2017Na(onalDNPConference•  Adverse Patient Outcomes: A Problem in Search

of a Solution •  Bill Howie, DNP, CRNA

•  R. Adams Cowley Shock Trauma Center •  La Salle Ballroom A/B

•  CE Value 1

•  15 Sept 2017 (0830-0930)

September 13-15, 2017 New Orleans (888) 259-8696

Tenth National Doctors of Nursing Practice Conference: New Orleans, LA

WhyaDNP?� Preparesnursesfornotonlyadvancedclinicalpractice,butforleadership,management,andpolicy.

� Providesnurseswithknowledgeandskillstoaddresstheneedsofincreasinglycomplexhealthcaresystems.

�  Increasesnumbersofeducatedproviders,faculty,andleaders.

� Moreeducationtypicallytranslatestobetterpatientoutcomes.

�  Source:AmericanNursesAssociation.FrequentlyaskedquestionsabouttheDoctorofNursingPractice.Availableat:http://www.nursingworld.org/DNPFAQ

NursingEduca(onMakesaDifference�  10%increaseinproportionofbaccalaureate-preparednursesonhospitalunitsassociatedwithloweringoddsofpatientmortalityby10.9%.

�  Cross-sectionalstudyof21HealthsystemConsortiumHospitalsfoundthosewithhighernumbersofBSNorhigherdegreesinnursinghadlowerratesofcongestiveheartfailuremortality,decubitusulcers,failuretorescue,postoperativeDVTs,pulmonaryembolism,andshorterlengthsofstay.Dataarecompellingthateducationmakesatremendousdifference!

�  Sources:Yakusheva,O.(2014).Economicevaluationofthe80%baccalaureatenurseworkforcerecommendation.MedicalCare.Availableat:http://journals.lww.com/lww-medicalcare/pages/default.aspx.

�  InstituteofMedicine.(2011).TheFutureofNursing:FocusonEducationhttp://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Brief-Education.aspx

IOMandRWJReport�  “Thewaysinwhichnurseswereeducatedduringthe20thcenturyare

nolongeradequatefordealingwiththerealitiesofhealthcareinthe21stcentury.Aspatientneedsandcareenvironmentshavebecomemorecomplex,nursesneedtoattainrequisitecompetenciestodeliverhigh-qualitycare…[including]leadership,healthpolicy,systemimprovement,researchandevidence-basedpractice,andteamworkandcollaboration,aswellascompetencyinspecificcontentareassuchascommunityandpublichealthandgeriatrics.”

�  “Nursesalsoarebeingcalledupontofillexpandingrolesandtomastertechnologicaltoolsandinformationmanagementsystemswhilecollaboratingandcoordinatingcareacrossteamsofhealthprofessionals...theIOMcommitteecallsfornursestoachievehigherlevelsofeducationandsuggeststhattheybeeducatedinnewwaysthatbetterpreparethemtomeettheneedsofthepopulation.”

�  Source:InstituteofMedicine&RobertWoodJohnsonFoundation.(2011).Thefutureofnursing:Focusoneducation.Availableat:http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Brief-Education.aspx.

Pa(entOutcomesareaConcern� Giventhenumberoferrorsinhospitals,itisliterallysafertoskydive!Fourstudiesencompassingmorethan4,200patientsdeterminedthatseriousadverseeventsoccurredinabout21%ofcasesandratesoflethaladverseeventshappenedabout1.4%ofthetime.Bywayofextrapolation,preventableerrorscontributetoabout210,000patientdeathsinhospitalseachyear.

Source:Allen,M.(2013).HowmanydiefrommedicalmistakesinU.S.hospitals?NationalPublicRadio.Availableat:http://

www.npr.org/blogs/health/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals.

Objec(ves�  Followingthispresentationtheparticipantwill:

�  Statecommonsourcesofadverseeventsinhealthcare.� Discusshowfacilityqualityimprovementdatacanbeusedtoaddresscommonadversepatientoutcomes/sentinelevents.

� Discusshowchecklistscanbeusedtoaffectidentifiedadversepatientevents.

� Discusswaystomakepatientsafetypartoftheorganization’smission.

Objec(ves� Describefactorsthatcommonlyleadtoextubationfailureinadultpatients(attheSTC).

� Discusshowanextubationchecklistcanpotentiallydecreasetheincidenceofextubationfailurepostoperatively.

�  Identifyevidencedbasedguidelinestoincludeinthepre-extubtionchecklist.

Whatislearnedfrommistakes?

