Extubation Readiness PIN presentation

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Evidence-Based Practice presentation presented at the Pacific Institute for Nursing (PIN) conference

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  • Extubation Readiness PIN presentation

    1. 1. Extubation Readiness in thePICUCreating a GuidelineKolea Chong RN, BSN, CCRNSusan Bankhead, MSN, CCRN, CNML
    2. 2. No Financial Disclosures toNote2
    3. 3. Objectives• Decrease failed extubations• Develop assessment tool for extubationreadiness for PICU patients with non-chroniclung/musculoskeletal conditions• Increase nursing and RT comfort/satisfactionand collaboration• Standardize multi-disciplinary team approach toextubation• Develop a culture of evidence based practice
    4. 4. Our Beginnings• 2010– EBP workshop (Hawaii State Center for Nursing)• Introduction to the Iowa Model of EBP– PICO development– Based on Triggers– To decrease the need for reintubation andimprove staff collaboration in the extubationprocess for intubated PICU patients with non-chronic lung conditions by implementing aweaning readiness assessment score/toolwhich includes acceptable ventilator settings,sedation level and ability to protect airway priorto extubation4
    5. 5. 5
    6. 6. Triggers• 4 failed extubations in past 12 month prior to project• Traumatic physically and psychologically to patients andparents• Lack of agreement/collaboration among caregivers aboutwhen a patient is ready for extubation• No standardized approach or criteria for extubation• Decisions not necessarily based on evidence6
    7. 7. Team Formation• Multidisciplinary team approach• Physician Champion• Nursing• Respiratory• Pharmacy• Management7
    8. 8. Is Therea SufficientResearchBase?Assemble Relevant Research & Related LiteratureCritique & Synthesize Research for Use in PracticePilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-BasedPractice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice GuidelineBase Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. TheoryConductResearchYes No= a decision PointThe Iowa Model ofEvidence Based Practice to Promote QualityCare
    9. 9. Literature?• Pediatric literature limited– RTC not necessarily done for children– Adult studies translated to pediatric care• Fit to the settings• Levels of Evidence– One guideline non pediatric– 2 extubation readiness tools used by other hospitalPICU– 7 articles Pediatric based• 1 level II• 2 level VI• 4 level VII9
    10. 10. Nursing/RT Staff Survey• 66% of staff indicated varied practice forextubation• 33% of staff indicated multidisciplinarycollaboration during extubation process• 83% of staff indicated an extubationreadiness tool would be helpful10
    11. 11. Our Tool11
    12. 12. 12
    13. 13. Paper Trial of ExtubationProtocol• >1 year of trial• Multiple extubations delayed due tocriteria not met• During Trial period - 0 failed extubationswhen protocol followed13
    14. 14. Is ChangeAppropriate forAdoption inPractice?Continue to EvaluateQuality of Care andNew KnowledgeNo YesInstitute the Change in PracticeMonitor and Analyze Structure,Process, and Outcome Data- Environment- Staff- Cost- Patient and FamilyDisseminate Results= a decision PointDO NOT REPRODUCE WITHOUT PERMISSIONREQUESTS TO:Marita Titler, PhD, RNOffice of Nursing ResearchThe University of Iowa Hospitals and ClinicsIowa City, IA 52242-1009Revised: April 1998 © UIHCTitler, M.G., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp Reimer, T.,& Goode, C. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care NursingClinics of North America, 13(4):497-509.
    15. 15. Electronic Implementation15
    16. 16. Electronic Implementation16
    17. 17. Lessons Learned• Consider the culture of the unit:– “If we don’t have failed extubations we are notdoing our job.”– Communicate….• Frequently• Follow-up• Have set team meetings: time & place• Point persons are vital• Identify the roles• Time frames and deadlines17
    18. 18. More Lessons Learned• Trialing takes time (piloting the change)• Expect Multiple changes– 3 revisions to paper form of extubation readinessprotocol• Acknowledge the set backs• Connect with IT early• How do we operationalize this?18
    19. 19. Clinical Results• Extubation Readiness tool is part of thePICU standard order set for intubation• No failed extubation to date for thosepatients meeting criteria!!• Staff survery showed increased feelings ofcollaboration and consistency in practice19
    20. 20. 20
    21. 21. Nurse/RT Survey ResultsPost Protocol Implementation• 0% of staff indicated varied practice forextubation (prevously 66%)• 68% of staff indicated multidisciplinarycollaboration during extubation process(previously 33%)21
    22. 22. Contact• Kolea Chong RN, BSN, CCRN– Kolea.chong@kapiolani.org– Kapiolani Medical Center for Women & Children• Susan Bankhead MSN, CCRN, CNML– Susan.bankhead@kapiolani.org– Kapiolani Medical Center for Women & Children22
    23. 23. ReferencesBaumeister, B.L., El-Khatib, M., Smith, P.G., Blumer, J.L. (1997) Evaluation of predictors of weaningof mechanical ventilation in pediatric patients. Pediatric Pulmonology, 24(5): 344-52.Farias, J.A., Alia, I., Esteban, A., Golubicki, A.N., Olazarri, F.A. (1998) Weaning from MechanicalVentilation In Pediatric Intensive Care Patients. Intensive Care Medicine, 24(10); 1070-5.MacIntyre, N.R., Cook, D.J., Ely, E.W., Epstein, S.K., Fink, J.B., Heffner, J.E., et al (2002) Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. Respiratory Care, 47(1):69-89.Meade, M.O., Ely, E.W. (2002) Protocols to Improve the Care of Critically Ill Pediatric and AdultPatients. JAMA, 228(20): 2601-03Newth, C.J., Venkataraman, S., Willson, D.F., Meert, K.L., Harrison, R., Dean, J.M. et.al (2009)Weaning and extubation readines in pediatric patients. Pediatric Critical Care Medicine, 10(1): 1-11.Titler, M.G., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L.Q., Buckwalter, K.C., TrippReimer, T., & Goode, C. (2001). The Iowa Model of Evidence-Based Practice to Promote QualityCare. Critical Care Nursing Clinics of North America, 13(4):497-509.Venkataraman, S.T., Khan, N., Brown, A. (2000) Validation of predictors of extubation success andfailure in mechanically ventilated infants and children. Critical Care Medicine, 28(8): 2991-2996.Wratney, A.T., Cheifetz, I.M. (2006) AARC Clinical Practice Guideline; Removal of the EndotrachealTube-2007 Revision and Update. Respiratory Care, 52(1): 81-93.Wratney, A.T., Cheifets, I.M. (2006) Extubation Criteria in Infants and Children. Respir Care Clin NAm., 12(3); 469-81.23
    24. 24. • This EBP project was generously supported, inpart, by the Hawaii State Center for Nursing• This project was supported by grant numberR13HS017892 from the Healthcare Researchand Quality. The content is solely theresponsibility of the authors and does notnecessarily represent the official views of theAgency for Healthcare Research and Quality.24

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