Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol.

BACKGROUND: Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient's baseline physiological condition, workflow processes, and provider practice patterns. LOCAL PROBLEM: Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. METHODS: This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. RESULTS: In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. CONCLUSIONS: The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

Suitability of capillary blood glucose analysis in patients receiving vasopressors.

BACKGROUND: Glycemic control in critically ill patients decreases infection and mortality. Patients receiving vasopressors have altered peripheral perfusion, which may affect accuracy of capillary blood glucose values measured with point-of-care devices. OBJECTIVES: To compare capillary and arterial glucose values measured via point-of-care testing (POCT) with arterial glucose values measured via clinical chemistry laboratory testing (CCLT) in patients after cardiothoracic surgery. To determine if vasopressors or diminished peripheral perfusion influence the accuracy of POCT values. METHODS: In a prospective, convenience sample of 50 adult postoperative cardiothoracic patients receiving insulin and vasopressors, 162 samples were obtained simultaneously from capillary and arterial sites during insulin infusion and tested via both POCT and CCLT. Clarke error grid analysis and ISO 15197 were used to analyze level of agreement. Two-way analysis of variance was used to analyze differences in glucose values with respect to vasopressor use and peripheral perfusion. RESULTS: An unacceptable level of agreement was found between the capillary POCT results and arterial CCLT results (only 88.3% of values fell in zone A, or within the ISO 15197 tolerance bands). Arterial POCT results showed acceptable (94.4%) agreement with CCLT results. Vasopressor use had a significant effect on the accuracy of arterial blood glucose values (F=15.01; P<.001). CONCLUSIONS: Even when the more accurate POCT with arterial blood is used, blood glucose values are significantly less accurate in patients receiving more than 2 vasopressors than in patients receiving fewer vasopressors. CCLT may be safer for titrating insulin doses in these patients.