}  Maryland Health Claims Arbitration }  National Practitioner Database }  Facility QI Committee }  State Boards of Nursing }  Facility Risk Management Department }  Joint Commission }  State Boards of Health

}  9,744 cases (1990-2010) }  Just over 6% died;33% had permanent

damage; 59% suffered temporary injury. }  Estimated that 4,082 mistakes occur in US

each year (wrong site/wrong procedure/ object left in patient).

}  American Hospital Association estimates 53 million surgeries occur annually in the US and the rate of these critical incidents are very rare.

Miller, K.P. (2013). The National Practitioner Data Bank: An annual update. J. Nurse Practitioners. 8(9), 576-580).

Miller K.P. (2013). The National Practitioner Data Bank: An annual update. J. of Nurse Practitioners. 8(9) 576-580).

�  A foreign object (sponge/towel/needle, etc.) estimated to be left in a patient 39 times/week and a wrong procedure or wrong body site is involved 20 times per week.

�  1990-2010, 9,744 paid malpractice claims for these “ never events” totaled $1.3 billion.

�  These numbers most likely underestimate the true occurrence.

�  Can anesthesia be named in one of their lawsuits? Mehtsun.W,T., et al. (2013). Surgical never events in the United States. Surgery,153, 465-472.

}  The Closed Claims Project dedicated to scientific studies of adverse anesthetic outcomes.

}  Studies malpractice claims against anesthesiologists.  The project has 10,000+ claims for events from 1970-2013. 

}  20-25 ASA member reviewers travel 50-60 days annually to review claim files; 21 insurance companies participate who insure more than 13,000 anesthesiologists.

CanaDNPCapstoneProjectPosi(velyImpactQualityofPa(entCare?� Whatfactorsdeterminethesuccessofimprovedpatientoutcomes?(patienteducation/providereducation/cultureofsafetythatstressesselfreportingof“near-miss”andactualpatientinjury).

� Howcanelectronicmedicalrecordsbeusedtofacilitateimprovedpatientsafety?

� Howcanelectronicmedicalrecordsbeusedtoimproveprovidercompliancewithevidence-basedbestpracticeguidelines?

TheKeytoSuccessfulReduc(onInAdversePa(entEventsistoPickProblemsthatOccurOOenEnoughtoMeasureandtoFix.

BillHowieDNP,CRNADNPConferenceSeptember2017

Applica(onoftheAgencyforHealthcareResearchandQuality(AHRQ)ModeltoExtuba(on

FailureinAdultTraumaPa(entsatShockTraumaCenter(STC)

1KnowledgeCrea.onand

Dis.lla.on

2DiffusionandDissemina.on

3Adop.on,

Implementa.onandIns.tu.onaliza.on

Process 1a.Crea(onofanewknowledgeonfactorsrelatedtoextuba(onfailureinadulttraumapa(ents.1b.Dis(lla(onofkeyknowledgeonextuba(oninadulttraumapa(ents

2a.Crea(onofdissemina(onpartnerships/knowledgetransferteamsatSTCQualityAssuranceCommiXee2b.Massdiffusionofkeyknowledgerelatedtoextuba(onfailuretoSTCanesthesiaproviders.2c.Targeteddissemina(on/persua(oninORandPACU.

3a.Developmentofextuba(oncriteria.3b.Adop(onandimplemen(onofstandardizedextuba(oncriteria.3c.Confirma(on,adap(onandinternalins(tu(onal-Iza(onofextuba(oncriteriaonpa(entrecord.3d.Externalrou(niza(onofextuba(oncriteriainalladulttraumapa(ents.

Knowledge/Dissemina(onSourcesActorsTargetAudience

Extuba(onGuidelinesQACommiXee,anesthesiaexpertsASA,AANAGuidelinesforExtuba(onAdultpost-oppa(entsrequiringextuba(onAnesthesiaproviders

QACommiXee,STCEduca(onalCommiXeeAHRQNa(onalPa(entSafetyFounda(onTheJointCommissionASA,AANAJournals,AnesthesiaConferencesandInservices,ANAProfessionalleadersaretheQACommiXee

Dissermina(onpartnershipswithothertraumacentersAnesthesiaandcri(calcareprovidersinOR,PACUIOM,AANA,MD.CostReviewCommission,Insurers

Ac(vi(es RecordreviewofSTCQualityAssuranceDataBaseandpa(entrecordsSynthesisofliteratureonextuba(onfailureConsensusofQACommiXeeandexpertanesthesiaprovidersforpriori(es

Publica(onsandconferencepresenta(onsrelevanttoanesthesiaprovidersInservices,workshops,andwebcaststosurroundingtraumacenters

Trainingonextuba(onCulturallysensi(veteachingSTCinservices,grandrounds,Intranetpos(ngofguidelinesComparecostsofusingnewguidelineswithcostsofextuba(onfailuresinthepastMeasuredecreaseinextub.failureEBPpolicyonextuba(on

HowImportantareChecklists?

