Readiness Assessment for Extubation Planning in the Intensive Care Unit: A Quality Improvement Initiative

2021 ◽  
Vol 41 (3) ◽  
pp. 42-48
Author(s):  
Jace D. Johnny
Keyword(s):  
High Risk ◽  
Failure Rate ◽  
Noninvasive Ventilation ◽  
Extubation Failure ◽  
High Flow ◽  
Nasal Cannula ◽  
High Flow Nasal Cannula ◽  
Prophylactic Measure ◽  
High Risk Patients ◽  
Risk Patients

Background Extubation failure is the reintubation of patients meeting criteria for weaning from mechanical ventilation. Extubation failure is correlated with mortality, prolonged mechanical ventilation, and longer hospital stays. Noninvasive ventilation or high-flow nasal cannula oxygen therapy after extubation is recommended to prevent extubation failure in high-risk patients. Local Problem The extubation failure rate is unknown. Prophylactic measures (noninvasive ventilation or high-flow nasal cannula) after extubation are not commonly used and vary among clinicians. The objective was to assess extubation planning readiness by determining extubation failure rate, identifying high-risk patients, and determining prophylactic measure compliance. Methods A quality improvement initiative included an evidence-based extubation failure risk assessment that identified high-risk patients and determined prophylactic measure compliance. A 2-year retrospective medical record review was used to determine baseline patient characteristics and extubation failure rate. Results Extubation failure rate within the retrospective cohort was 13 of 146 patients (8.9%). Extubation failure did not correlate with previously identified risk factors; however, 150 identified patients were excluded from analysis. During risk assessment integration, the extubation failure rate was 3 of 37 patients (8.1%) despite identifying 24 high-risk patients (65%). Few high-risk patients received prophylactic measures (noninvasive ventilation, 17%; high-flow nasal cannula, 12%). Conclusions Extubation failure should be routinely measured because of its effects on patient outcomes. This project reveals the multifactorial nature of extubation failure. Further research is needed to assess patients’ risk and account for acute conditions. This project used best practice guidelines for routine patient care and added transparency to a previously unmeasured event.

Prognostic factors for extubation failure in high risk patients using high-flow nasal cannula

2019 ◽  
Author(s):  
Paulina Ezcurra ◽  
María Sofia Venuti ◽  
Emiliano Gogniat ◽  
Marcela Ducrey ◽  
Jose Dianti ◽  
...  
Keyword(s):  
Prognostic Factors ◽  
High Risk ◽  
Extubation Failure ◽  
High Flow ◽  
Nasal Cannula ◽  
High Flow Nasal Cannula ◽  
High Risk Patients ◽  
Risk Patients

scholarly journals Effect of Postextubation High-Flow Nasal Cannula vs Noninvasive Ventilation on Reintubation and Postextubation Respiratory Failure in High-Risk Patients

JAMA ◽  
2016 ◽  
Vol 316 (15) ◽  
pp. 1565 ◽  
Author(s):  
Gonzalo Hernández ◽  
Concepción Vaquero ◽  
Laura Colinas ◽  
Rafael Cuena ◽  
Paloma González ◽  
...  
Keyword(s):  
Respiratory Failure ◽  
High Risk ◽  
Noninvasive Ventilation ◽  
High Flow ◽  
Nasal Cannula ◽  
High Flow Nasal Cannula ◽  
High Risk Patients ◽  
Risk Patients

scholarly journals 3081 Reducing Reintubation Risk in High-Risk Cardiac Surgery Patients with High Flow Nasal Cannula

2019 ◽  
Vol 3 (s1) ◽  
pp. 29-29
Author(s):  
Robert Edward Freundlich
Keyword(s):  
Risk Factors ◽  
Cardiac Surgery ◽  
High Risk ◽  
Length Of Stay ◽  
Cardiac Surgical Procedures ◽  
High Flow ◽  
High Flow Nasal Cannula ◽  
High Risk Patients ◽  
Risk Patients ◽  
Using Data

