INTRODUCTION/HYPOTHESIS: Complications of Mechanical Ventilation (MV) are well-described and related to duration of exposure to the intervention. A protocolized approach to MV liberation is recommended by Critical Care society guidelines and avoidance of delay to MV liberation was recently selected as one of five 2021 Choosing Wisely® for Critical Care recommendations. Baseline data in our tertiary hospital Medical Intensive Care Unit (MICU) showed that the average time of extubation was 1:30PM, with only 16% of patients extubated in the morning before 10AM. These findings prompted a Quality Improvement (QI) initiative aimed at achieving earlier extubation of eligible patients. METHODS: A multidisciplinary QI project team was formed, with representation from attending physicians, respiratory therapists, nurses, and physicians-in-training. A SMART Aim was created in September of 2020, with a goal set for the rate of morning (6AM to 10AM) extubation for eligible patients to increase from 16% to 20% or greater by June of 2021. Countermeasures were developed based on root cause analysis and targeted early morning initiation of Spontaneous Breathing Trials (SBTs), limiting overnight sedation, and staff education on hospital SBT and extubation protocols. A novel telemedicine Respiratory Therapy service, initially formed in response to the COVID-19 pandemic, was leveraged to ensure early SBTs and sedation minimization. PDSA cycles were performed to optimize educational and telemedicine countermeasures. RESULTS: 334 patients were extubated during the study period. The cumulative rate of extubation between 6AM - 10AM increased from 16% in the pre-intervention period to 27% in the post-intervention period and an upward shift in the run chart baseline was observed. Reintubation rate within 48 hours was monitored as a balancing measure and did not increase in the post-intervention period. There was no shift in median ICU length of stay or median MV duration in the postintervention period. CONCLUSIONS: A multidisciplinary QI initiative was able to increase the rate of morning extubations in a tertiary hospital MICU. The initiative demonstrated the value of a novel telemedicine Respiratory Therapy service to ensure adherence to best practices and achieve improvements in quality of care.
Earlier extubation in a tertiary hospital micu: A quality improvement initiative