Early Extubation After Cardiac Surgery: An Evidenced-Based, Nurse-Driven Protocol

Prolonged mechanical ventilation in cardiac surgery patients has been associated with increased hospital stay, increased intensive care unit (ICU) length of stay, higher health care costs, and higher morbidity from atelectasis, intrapulmonary shunting and pneumonia. Early extubation of post-operative cardiac surgery patients has been associated with shorter ICU and overall hospital stays, reduced mortality, decreased resource use, and is safe and effective in elderly patients with no increased risk of reintubation. As such, the question arises in intubated post-operative cardiac surgery patients, how does a nurse-driven extubation protocol compared to no standardized protocol affect extubation rates within six hours post-operative? Per evidence synthesis, the recommendation was to develop and implement a nurse-driven multidisciplinary protocol to facilitate standardized early extubation (i.e., within six hours post-operative) in cardiac surgery patients. The Iowa Model helped to craft the evidence-based implementation plan, with a clear outline from the synthesis to intervention, outcomes viii and process. The theoretical framework was based on the AACN Synergy Model of Patient Care. Data was collected on six cardiac surgery procedures; coronary artery bypass graft (CAB), aortic valve replacement (AVR), AVR/CAB, mitral valve repair (MVR), MVR/CAB, and mitral valve replacement. The percentage of patients extubated in less than six hours went from 10.4 to 39.8 for AVR; 6.9 to 29.1 for AVR/CAB; 21.7 to 38.1 for CAB; 7.7 to 50.4 for MVRepair; 0 to 13.8 for MVRepair/CAB; 23.8 to 50 for MVReplace. In 2016 the average percentage for early extubation of cardiac surgery patients was 11.7. For the data February through August 2018, it was 36.9; an increase of 25.2%. The implementation of this project has a cost savings of 2.2 million dollars. The project plan was grounded in planning for sustainability. All process makers and data collection were selected to move early extubation from project to standard of care. Keywords: evidence-based, nurse-driven, extubation, cardiac surger