Implementation of a nurse-led protocol for early extubation after cardiac surgery: A pilot study

Abstract

Background: Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). Early extubation is a cornerstone of fast-track cardiac surgery, and it has been mainly implemented in post-anaesthesia care units. Introducing a nurse-led extubation protocol may lead to reduced extubation time.

Aim: To investigate results of the implementation of a nurse-led protocol for early extubation after elective cardiac surgery, aiming at higher extubation rates by the third postoperative hour.

Methods: A single centre prospective study in an 18-bed, consultant-led Cardiothoracic ICU, with a 1:1 nurse-to-patient ratio. During a 3-wk period, the protocol was implemented with: (1) Structured teaching sessions at nurse handover and at bed-space (all staff received teaching, over 90% were exposed at least twice; (2) Email; and (3) Laminated sheets at bed-space. We compared "standard practice" and "intervention" periods before and after the protocol implementation, measuring extubation rates at several time-points from the third until the 24^th postoperative hour.

Results: Of 122 cardiac surgery patients admitted to ICU, 13 were excluded as early weaning was considered unsafe. Therefore, 109 patients were included, 54 in the standard and 55 in the intervention period. Types of surgical interventions and baseline left ventricular function were similar between groups. From the third to the 12^th post-operative hour, the intervention group displayed a higher proportion of patients extubated compared to the standard group. However, results were significant only at the sixth hour (58% vs 37%, P = 0.04), and not different at the third hour (13% vs 6%, P = 0.33). From the 12^th post-operative hour time-point onward, extubation rates became almost identical between groups (83% in standard vs 83% in intervention period).

Conclusion: The implementation of a nurse-led protocol for early extubation after cardiac surgery in ICU may gradually lead to higher rates of early extubation.

Keywords: Extubation protocol; Fast-track; Implementation strategies; Intensive care; Mechanical ventilation.

Figure 1

Protocol for the management of patients after cardiac surgery. ABG: Arterial blood gas; BE: Base excess; CPAP: Continuous positive airway pressure; CV: Cardiovascular; IBW: Ideal body weight; PS: Pressure support.

Figure 2

Study periods. Three study periods were identified: “standard practice”, “implementation” and “intervention”. The duration of each period is indicated in the figure.

Figure 3

Rates of patients extubated at different time-points. The analysis starts at the third postoperative hour. Standard practice group is shown in black colour (series 1) and intervention group in grey (series 2). ^aP < 0.05, standard practice group vs intervention group.