Authors (including presenting author) :
Wong KW(1), Yau WS(2), Wan HYS(1), Lau CC(1), Yeung WY(1), Fung SS(1), Wong LY(1)
Affiliation :
(1)Department of Cardiothoracic Surgery, Queen Mary Hospital, (2)Department of Cardiothoracic Anaesthesia, Queen Mary Hospital
Introduction :
Protocol-driven mechanical ventilation(MV) management and timely postoperative extubation within 6 hours after ICU arrival are deemed to be the significant components for enhanced recovery after cardiac surgery with listed positive patient outcomes including early resumption of preoperative functional state, early rehabilitation, earlier readiness for ICU discharge and hospital discharge as well. Concurrently, owning the expanding demand for cardiac surgeries in the Department of Cardiothoracic Surgery, Queen Mary Hospital(CTSD), a multidisciplinary fast-track extubation protocol(FTEP) with the component of nurse-performed extubation was piloted to re-engineer the care process of elective cardiac surgery patient in Cardiothoracic Surgical Intensive Care Unit(CTSICU).
Objectives :
1. To benchmark the framework to implement early extubation for elective cardiac surgery patients in QMH CTSICU.
2. To establish a safe, systematic, and prudent practice of nurse-performed extubation in QMH CTSICU.
Methodology :
In August 2024, the cardiothoracic surgeon, anesthesiologist, and CTSICU nursing team jointly formulated the FTEP, which streamlined the algorithm to accomplish expeditious MV discontinuation including patient criteria, 6-hour immediate postoperative care checkpoints, pre-extubation preparation, and post-extubation follow-up actions. The specific roles and responsibilities of cardiothoracic anesthesiologist and CTSICU nurse were also delineated to guide the collaboration in stepwise approach. Afterward, responsible colleagues delivered protocol orientation sessions within the team. Furthermore, focused training and assessment on patient monitoring and extubation techniques were conducted for fellow CTSICU nurses, who assumed the major roles of caring for and extubating the selected patients as stated within the protocol. Subsequently, the FTEP has been piloted in clinical trials since September 2024.
Result & Outcome :
Between September and December 2024, the cardiothoracic anesthesiologists enrolled 81 elective cardiac surgery patients intraoperatively and 63.1%(n=53) of them were extubated within 6 hours after CTSICU arrival according to the FTEP algorithm. Multifactorial vital sign abnormalities, significant drainage output, and altered mental status were major identifiable factors to prolong the MV period. Among the 53 early extubation events, 66%(n=35) were extubated by 24 CTSICU nurses without major immediate post-extubation complications. The corresponding mean postoperative extubation time was 4.46±1.66 hours while the mean CTSICU length of stay was 31.36±25.55 hours.
To conclude, the preliminary findings of this piloted FTEP have demonstrated the efficacy of algorithm-guided MV discontinuation and the safety of nurse-performed extubation in managing elective cardiac surgery population. On the way forward, our team will review the protocol criteria and logistic flow to refine the relevant generalizability in CTSICU.
