Survey of RT extubation Practices Prior to Introduction of an RT-driven Extubation Pathway
CCCF ePoster library. Khosravani H. Nov 1, 2016; 150932; 55 Disclosure(s): None
Dr. Houman Khosravani
Dr. Houman Khosravani
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Abstract
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#55

Topic: Quality Assurance & Improvement

Survey of RT extubation Practices Prior to Introduction of an RT-driven Extubation Pathway


Khosravani, Houman1; Fuller, John 1,2
1
Division of Critical Care Medicine, Western University, 2Department of Anesthesia and Perioperative Medicine, Western University



Abstract:

Introduction
The need to re-intubate patients in the ICU within 24-72 Hrs of a planned extubation is reported to be on the order of 2-25% of extubations and may be more prevalent in unplanned extubations. Re-intubation in this setting can bring forth risk and complications. Relative to intubation practices, there is less data on best extubation practices and also RT practice preferences and viewpoints on extubation. Thus, there exists an opportunity to survey current practice prior to implementation of an evidence-informed extubation pathway.
 
Objective
To survey RT extubation practices in a mixed medical-surgical academic intensive care unit.
 
Methods
We conducted a literature review using PubMed (Medline) and Google Scholar spanning 1995-2015 for manuscripts addressing factors that anticipate extubation failure in critically-ill patients. We reviewed the literature in a manner to separate studies that assess patient readiness or preparedness for extubation and focused on the current evidence implicating factors that anticipate failure of extubation. We identified several key parameters relevant to extubation failure. We developed an evidence-informed extubation pathway through a clinical practice committee approval process. Prior to implementation of the pathway, we surveyed the RTs at both of our academic ICUs to assess their perspectives on various aspects of extubation as informed by the parameters collected during the development of the pathway.
 
Results
36 RTs responded. The majority of the RT respondents practice solely in an ICU setting (90%) with 23% of the RTs practicing greater than 30 years and greater than 80% working in 3 ICUs or less. Almost 2/3 suggested prior exposure to an extubation protocol however almost 50% suggested that they do not follow a standard extubation practice, but rather an individualized approach. Presence of secretions and neuromuscular weakness was self-reported to be important factors. However, other parameters, supported by the literature, were felt to be less important including: age, days ventilated, passing of a spontaneous breathing trial, neurologic triad, BMI, C-spine immobility, cuff-leak, and lung disease. The procedures used during extubation were fairly similar across RTs, however only a small minority extubate with the ventilator circuit connected and pre-oxygenate prior to extubation.  The remainder disconnect the circuit and effectively have the patient breathing room air for several breaths prior to extubation.
 
Conclusion
We developed an evidence-informed extubation pathway and thereby identified parameters that place patients at risk of extubation failure. These parameters were then assessed for their relative importance in a survey of RTs and some were felt to be important while others with literature-based support were felt to be less important by practicing RTs. In addition, almost half the RT respondents practice an individualized plan rather than a standard approach. Further education around safe extubation practices and standardization of a protocol, much like intubation, may have benefits in developing and fostering safe extubation practices.


References:

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