Rapid Weaning: A Multidiscipinary Approach

Sometimes all it takes is looking at a number to make positive change happen.

When staff members in the cardiac ICU at Athens Regional Medical Center, Athens, GA, compared their extubation rates to other leading institutions in the Society of Thoracic Surgeons database, what they had always considered “pretty good” suddenly became “below average.” Nationally, 39.3 percent of postop open-heart patients are extubated within 6 hours, at Athens Regional, that number was 33 percent.

“That phrase ‘You manage what you measure,’ really is true,” said Antonio Arata, BSN, RN, NE-BC, director of the cardiac ICU/cardiology/CVSU at Athens Regional Medical Center. “Over the last few years, we’ve really ramped up our transparency and accountability in our facility for performance improvement measures and comparing quality outcomes. It’s amazing when you start seeing the data, how much you start making improvements.”

But making that improvement happen – at least so far as fast-tracking extubations was concerned – wouldn’t necessarily be easy.

Meeting the Challenge

The challenge lies in the fact that so many factors are involved in extubation. Open-heart surgery is already an incredibly complex procedure – patients often take longer to wake, and there are greater risks for bleeding and other complications. Implementing a fast-track extubation protocol would involve the entire healthcare team working together to make it happen.

A positive sign was when cardiothoracic surgeon Cullen Morris, MD, was the first to throw down the gauntlet. “My job as the medical director is to make sure we’re looking at quality, and one of the things we looked at was how long patients were on the ventilator after heart surgery,” Morris said. “You don’t want patients on the ICU very long, or on the respirator any longer than they have to be. It’s a quality point measure for cardiac bypass and for programs doing bypass surgery.”

With physician buy-in established, Candis Klef, RN, CCRN, manager of the cardiac ICU, took the lead by organizing a committee made up of surgeons, anesthesiologists, nurses and respiratory therapists to examine evidence-based research and develop a fast-track protocol that emphasized best practice.

And staff responded. Every discipline worked to take ownership of their role.

For anesthesia, it was looking at timing and the amount of sedation for each patient. Respiratory therapy focused on educating therapists on the difference between weaning open-heart and long-term patients, evaluating patients for readiness to wean, and performing the actual extubation.

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Nursing made sure patients had lab work, fluids and appropriate medications, and kept a close watch on patient condition post-surgery, including neurological status, bleeding, blood gas level, and hemodynamics.

Therapists and nurses also had to be willing to collaborate as the primary team members for extubation once the patient was on the unit. And the surgeons had to be highly engaged to ensure everything was being done accurately and efficiently in the OR so patients could have a timely extubation.

Reaching the Goal

The team set an initial extubation goal of within 6 hours postop, and has recently increased that goal to 4 hours. An extubation sheet tool notes the time patients are admitted, so the nurse and respiratory therapist can work toward that goal. Those busy hours when patients are first admitted fly by, so the tool helps staff stay on track.

“Putting a number on it spurs us on,” said Sean Turner, RN. Also noted are when the patient was extubated, and any factors that prevented extubation.

Family members are also considered part of the care team. “We do a lot of education with the family,” Klef said. “We go out in the morning with the family to give them an education book and we let them know that one of the first goals of the day is to get the breathing tube out. We set that expectation up front.”

Still, not every patient automatically falls under the fast-track protocol. Staff evaluates patients individually, and if underlying pulmonary conditions are present, patients may need to remain ventilated for 24 hours. Both the respiratory therapist and nurse must be in full agreement prior to any extubation.

But the protocol’s multidisciplinary approach to this issue certainly has resulted in rapid improvement. As of November 2011, the average percentage of postop open-heart patients extubated within 6 hours was 57.15 percent, and in some months that number was as high as 71 percent.

“[The nurses and RTs] have just done an incredible job of communicating and evaluating the patients,” said Sheldon Spivey, respiratory therapist and clinical manager. “That’s good to see from a management standpoint, that a multidisciplinary approach really does work.”

Hospital Wide Benefits

While he had never examined the data, Turner, a staff nurse on the CICU, had always suspected a more rapid extubation would result in benefits for patients. “From what I had already seen.those people [who were extubated earlier] always seemed to do well,” he said. “Their stay on the step-down unit was shorter; they got up and were walking around more quickly.”

It turns out that his suspicions are correct. According to recent studies, rapid weaning can shorten length of stay in the ICU and the hospital and reduce risk of ventilator-associated pneumonia. (At Athens Regional, VAP rates remain under the national average.)

With more than 500,000 open-heart surgery procedures performed annually in the U.S., hospitals implementing a rapid wean protocol could see a big impact on costs as well.

Fast-tracking extubation also impacts patient and family satisfaction. Waking up with a tube in your throat is uncomfortable to say the least, and often alarming for both patients and anxious family members. Being able to extubate quickly reduces the time patients must cope with a tube in their throat, decreasing agitation and any need for restraints. It also helps with issues like pain control, since patients are able to better communicate their needs.

Secret to Their Success

So, how do you manage to get healthcare workers from so many different disciplines at the same table and working together, successfully? Culture, for one. For the past several years, Athens Regional has been focused on building a more cohesive staff culture.

Good communication was another factor. During the development of the extubation protocol, the entire team was encouraged to toss ideas around the table, and respiratory therapy and nursing in particular have continued to work closely together. “Communication has been the key to all of this and a willingness for all the disciplines to listen to each other and take that information and put it together to get a really good clinical picture,” Spivey said.

Transparency in data has also made all staff members feel involved and improved autonomy. Data on extubations is posted on the employee intranet and shared at staff meetings.

The data-driven process also made it easy for staff to understand why the protocol was necessary. “We presented everybody with the facts, that we could do better and that there could be a lot of improvement. No one was resistant, they were very accepting of it,” said Klef.

But the work isn’t over. The success of the fast-track protocol has spurred the multidisciplinary team to continue to meet and evaluate other ways they can improve care on the CICU, such as reducing surgical site infections and blood usage.

“It’s a challenge that all hospitals have, taking a quality indicator and working as a team to improve it and getting that buy in,” Arata said. “Because the challenges never stop, it’s never ‘OK, we’re done, we’ve done all the quality we can.’ There are always new improvements we can make with quality. So, the more you can do quality improvement plans that incorporate teamwork, I think you have a higher likelihood of success.”

Danielle Wong Moores is a frequent contributor to ADVANCE.

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