OBJECTIVES/SPECIFIC AIMS: More than half a million adult patients nationally undergo cardiac surgery each year. Reintubation following cardiac surgery is common and associated with higher short- and long-term mortality, increased cost, and longer lengths of stay. The reintubation incidence is estimated at 5-10%. Patients undergoing cardiac surgery are increasing in age and comorbidity burden, and receive increasingly complex cardiac surgical procedures, complicating decision making around when to extubate postoperative patients. Compounding this complexity are financial pressures to maintain high throughput and maximize ICU bed availability. Providers are often compelled to extubate high-risk patients earlier, despite the potential for an increased risk of reintubation. Understanding the risk factors for reintubation after cardiac surgery and identifying effective interventions to reduce these reintubations is of critical importance to optimize patient outcomes. High-flow nasal cannula (HFNC) provides up to 60 liters per minute of 100% oxygen, dead space washout, and humidification to improve secretion clearance, and has shown some benefits in improving hypoxia and reducing reintubation in select populations. However, its benefit in high-risk patients undergoing cardiac surgical procedures is not known and therefore clinicians may still be reluctant to extubate these patients early and introduce HFNC, despite the known risks of prolonged intubation. To address this important issue, we aim to develop and validate a model to predict postoperative reintubation after cardiac surgery using data readily available from the electronic health record (EHR) and use this data to complete a pilot randomized controlled trial (RCT) of post-extubation HFNC to prevent reintubation in cardiac surgery patients identified as at high risk for reintubation. METHODS/STUDY POPULATION: Based on retrospective data demonstrating a 4.7% reintubation incidence within 48 hours in our CVICU, we estimate that there will be 340 reintubations available for analysis of the risk factors for reintubation to develop our predictive model from November 2, 2017 (our EHR go-live). We require 15 events per predictive variable to avoid overfitting the model, giving us at least 22 variables for analysis and inclusion in the model. Model validation and calibration will be performed using a bootstrapped validation cohort. Next, we will prospectively study 120 patients with a greater than 10% predicted risk of reintubation (double the baseline risk of the overall population) and randomly assign them to either HFNC or usual care, to test the hypothesis that HFNC decreases the rate of reintubation in high-risk patients. RESULTS/ANTICIPATED RESULTS: In addition to developing a predictive model, refining it, and validating its ability to predict the primary outcome of reintubation within 48 hours, I will further assess whether HFNC reduces total duration of mechanical ventilation, hospital length of stay, and ICU length of stay in this high-risk population. I will use these data to establish the feasibility of EHR-integrated predictive modeling and randomization, as well as to guide a future multicenter clinical trial that will pragmatically leverage the EHR for patient selection, enrollment, randomization, and data collection. DISCUSSION/SIGNIFICANCE OF IMPACT: Assuming HFNC decreases reintubation rates by 50%, at a 1:1 ratio of cases to controls, we will require 435 patients in each group (970 total), to have an 80% power and alpha of 0.05 to detect a difference. As this will require a multicenter study, we will instead focus on using data from this pilot study to: 1) refine our sample size estimates. 2) demonstrate the feasibility of our novel EHR-integrated pragmatic trial design. 3) identify and screen collaborators at other institutions, including obtaining important regulatory and legal approval. 4) establish a data safety monitoring board for the trial. 5) refine the data collection infrastructure, leveraging commercially available resources in one of the largest enterprise EHR systems (Epic) and associated resource-sharing products, such as Epic’s App Orchard.

scholarly journals Noninvasive ventilation versus conventional oxygen therapy after extubation failure in high-risk patients in an intensive care unit: a pragmatic clinical trial

2021 ◽  
Vol 33 (3) ◽  
Author(s):  
Alberto Belenguer-Muncharaz ◽  
Maria-Lidón Mateu-Campos ◽  
Bárbara Vidal-Tegedor ◽  
María- Desamparados Ferrándiz-Sellés ◽  
Maria-Luisa Micó-Gómez ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
High Risk ◽  
Noninvasive Ventilation ◽  
Oxygen Therapy ◽  
Extubation Failure ◽  
Pragmatic Clinical Trial ◽  
High Risk Patients ◽  
Risk Patients

A comparison between high‐flow nasal cannula and noninvasive ventilation in the management of infants and young children with acute bronchiolitis in the PICU

2020 ◽  
Vol 55 (2) ◽  
pp. 455-461 ◽  
Author(s):  
Basel Habra ◽  
Ibrahim A. Janahi ◽  
Hajer Dauleh ◽  
Prem Chandra ◽  
Ahmed Veten
Keyword(s):  
Young Children ◽  
Noninvasive Ventilation ◽  
High Flow ◽  
Nasal Cannula ◽  
Acute Bronchiolitis ◽  
High Flow Nasal Cannula ◽  
Infants And Young Children

scholarly journals Effect of Postextubation High-Flow Nasal Cannula vs Conventional Oxygen Therapy on Reintubation in Low-Risk Patients

JAMA ◽  
2016 ◽  
Vol 315 (13) ◽  
pp. 1354 ◽  
Author(s):  
Gonzalo Hernández ◽  
Concepción Vaquero ◽  
Paloma González ◽  
Carles Subira ◽  
Fernando Frutos-Vivar ◽  
...  
Keyword(s):  
Oxygen Therapy ◽  
High Flow ◽  
Nasal Cannula ◽  
Low Risk ◽  
High Flow Nasal Cannula ◽  
Risk Patients
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