽  
Prolonged Intubation

Surgical re-explorations represent 3–5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: “planned” and “unplanned”. Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs 7%, p = 0.004), prolonged intubation (46.8% vs 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs 7%, p = 0.91) and DSWI rates (1.8% vs 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

Readmission to the intensive care unit after “fast-track” cardiac surgery: risk factors and outcomes

2003 ◽  
Vol 76 (2) ◽  
pp. 503-507 ◽  
Author(s):  
Alexander Kogan ◽  
Jonathan Cohen ◽  
Ehud Raanani ◽  
Gideon Sahar ◽  
Boris Orlov ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Fast Track

Critical Care for the Surgical Patient

2002 ◽  
Vol 12 (7) ◽  
pp. 258-265 ◽  
Author(s):  
Chris Aps
Keyword(s):  
Intensive Care Unit ◽  
Critical Care ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Postoperative Management ◽  
Surgical Patient ◽  
Care Provision ◽  
Fast Tracking ◽  
Patient Dependency ◽  
The Impact

Dr Chris Aps has been involved, since the early 1980s, with the impact of the surgical patient on critical care provision. At that time, he established clinical techniques to lower patient dependency after cardiac surgery. This allowed for the postoperative management of such patients in a general recovery facility rather than in the formal Intensive Care Unit (ICU). This became known as cardiac fast-tracking and led to the development of the Overnight Intensive Recovery (OIR) concept.

scholarly journals Changes in Nursing Team Composition and Risk of Device Associated Infection in Intensive Care Units

2020 ◽  
Vol 41 (S1) ◽  
pp. s465-s465
Author(s):  
Hirsh Shah ◽  
Shelley A Knowlson ◽  
Audrey Roberson ◽  
Emily Godbout ◽  
Michael Stevens ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Intensive Care Units ◽  
Ventricular Assist Devices ◽  
Direct Patient Care ◽  
Small Unit ◽  
Complexity Score ◽  
Tract Infections ◽  
The Impact

Background: The relationship between nursing staffing and healthcare-associated infections (HAIs) has been explored previously, with conflicting results. Intensive care units increasingly struggle to maintain trained staff. In May 2019, clinical coordinator (CC) roles changed to include 50% of time in direct patient care rather than supportive roles. In this study, we used shift records to explore the impact of staffing on HAI risk. Methods: Daily staffing records from December 2018 August 2019 for the medical-respiratory unit (MRICU) and the cardiac surgery unit (CSICU) were reviewed. Both units staff a fixed 2:1 patient:nurse ratio (1:1 for specific cardiac surgeries). Staff deficiency was defined as assignments filled by nurses pulled from other units/supplemental/or CC roles. Staff support comprised nursing assistants and unit secretaries. Census, admissions, and complexity score for number of devices were used to estimate care acuity. In CSICU, additional points were added for continuous renal replacement therapy, extracorporeal membrane oxygenation, ventricular assist devices, transplant, operative cases. NHSN definitions were used for central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). The Spearman correlation coefficient was used to determine relationship between staffing, acuity, and risk window for HAI (days 1–10 preinfection). Linear regression was used to determine whether staffing deficiencies and/or support associate with the risk window prior to HAI. The final model included census and complexity score as control variables. The statistical analysis was performed using SAS version 9.4 software (Cary, NC). Results: Overall, 8 HAIs occurred in the study period: medical-respiratory intensive care unit (MRICU: 3 CAUTIs and 1 CLABSI) and cardiac surgery intensive care unit (CSICU: 1 CAUTI and 3 CLABSIs). Staffing and census fluctuated daily (Table 1). Total number of nurses correlated with complexity scores (r = 0.35; P < .0001) and daily census (r = 0.31; P < .0001) in the CSICU, and the census (r = 0.12; P = .04) in the MRICU. Nursing deficiencies correlated with days 1–10 before infection (r = 0.20; P = .0013) in the CSICU. In the regression model for the CSICU, nursing deficiencies increased in the time prior to HAI (P = .004), and support staff decreased in the time prior to HAI (P = .034) while controlling for census and complexity. These relationships were not significant in the MRICU. Conclusion: The lack of core nurses to support the staffing structure in CSICU correlated with periods prior to CLABSI or CAUTI in this small, unit-based study. Failure to recruit and retain highly skilled core staff may produce HAI risks, particularly for CLABSI in specialized units.Funding: NoneDisclosures: Michelle Doll, Research Grant from Molnlycke Healthcare

scholarly journals A Written Guideline Implementation Can Lead to Reductions in Laboratory Testing in an Intensive Care Unit

1997 ◽  
Vol 25 (1) ◽  
pp. 33-37 ◽  
Author(s):  
S. M. Mehari ◽  
J. H. Havill ◽  
C. Montgomery
Keyword(s):  
Intensive Care Unit ◽  
Cardiac Surgery ◽  
Intensive Care ◽  
Laboratory Testing ◽  
Cost Savings ◽  
Blood Gases ◽  
Arterial Blood Gases ◽  
Blood Tests ◽  
Arterial Blood ◽  
The Impact

The impact of developing guidelines for laboratory testing in an Intensive Care Unit (ICU) was examined. Targeted blood tests were recorded on fifty cardiac surgery and fifty general intensive care patients retrospectively. Following the introduction of guidelines, the study was repeated with prospective data collection. Comparison of the samples before and after the intervention showed a 25.9% reduction in all blood tests and a 17.1% reduction in arterial blood gases in the post cardiac surgery group. In general ICU patients, the drop in all tests was 16.6% and in arterial blood gases 21.9%. The cost savings from the cardiac surgery sample was N.Z.$3,637 and general ICU N.Z.$3,166, giving a sum total of N.Z.$6,803 in 100 patients. The potential cost savings for the annual admissions of 1,200 patients is N.Z.$81,636. This study shows that written guidelines can bring about major cost reduction in the short-term.

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