UseofChecklistinHealthcare�  "Checklistscanbeagoodwayofmakinghealthcaresafer.There'snodoubtaboutthat.Theyworkbyimprovingrecall-promptingpeopletodoallthenecessarysteps-andbymakingcleartheminimumexpectations.Buttheyhavetobeusedwisely,"ProfessorPronovost.(2017)

�  Themistakemostcommonlymadeistoassumethatachecklist-atechnicalsolution-cansolveaculturalproblem.Manyprovidersresistusingchecklistsbecauseofhowtheyaresocialized."Andit'samistaketothinkthatyoucangetworkerstousechecklistsjustbyinsistingonit.”

http://catalyst.nejm.org/patient-centered-checklists-next-frontier/

Checklistareeverywhere

B52BomberandAnesthesiaMachine

HighReliabilityOrganiza(ons(HROs).� ChecklistshavebeenacornerstoneofsafetymanagementinHROsfornearlyacentury,andarebecomingincreasinglypopularinmedicine.

�  Acceptanceandcompliancearecrucialforchecklistimplementationinhealthcare.

� ExperiencesfromHROsmayprovidevaluableinputtochecklistimplementationinhealthcare.

�  ScandinavianJournalofTrauma,ResuscitationandEmergencyMedicine2011,19:53doi:10.1186/1757-7241-19-53

PugelAE.,etal.Useofthesurgicalsafetychecklisttoimprovecommunicationandreducecomplications(2015)JournalofInfectionandPublicHealth.8,p219-225.

DevelopmentandImplementationofEvidencedBasedGuidelinesfortheExtubationofAdultTraumaPatentsintheEarlyPostoperativePeriod.

William Howie University of Maryland Medical Center R Adams Cowley Shock Trauma Center The Johns Hopkins School of Nursing

ClinicalQuestion

SearchMethods

ForthistemplateweusetheArialfontfamilyatseveralrecommendedtextsizes.Youcanuseanytypefaceyoulikeandatanysizebuttrytostayclosetothesuggestedlimits.Figure4givesavisualreferenceofwhatdifferentfontsizeslooklikewhenprintedat100%andat200%.DuetoapagesizelimitationinPowerPointandunlessyourposterisgoingtobelessthan56”inlength,alltheworkdoneonthistemplateisathalfthesizeofthefinalposter.Forexample,ifyouchoosea21pointfontforthisposter,theactualprintedsizewillappearas42points.

MethodofGradingEvidence

.SynthesisofFindings

Factorspredictiveofextubationfailuregleanedfromqualityassuranceandmedico-legalsourcesservetoclearlydefinemanykeyfactorsthatcommonlyleadtofailedextubation.Residualneuromuscularblockade,excessivenarcotics,oversedation,failuretoemploystandardintubationguidelines,orinadequateuseofbasicextubationcriteriawerethemostlikelycausesoftheextubationfailure.Availableevidencesupportsadherencetostandardizedextubationguidelines(awake,followscommands,reversalofmusclerelaxant)andtakingappropriatestepstosecuretheairway(ASAairwayalgorithm)minimizesairwaymisadventures

SUMMARYOFRESEARCHFactorspredictiveofextubationfailure

Levelofconsciousness(doesnotfollowcommands)GCS<8(69%failurerate)Notabletoprotecttheairway(inadequatecough)Abundantsecretions(16timesmorelikelytofailextubation)Hemoglobinlevel<10(5timesmorelikelytofail)Doesnotfollowcommands,abundantsecretionsandineffectivecoughstrength(closeto100%fail)Advancingage(>60),higherASAclassification,lowalbumenlevels,emergencysurgery,abdominalsurgery,thoracicsurgery,morecomplicatedsurgery.Smokinghistory,COPDordebilitatingpulmonarydisease.Overresuscitationorunder-resuscitationofthesurgicalpatient

TranslationFramework

ApplicationoftheAgencyforHealthcareResearchandQuality(AHRQ)Modelto

ExtubationFailureinAdultTraumaPatientsatShock

TraumaCenter(STC)

RelevantStandardsandGuidelines

Importingtables,chartsandgraphsiseasierthanimportingphotos.ToimportchartsandgraphsfromExcel,Wordorotherapplications,gotoEDIT>COPY,copyyourchartandcomebacktoPowerPoint.GotoEDIT>PASTEandpastethechartontheposter.YoucanscaleyourchartsandtablesproportionallybyholdingdowntheShiftkeyanddragginginoroutoneofthecorners.

