Statistics show that the less time a patient spends on a ventilator, the better the outcomes.
The risks associated with prolonged time on a ventilator range from swollen vocal chords, tracheal damage and difficulty swallowing to ventilator-associated pneumonia and sepsis.
By revising a cardiothoracic perioperative respiratory bundle, UF Health Shands Hospital decreased ventilator time by one day. The same protocol also led to a one-day reduction in ICU length of stay.
“We are committed to reducing respiratory complications associated with cardiac surgery and had the biggest improvement of any University Hospital Consortium facility in the country, compared to last year,” said Sean Kiley, MD, an assistant professor of anesthesiology in the UF College of Medicine.
A multidisciplinary group of cardiothoracic surgeons, intensive care specialists, anesthesiologists, nurses, pharmacists and respiratory therapists identified several aspects of the cardiothoracic patient treatment pathway that could be enhanced in order to optimize respiratory function postoperatively.
After careful literature review, a revised pathway was implemented to improve cardiothoracic patient outcomes. The treatment pathway is divided into three sections. In the preoperative phase, the care team sought to identify patients — based on medical history, lung capacity and physical examination — who were most at risk for post-ventilator respiratory failure.
All patients are seen two to four weeks before surgery for pulmonary testing. If necessary, the patient is referred for pulmonary rehabilitation.
“We are in the process of designing a testing system that may more accurately identify these patients who would benefit the most from this kind of rehab,” Kiley said.
During the intraoperative phase, the anesthesiologist is charged with following an enhanced protocol to maintain safe oxygen concentration levels, low tidal volume ventilation, and positive end expiratory pressure appropriate for the patient’s current condition. The postoperative phase focuses on transfer of patient care from the anesthesiologist to the intensivist. The intensivist then briefs the surgeon, nurse practitioner or physician assistant, nurse and respiratory therapist before moving forward with a plan of care.
“That discussion includes extubation goals and any risks the patient faces,” Kiley said. “As the day progresses, a huddle may occur to discuss progress and adjust the care plan accordingly.”
Part of the postoperative care also includes evaluating a patient for fast-track extubation.
“Just because a patient had a major operation does not mean they should be intubated. It’s better for them if we can get the breathing tube out,” Kiley said.
Patients who meet certain criteria are extubated within four hours of transfer to the unit from the OR.
“The fast-track protocol is entirely respiratory therapist- and nurse-driven,” Kiley said. “We get a text saying that the patient has been extubated. We are working on that data now.”
The fast-track protocol has led to other improved patient care measures.
“We’re able to remove Foley catheters sooner to reduce the risk of urinary tract infections. We also can ambulate patients sooner, which is associated with earlier transfer from the ICU and quicker discharge to home,” Kiley said.