Abstract
Background: Many patients who are mechanically ventilated are often extubated long after being clinically ready. Extended and unnecessary mechanical ventilation time can lead to several negative outcomes, such as increased risk of infection, ventilator-induced lung injury (VILI), ventilator-associated events (VAE) and increased length of stay (LOS). At our medical center, patients’ extubations were found to be delayed (after meeting criteria) for several reasons, including resident physician hesitancy, lack of attending physician presence, or proximity to end of shift. Our goal was to define and implement a protocol with a set of objective criteria for weaning and extubation. Using this protocol, the respiratory therapist (RT) would extubate the patient without a physician evaluation – eliminating delay and shortening course of mechanical ventilation without any unplanned reintubations.
Methods: Every evening during rounds, weaning and extubation evaluation for every ventilated patient would be discussed between the RT and resident provider. If weaning readiness criteria was met, a daily 1-h weaning trial would be performed between the hours of 04:00 am – 06:00 am. If a successful trial was completed, the RT would perform pulmonary mechanics and Rapid Shallow Breathing Index (RSBI) to assess extubation readiness (per protocol). If the patient met extubation criteria, they would be extubated by the RT. Success was defined as remaining ventilator free for 72 h post-extubation.
Results: There were a total of 34 patients during the evaluation period who met criteria for weaning and completed a successful 1 hour weaning trial. Of these, 12 (35.3%) were successfully extubated by an RT following the protocol. Poor neurological status, provider declined, planned procedures, and other (12, 5, 2, 4 respectively), were given as reasons for not extubating the other 22 patients. None of the RT driven protocol extubations required reintubation within the 72-h window.
Conclusions: Implementing a respiratory therapy driven weaning and extubation protocol can help successfully facilitate and expedite extubation by RTs. With clearly defined criteria and a care plan in place, the RT can successfully evaluate, assess, and perform extubation without direct physician guidance.
Footnotes
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