ProjectWorkBreakdownStructure

Theblueheadersareusedtoidentifyandseparatethemaintopicsofyourpresentation.Themostcommonlyusedheadersinposterpresentationsare:

Task1Collectretrospectivedataonfailedextubation,usingexistingtraumadatabase.Analyzedata.

Task2Meetingsanddiscussionofthedatawithkeyindividualsthatwillleadtothedevelopmentofevidencedbasedguidelines.Comparewithevidencefromliteratureanddeviseevidencedbasedsetofextubationguidelinesfortheadulttraumapatient

Task3Orientanesthesiaprovidersonhowtoimplementtheevidencedbasedextubationguidelinesintheformofstaffin-servicesandplacementofprintedguidelinesinpatientcareareas

Task4Encourageimplementationoftheguidelinesapartofdailypracticeforallanesthesiacareproviders

Task5Monitorfrequencyoffailedextubationforaperiodof3months.Reviseguidelines,asneeded.Incorporateguidelinesinpracticetodecidewhenanadultpatientshouldbeextubation.

Reassess

ProjectedProjectTimeline

References

NamenAM,ElyEW,TatterSB,etal.Predictorsofsuccessfulextubationinneurosurgicalpatients.AmJRespirCritCareMed.2001;163(3),658-664.KhamieesM,RajuP,DeGirolamoA,Amoatend-AdjepongY,ManthousCV.Predictorsofextubationoutcomeinpatientswhohavesuccessfullycompletedaspontaneousbreathingtrial.Chest.2001;1262-1270.SalamA,TilluckdharryL,Amoateng-AdjeppongY,ManathousCA.Neurologicstatus,cough,secretionsandextubationoutcomes.IntensiveCareMed.2004;30,1334-1339.LeePJ,MacLennanA,NaughtonNN,O’ReillyM.Ananalysisoffailedextubationsfromaqualityassurancedatabaseof152,000cases.JofClinAnesthesia.2003;15(8):571-581.ArozullahAM,DailyJ,HendersonWG,KhuriSF.Multifactorialriskindexforpredictingpostoperativerespiratoryfailureinmenaftermajornoncardiacsurgery.AnnalsofSurgery2000;232(2),242-253.JohnsonRG,ArozullahAM,NeuramayerL,etal.Multivariablepredictorsofpostoperativerespiratoryfailureaftergeneralandvascularsurgery:Resultsfromthepatientsafetyinsurgerystudy.JoftheAmericanCollegeofSurgeons.2007;204,1188-1198.VidottoMC,SogameLC,CalciolariCC,etal.Thepredictionofextubationsuccessofpostoperativeneurosurgicalpatientsusingfrequency-tidalvolumeratios.NeurocriticalCare.2008;9(1),83-89.RobriquetL,GeorgesH,LeroyO,etal.Predictorsofextubationfailureinpatientswithchronicobstructivepulmonarydisease.JofCritCare.2006;21(2),185-190.SeymourCW,MartinezA,ChristieJD,FuchsBD.Theoutcomeofextubationfailureinacommunityhospitalintensivecareunit:Acohortstudy.CritCare.2004;8(5),R322-327.

Activity Time Start Time Finish

Faculty approval of Comprehensive Plan 16 Mar 2009 08 May 2009

IRB Approval from UMMS and JHU 14 Feb 2009 23 May 2009 (estimated)

Collect/Analyze data 24 May 2009 23 Aug 2009

Develop guidelines 24 Aug 2009 24 Sept 2009

Staff in-services 25 Sept 2009 25 Oct 2009

Implement guidelines 26 Oct 2009 15 Jan 2010

Assess for changes in reintubation rate 16 Jan 2010 17 Feb 2010

Incorporate guidelines as standard practice standard

18 Feb 2010 Indefinitely

1TranslationalFrameworkFrameworkappearstobeappropriate.

KnowledgeCreationandDistillation

2DiffusionandDissemination

3Adoption,ImplementationandInstitutionalization

Process 1a.Creationofanewknowledgeonfactorsrelatedtoextubationfailureinadulttraumapatients.1b.Distillationofkeyknowledgeonextubationinadulttraumapatients

2a.Creationofdisseminationpartnerships/knowledgetransferteamsatSTCQualityAssuranceCommittee2b.MassdiffusionofkeyknowledgerelatedtoextubationfailuretoSTCanesthesiaproviders.2c.Targeteddissemination/persuationinORandPACU.

