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Clinical Pathway Helps Reduce Reintubation Rates

Oct 04, 2018

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University of Maryland Medical Center develops clinical pathway to improve extubation outcomes for neurocritical patients

ALISO VIEJO, Calif. – Oct. 4, 2018 – Implementation of a clinical pathway at a Maryland hospital led to sustained changes in practice and contributed to improved extubation outcomes for patients in its neurocritical care unit (NCCU), according to a study published in October’s Critical Care Nurse (CCN).

An interdisciplinary team of providers at the University of Maryland Medical Center (UMCC) in Baltimore developed the clinical pathway after noticing high rates of postextubation stridor (PES) among patients in the 22-bed NCCU.

Patients with PES have an audible, high-pitched whistle when they inhale, a sign of severe laryngeal edema and a frequent complication associated with being intubated. In serious cases, a patient’s trachea can become so narrow that breathing is impaired and they have to be reintubated.

Unsuccessful extubation is associated with increased lengths of stay in critical care units and in the hospital, hospital costs, need for tracheostomy, risk for developing pneumonia, and morbidity and mortality rates. Brain-injured patients, such as those in UMMC’s NCCU, are at especially high risk for prolonged intubation and unsuccessful extubation.

Implementation of a Clinical Pathway to Reduce Rates of Postextubation Stridor” provides an overview of the UMMC quality improvement project and the results from the initial 12-week implementation.

“Multidisciplinary input and support was critical at every stage of this initiative,” said co-author Megan Lange, DNP, ACNP-BC, acute care nurse practitioner in the NCCU. “Our aim was to affect institutional practice and improve the quality of care provided in the NCCU. By working together, we were able to provide more consistent care and improve our rates of successful extubation.”

Clinical outcomes included a significant reduction in overall rates of PES, reintubation and reintubation due to PES; however, the researchers caution that these findings are limited due to the short implementation period and small sample size.

Several changes in practice were also noted, including:

  • Regular assessment of patient risk factors
  • Use of inhaled budesonide in high-risk patients
  • Consistent use of a single-dose steroid for high-risk patients

The researchers note that it’s difficult to determine which individual change had the greatest impact or whether confounding variables contributed to the outcomes. For example, increased attention to extubation criteria may have prevented premature extubation in certain patients. Additionally, the transition to a single-dose steroid may have contributed to the overall decrease in duration of mechanical ventilation, thereby decreasing the risk for PES. Decreased duration of intubation may have decreased the risk for ventilator-associated pneumonia that might require reintubation.

The interdisciplinary team consisted of an NCC intensivist, a neuroanesthesiologist, an NCC fellow, a pharmacist, two nurse practitioners and a physician assistant. Together, they reviewed the literature to identify patients at high risk for PES and to determine appropriate treatment.

The resulting clinical pathway incorporated the best available research to create consistency in evaluation of patients receiving mechanical ventilation before extubation and to guide decisions regarding care and treatment.

Prior to implementing the clinical pathway, all prescribing providers in the NCCU were trained on its use. All nurse practitioners, physician assistants and NCC fellows received additional one-on-one training with information about the checklist that outlined the clinical pathway.

The checklist was to be completed for every intubated patient during morning rounds, when extubation decisions are generally made. Although all providers participated in decision-making based on the clinical pathway, the nurse practitioner or physician assistant assigned to each patient was responsible for completing the checklist.

The implementation phase of the study lasted 12 weeks, with updates posted weekly to encourage compliance and reinforce the training.

During the study period, the pathway was completed on all intubated patients daily, with a total of 606 days of mechanical ventilation and an overall compliance rate of 88 percent. Of the 56 patients extubated during the trial, 54 had a checklist completed, for 96 percent compliance on the day of extubation.

Plans for permanent implementation include adding the pathway into the electronic medical record to decrease paperwork and help reduce workload.

As the American Association of Critical-Care Nurses’ bimonthly clinical practice journal for high-acuity, progressive and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The award-winning journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in high-acuity, progressive and critical care settings. CCN enjoys a circulation of more than 120,000 and can be accessed at http://ccn.aacnjournals.org/.

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than half a million acute and critical care nurses and includes more than 200 chapters in the United States. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution.

American Association of Critical-Care Nurse s, 101 Columbia, Aliso Viejo, CA 92656-4109; 949-362-2000; www.aacn.org; facebook.com/aacnface; twitter.com/aacnme