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Advancing extubation time for cardiac surgery patients using lean work design.

Publication ,  Journal Article
Gutsche, JT; Erickson, L; Ghadimi, K; Augoustides, JG; Dimartino, J; Szeto, WY; Ochroch, EA
Published in: J Cardiothorac Vasc Anesth
December 2014

BACKGROUND: Early extubation in select cardiac surgery patients reduces tracheal intubation times, intensive care unit length of stay, and hospital length of stay. While there is good evidence in the literature to support early extubation, there is very little published research that describes how to study and redesign processes of care to increase early extubation rates. OBJECTIVE: To improve rates of early extubation by redesigning patient care processes using Lean principles to remove barriers to desired care and facilitate early extubation with guideline management. DESIGN: Retrospective data analysis. SETTING: Sixteen-bed intensive care unit in a mid-sized, academic community hospital. PATIENTS: Four hundred four patients undergoing coronary artery bypass graft surgery, aortic valve replacement, or mitral valve replacement/repair. INTERVENTION: The process of care for cardiac surgery patients, beginning with the immediate preoperative period and ending with extubation in the postoperative period, was analyzed using Lean methodologies. A value stream analysis was performed to identify waste in the process, and root causes for the largest sources of waste were identified. Hypothermia on admission to the intensive care unit, prolonged weaning using arterial blood gas results, hypertension management with pain medications and sedation medications, and delays in obtaining equipment were the primary reasons early extubation was delayed. Process redesign using Lean work design principles was implemented to eliminate these issues. MEASUREMENTS: The rate of patients being extubated in fewer than 6 hours and length of intubation. RESULTS: One hundred ninety-five pre-intervention subjects were compared with 171 post-intervention subjects. The pre- and post- groups did not differ in demographic predictors (Table 1). The intervention predicted extubation in<6 hours (pre-intervention 27% versus post-intervention 50%, p = 0.0001). Age, renal failure, and gender also predicted whether intubation occurred within 6 hours. The median length of intubation was lower post-intervention (pre-intervention 9.7 v post-intervention 6.1 hours, p = 0.0019) LIMITATIONS: The effect of this nonrandomized intervention could be due to other factors associated with a different care epoch. CONCLUSIONS: The closely planned, coordinated, and integrated care paradigm dramatically increased the likelihood of extubation within 6 hours of arrival in the SICU.

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Published In

J Cardiothorac Vasc Anesth

DOI

EISSN

1532-8422

Publication Date

December 2014

Volume

28

Issue

6

Start / End Page

1490 / 1496

Location

United States

Related Subject Headings

  • Time Factors
  • Retrospective Studies
  • Practice Guidelines as Topic
  • Postoperative Period
  • Middle Aged
  • Male
  • Length of Stay
  • Humans
  • Female
  • Cardiac Surgical Procedures
 

Citation

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Gutsche, J. T., Erickson, L., Ghadimi, K., Augoustides, J. G., Dimartino, J., Szeto, W. Y., & Ochroch, E. A. (2014). Advancing extubation time for cardiac surgery patients using lean work design. J Cardiothorac Vasc Anesth, 28(6), 1490–1496. https://doi.org/10.1053/j.jvca.2014.05.024
Gutsche, Jacob T., Lee Erickson, Kamrouz Ghadimi, John G. Augoustides, Joseph Dimartino, Wilson Y. Szeto, and E Andrew Ochroch. “Advancing extubation time for cardiac surgery patients using lean work design.J Cardiothorac Vasc Anesth 28, no. 6 (December 2014): 1490–96. https://doi.org/10.1053/j.jvca.2014.05.024.
Gutsche JT, Erickson L, Ghadimi K, Augoustides JG, Dimartino J, Szeto WY, et al. Advancing extubation time for cardiac surgery patients using lean work design. J Cardiothorac Vasc Anesth. 2014 Dec;28(6):1490–6.
Gutsche, Jacob T., et al. “Advancing extubation time for cardiac surgery patients using lean work design.J Cardiothorac Vasc Anesth, vol. 28, no. 6, Dec. 2014, pp. 1490–96. Pubmed, doi:10.1053/j.jvca.2014.05.024.
Gutsche JT, Erickson L, Ghadimi K, Augoustides JG, Dimartino J, Szeto WY, Ochroch EA. Advancing extubation time for cardiac surgery patients using lean work design. J Cardiothorac Vasc Anesth. 2014 Dec;28(6):1490–1496.
Journal cover image

Published In

J Cardiothorac Vasc Anesth

DOI

EISSN

1532-8422

Publication Date

December 2014

Volume

28

Issue

6

Start / End Page

1490 / 1496

Location

United States

Related Subject Headings

  • Time Factors
  • Retrospective Studies
  • Practice Guidelines as Topic
  • Postoperative Period
  • Middle Aged
  • Male
  • Length of Stay
  • Humans
  • Female
  • Cardiac Surgical Procedures