3a.Developmentofextubationcriteria.3b.implementionofstandardizedextubationcriteria.3c.Confirmation,adaptionandinternalinstitutional-Izationofextubationcriteriaonpatientrecord.3d.Externalroutinizationofextubationcriteriainalladulttraumapatients.

Knowledge/DisseminationSourcesActorsTargetAudience

ExtubationGuidelinesQACommittee,anesthesiaexpertsASA,AANAGuidelinesforExtubationAdultpost-oppatientsrequiringextubationAnesthesiaproviders

QACommittee,EducationalCommitteeAHRQNationalPatientSafetyFoundationTheJointCommissionASA,AANAJournals,AnesthesiaConferencesandInservices,

DisserminationpartnershipswithothertraumacentersAnesthesiaandcriticalcareprovidersinOR,PACUIOM,AANA,MD.CostReviewCommission,Insurers

Process RecordreviewofSTCQualityAssuranceDataBaseandpatientrecordsSynthesisofliteratureonextubationfailureConsensusofQACommitteeandexpertanesthesiaproviders

PublicationsandconferencepresentationsrelevanttoanesthesiaprovidersInservices,workshops,andwebcaststosurroundingtraumacenters

TrainingonextubationCulturallysensitiveteachingSTCInservices,grandrounds,IntranetpostingofguidelinesComparecostsofusingnewguidelineswithcostsofextubationfailuresinthepastMeasuredecreaseinextub.failureEBPpolicyonextubation

Further exploration is required to determine which patient risk factors play significant roles in patients who fail an elective extubation despite meeting standard extubation criteria. Because the process of reintubation and mechanical ventilation places patients at an increased risk for airway misadventures, prolonged hospitalization/ICU stay, ventilator acquired pneumonia, and higher levels of morbidity and mortality.Whatarethepredictorsofextubationfailureintheadulttraumapatientwhomeetstandardextubationcriteria?

TheliteraturesearchforthissystematicreviewwasperformedduringDecemberof2008usingPubmed,Medline,CINAL,CochraneDatabase,Googlescholar,andaselectivehandsearch.Approximately110articlesthatwerewritteninEnglishandcontainedthesearchterms:“re-intubation”,“failedextubation”,“extubationfailure”,“respiratoryfailure”,“postoperative”,“perioperative”,“trauma”,“post-surgical”,“multipletrauma”,“polytrauma”,“traumapatient”,“extubationcriteria”,“adult”,“anesthesia”,“complications”,and“adverseevents”..

Thearticleswerereviewedforrelevance,andatotalof13articlespublishedbetween1996and2008wereselectedforin-depthreview(Table1),including1randomizedcontroltrial(RCT),4prospectiverecordreviews,and8retrospectivereviews.Suchstudieshavegenerallybeensetting-specific(neurologicalICU,teachinghospital,pediatricintensivecareunit).

ClinicalAreaofConcern�  STCthededicatedacutecaretraumahospitalforMaryland

� Admitsapproximately8,500patients/year� Approx6,500operativecasesareperformedannually.� Approx5,000intubationsareconductedeachyear.� Approx30patientsre-intubatedfollowingextubationinthefirst24hourspost-op

�  Failedextubationthemostfrequentlyreportedsentineleventsince2000,occurringatarateof2to3casespermonth.

ClinicalAreaofConcern�  Extubationfailurecanproduceoutcomes,includingcyanosis,hypoxia,tachycardia,hypertension,negative-pressurepulmonaryedema,acutebronchospasm,agitationandinaworstcasescenario,cardiopulmonaryarrest(Hagberg,Georgi,&Krier,2008;Lobato,2008).

� Literaturenotesasignificantlyincreasedrisktothesepatientsintermsofprolongedhospitalization/ICUstay,ventilatoracquiredpneumonia,andhigherlevelsofmorbidityandmortality(Epstein,1997,2001,2002,2004).

Systema(cReviewofEvidence� AccordingtothefifthannualPatientSafetyinAmericanHospitalsStudy,medicallyrelatederrorscostupwardsof$8.8billionandresultedin238,337potentiallypreventabledeathsfrom2004through2006.

� Of1.1millionpatientssafelyincidentsat249hospitals,post-operativerespiratoryfailurewasamongthemostfrequentlycitedevents,occurringatarateofoneoutofevery16patient-safetyincidents(HealthGrades2008,p.2).

Systema(cReviewoftheEvidence�  Anestheticrecordsbetween1994to1999wereexamined(152,939cases).191casesoffailedextubationwerereported.

�  Prolongedneuromuscularblockadeoccurredin11cases(16/191,8.4%).Excessivenarcoticusewasreportedinninecases.

�  Respiratoryinsufficiency,respiratoryobstruction,andlaryngospasm/bronchospasmwereimplicatedin58.6%offailedextubations.Some71.6%casesofrespiratoryinsufficiencyoccurredinthePACU.

�  68.1%casesofrespiratoryobstruction/laryngospasm/bronchospasmoccurredintheoperatingroom.

WeaknessesoftheEvidence�  Dataderivedfromaself-reportingsystem.Theremustbe100%compliancetostrengthenconfidenceintheconclusionsthataredrawn.

�  Numberoffailedextubationswaslikelyunderestimated.�  Lackofdocumentationofneuromuscularblockade,intheformofatrainoffourscaleontheanestheticrecord.Theresearchersstatedthatitwasnotaproviderrequirementintermsofapolicy.

� Wouldhavebeenhelpfultoknow%ofpatientswhorequiredreintubationandmetstandardanesthesiaendotrachealweaningcriteria.Thiswasnotincludedintheirreview.

ReviewofEvidence�  ValueofChecklistUtilization�  Checklistrepresentsalistofessentialactionsorperformancecriteriaarrangedinasystematicmanner(Biddle,2010).

�  Encouragesusertorecordthepresenceorabsenceoftheitemslistedtoensuretheyareallconsideredorcompletedeachtimethechecklistisused(Hales,Pronovost,2006).

�  Aclinicallysoundchecklistclearlyhighlightsonlyessentialcriteriathatshouldbeconsideredinaparticulararea(Hales,Terblanche,Fowler,Sibbald,2007).

ReviewofEvidence� ValueofChecklistUtilization� TheuseofachecklistisaformofHumanFactorsEngineeringthatcancompensateforhumancognitionfailuresinavarietyofsettings(Leape,Berwick,Bates,2002).

�  Importantgoalofanychecklististolimiterrorsofomissionbyclearlydefiningexpectedproviderbehaviorsinavarietyofclinicalpatientcaresettings.

� Particularlytrueduringstressfulconditionswhenvigilance,memoryorclinicalreasoningmaybeadverselyeffected(Biddle,2010).

ShockTraumaDataCollec(on� Recordsof195patientsreviewedthatrequiredreintubationduring2000and2009.

�  171recordsmetthebasiccriteriaofrequiringreintubationfollowingelectiveextubationwithin6hours.

� DataobtainedfromSTCQArecords,patientrecords,andDrHyder’sselfproclaimedconfessionals.

� QAdatafromthesentineleventsselfreportingsystemutilizedatSTC.

Results� Thetimefromextubationuntilthepatientwasreintubatedwas:�  54%ofthepatientswithin5minutes.�  65%ofthepatientswithin10minutes.�  67%ofthepatientswithin15minutes.�  69%ofthepatientswithin20minutes.�  78%ofthepatientswithin30minutes.�  94%ofthepatientswithin120minutes.

Results� Thepatientswerereintubated:

�  34%ofthetimeintheOR.�  64%ofthetimeinthePACU.�  1%ofthetimeintheTRU.�  1%ofthetimeintheICU.

CauseofExtuba(onFailure:2000-2009�  CauseofFailure �  Frequency Percent Valid Percent �  Valid Laryngospasm 28 16.4 16.9 �  Airway Obstruction 27 15.8 16.3 �  Retained Secretions 10 5.8 6.0 �  Agitation 13 7.6 7.8 �  Respiratory Failure 57 33.3 34.3 �  Decreased LOC 8 4.7 4.8 �  Stridor 12 7.0 7.2 �  Apnea 4 2.3 2.4 �  Aspiration 4 2.3 2.4 �  Agitation DTs 3 1.8 1.8 �  Total 166 97.1 100.0 �  Missing System 5 2.9 �  Total 171 100.0

CauseofExtuba(onFailure:2000-2011�  Frequency Percent ValidPercent CumulativePercent

�  Valid Laryngospasm 35 17.4 17.9 17.9 �  AirwayObstruction 31 15.4 15.8 33.7 �  RetainedSecretions 10 5.0 5.1 38.8 �  Agitation 14 7.0 7.1 45.9 �  RespiratoryFailure 72 35.8 36.7 82.7 �  DecreasedLOC 10 5.0 5.1 87.8 �  Stridor 12 6.0 6.1 93.9 �  Apnea 4 2.0 2.0 95.9 �  Aspiration 4 2.0 2.0 98.0 �  AgitationDTs 3 1.5 1.5 99.5 �  Broncospasm 1 .5 .5 100.0 �  Total 196 97.5 100.0

�  Missing System 5 2.5 �  Total 201 100.0

CausesofFailurepost-extuba(on

Results:Trainof4Recorded

Results:FollowsCommands�  56%(96patients)Yes�  40%(68patients)No�  4%(7patients)Notdocumented

FollowsProvidersCommands

MuscleRelaxantReversed

Implica(onsandPlans�  Isitpossibletoreducethenumberoffailedextubationsinthishospital?

� Willincreasedconsiderationofbasicextubationcriterialeadtoreductioninpatientswhofailextubation?

� Aretherefactorsspecifictothetraumapatient/softtissuepatient/re-admitpatientthatcontributetoextubationfailure?

Plan�  ImplementationofPatientExtubationCheckListthatconsiders:�  Isthepatientawake/Cooperative/FollowingCommands?

�  Isthepatientagitated?�  Isthepatienthemodynamicallystable(BP/Temp)?� Didthepatienthaveatrainof4recorded/wasthepatientsmusclerelaxantreversed?

� Wasthepatientadifficultairway?� Wasaleaktestdoneforpatientswithpotentialstridor?

Plan�  Implementationoftheseguidelinesforabout12weeks.

� ContinuetotrackextubationfailurethroughongoingselfreportedQAsystem.

� Willthisplanreducethenumberofextubationfailures?

�  Shouldachecklistsimilartothisbemadeapartoftheanesthesiaflowsheet?

Systema(cReviewofEvidence�  FollowingIRBapproval(STCandJohnsHopkinsUniversity).areviewoffailedextubationsthatoccurredbetweenJanuary2000andOctober2009wasconducted.Atotalof240patientsfailedextubation.173failedextubationwithintheearlypostoperativeperiod(86.5%).

�  53%ofthetime,theanesthesiaproviderdidnotdocumentadherencetoevidence-based,nationallyrecognizedextubationcriteria.

Descrip(onoftheproject�  FindingsofQIchartreviewsharedwithallprovidersintheDepartmentofAnesthesiaatSTC.

�  Informationontheretrospectiverecordfindingspresentedduringtwoin-servicesessionstotheanesthesiadepartmentandthepost-anesthesiacareunit.

� ProviderinputandsuggestionsregardingitemsthatshouldbeincorporatedintothechecklistandfinalEBPTraumaExtubationChecklistwasobtained(Figure1).

Pa(entExtuba(onChecklist(Figure1)Criteria

(1)  Awake Yes No

(2)FollowsCommands Yes No

(3) Agitated Yes No

(4) Cooperative Yes No

(5)MuscleRelaxantReversed

Yes No/NA

(6) TemperatureWNL(97-99F)

Yes No

(7)HemodynamicallyStable

Yes No

(8)DifficultAirway Yes No

(9)ETTCuffLeak Yes No/NA

Comments:

Descrip(onoftheproject/interven(on�  Checklistwasimplementedfor12weeks(October152009throughJanuary152010).

�  Throughouttheinterventionphase,stafffrombothunitswerekeptinformed(viaregularemailupdatesandduringbedsideconsultations)regardingchecklistutilizationandresultsofthedatacollection.

�  Severalseniorstaffmembersservedasprojectchampionsandregularlyencouragedproviderstousethechecklist.

�  Allprovidersencouragedtoprovideeitherwrittenorverbalfeedbackpertainingtoperceivedconcernsorsuggestionstoimprovethechecklist.

Results� Totalof946patientsunderwentsurgeryatSTC.� Totalof622patientsextubatedeitherintheORorshortlyuponarrivaltothePACU.

� Ofthese622patients,atotalof488hadcompletedextubationchecklistsontheiranesthesiarecord,achecklistcompletionrateof77%.

Results:SuccessfullyExtubated� Comprisedprimarilyofmales(n=435,70.4%),withameanageof43.8years(range10-100years).

� Mostfrequentsurgicalprocedureswereorthopedicprocedures(n=259,41.5%),softtissueinfections(n=134,21.7%),andgeneralsurgeries(n=99,15.9%).

�  Surgicaltimeswereslightlylessthantwohoursonaverage(112.5minutes),andtheseindividualswereclosertoidealbodymassindex,withanaverageBMIof28.5.

Results� Onlyfourof622patientsfailedextubationduringutilizationofthechecklist(0.6%)

� Allthesepatientsweremales,andaveraged56yearsofage(range47-69).

� Mosthadsurgeryforasofttissueinfection(n=3,75%).Theremainingpatientwhofailedextubationwasareadmission,andhadageneralabdominalsurgery.

�  Thefailedextubationgroupsurgeriesaveragedslightlyoveronehour(76minutes).ThisgrouphadanaverageBMIof36.5(range27.9-50),placingallofthemintotheoverweightorobesecategories.

Results:FailedExtuba(on�  1:4patientsdocumentedtohavemetextubationcriteria.Hefailedextubationduetobrochospasm.

� Other3patientswerereintubatedduetorespiratoryfailure.

� Trainof4wasnotedononlyoneofthecases,despiteuseofamusclerelaxant.

� Only2ofthe4patientsweregivenareversalforthemusclerelaxant.

� Twoofthe4patientswerecaredforbythesameprovider.

Results� Priortoutilizationofthechecklist,approximately2-3patients/monthexperiencedanextubationfailure.

�  Followingutilizationoftheextubationchecklist,therewerefourextubationfailuresduringathreemonthperiod(1.25patients/month).

� Extubationcriteriawasdocumented92.5%ofthetimeontheanesthesiaflowsheetsofallpatientsextubatedduringtheinterventionphase.

Results�  AFisher'sExactTestconfirmedthatextubationfailureoccurredlessfrequentlywhentheextubationcriteriaweredocumentedthanwouldbeexpectedbychance(p=.001,Fisher'sexacttest).

Recommenda(ons� Resultsofthisprojectindicatethataextubationchecklistmaypositivelyinfluencebothproviderdocumentationofevidence-basedcriteriaforextubationaswellasreducetheoccurrenceofpreventableextubationfailures.

� Giventherelativelyshortdurationofthisevidence-basedproject,wasrecommendedthatthestudybereplicatedforalongerperiodoftime.

Recommenda(ons�  Impactofthechecklistwouldbeimprovedbyincreasingthesamplesize.Thus,alongerperiodofimplementationsuggested.

� Appropriateuseofanextubationchecklistmayhelpdetermineadditionalfactorspredictiveofextubationfailureintheadulttraumapopulation.

� Toimprovesustainability,recommendedthatregularstaffin-servicesbeconductedonproperuseofthechecklist.Thesein-serviceprogramscouldeitherbe"live"orcomputer-basedtutorials.

Dissemina(onandTransla(on�  FollowingthreemeetingswiththesystemadministratorfortheUMMCanesthesiadepartment,checklistwasincludedwithinthenewlyacquiredAnesthesiaInformationManagementSystem.

� TheAIMSsystemwent“live”inOctoberof2010.� TherateoffailedextubationshasremainedconsistentlylowerfollowingimplementationofchecklistandtheAIMSsystemasofJanuary2014.

CanaDNPCapstoneProjectposi(velyimpactlongtermqualityofpa(entcare?� Whatfactorsarenecessarytoprovethistobetrue?�  Shouldthepatientcareimprovementprojectbeintegratedintotheorganizationsdailyoperations?(placementoftheextubationchecklistintotheElectronicMedicalRecord)

� Wouldadoptionofanorganizationalsafetyculturehelptoreduceadversepatientoutcomes?(extubationfailure/catheteracquiredlineinfections/medicationerrors/patientfalls/hospitalre-admissions/etc.)

Resultsofdatacollec(on2010through2017(n=24,329)� PreventableExtubationfailureprechecklist2.5patients/month.

� Ratedroppedto1.2patients/monthpostchecklistuseto0.9patients/monthatendofthe7yearfollow-up.

� Determined that cases who failed had a mean checklist number that was less than their non-failure counterparts (mean=1.7; SD=1.9 versus mean=3.2; SD=1.8, p=0.0001).

2010to2017Results� Checklistnotusedfor5817oftheextubations(23.9%)� ClearlyanareaforimprovementthathasbeenaddressedwithnotesfromtheQIcommitteetoindividualproviders.(preventableorpotentiallypreventableextubationfailures)

� PeriodicpresentationofcasesatDepartmentalMorbidityandMortalityRounds.

�  Shouldamin-serviceontheuseofthischecklistberequiredofallnewhiresandinyearlyHospitalMandatoryTraining?

FailedExtuba(ons2010-2017outof23,329pa(ents

Sourcesofpoten(alqualityimprovementprojectstheJointCommission

MostChecklistsCanbeModifiedtoAddressPar(cularNeeds