PICO: When to Extubate



PICO: When to ExtubateLindsey RanstadlerFerris State UniversityAbstractProlonged intubation in post-op cardiac patients can result in multiple health complications. In this case, evidence will be reviewed regarding early extubation and mobilization programs. A recommendation for change in practice will be made, and how this can be accomplished will be discussed. Articles relevant to this discussion will be reviewed.PICO: When to ExtubateThe purpose of this essay is to look critically at a specific question and determine best practice for post-operative patients. Review of current, relevant nursing studies will be done and a recommendation will be made based on research findings. There will also be a plan for disseminating this information through the appropriate channels to communicate findings to the health care team for consideration for implementation.PICO QuestionThe PICO question I chose for consideration is: Does early extubatuion reduce post-op complications in cardiac patients compared to those who remain intubated past 6 hours? This question was originally posed by Nate Dixon. The concern is that prolonged mechanical ventilation after undergoing a cardiac surgical procedure can increase the risk of complications for the patient as well as increasing time spent in the ICU and associated costs (Hawkes, Foxcroft, & Yerrell, 2010). Cardiac professionals are seeing the benefit of early mobilization in post-op patients with decreased rates of pulmonary emboli, pneumonias and deep vein thrombosis (Freeman & Maley, 2013). The goal of this research is to determine what the evidence suggests about early extubation and make a recommendation for practice change based on the findings.The benefits to patient safety should the evidence find in favor of early extubation would primarily be in the form of their overall condition and how well they rebound after surgery. Improved pulmonary function and prevention of post-op complications are safety issues that directly involve the patient’s health directly. It is therefore in the best interest of the patient that consideration is made for this practice. The intention is to protect the patient from further harm by getting them extubated and up and moving as soon as possible.Once findings are determined, the evidence and recommendation must be presented to peers to enact the change. Barriers to enacting this change could be lack of nurses knowledge about nursing research, negative attitudes about nursing research and inadequate dissemination of research findings (Nieswiadomy, 2012). Exposing nurses to research and encouraging a positive attitude toward research then could help to make the environment would help to set the stage to bring in EBP. This could be done by leadership; however every nurse should be encouraging an inquisitive spirit in regards to nursing practice. Effort should be made when presenting research findings to ensure the audience has comprehension of the implications. Studies published may be presented at a level the average practicing nurse don’t understand (Nieswiadomy, 2012).To disseminate my findings, I would first educate my peers on the implications of prolonged intubation. They need to recognize there is a problem with prolonged intubation before they will be willing to accept a change in current practice. On my unit, I would present the literature to be reviewed and their findings on poster board in a common area such as the break room where people could frequently see it. As part of the patient safety committee, I would present my research and findings at a meeting which would include the use of PowerPoint presentation with time given for discussion at the end.Research FindingsThe first article I reviewed was Clinical guideline for nurse-led early extubation after coronary artery bypass: an evaluation. This article appeared in the Journal of Advanced Nursing in 2010. It is original nursing research reporting on the process of development and implementation of a nurse-led early extubation protocol (Hawkes et al., 2010). The study took place in the UK and a single cardiac surgical center and was conducted by nurse researchers (Hawkes et al., 2010). This study was concerned more with the process of implementing an early extubation clinical guideline rather than early extubation itself. The qualitative findings revealed that clinicians did not require a change in practice, though it may have had a supportive role in current practice through education (Hawkes et al., 2010). This article would perhaps be more appropriate for a PICO question regarding the implementation of process change rather than the merits of early extubation itself.The next article I reviewed was Impact of Early Mobilization Protocol on the Medical-Surgical Inpatient Population. This article appeared in Clinical Nurse Specialist in 2012. It is a literature review written by two nurses on the risks of prolonged immobility and the benefits of early ambulation in the medical-surgical population (Pashikanit & Von Ah, 2012). At the time the article was written, there were no evidence based guidelines in regards to early ambulation in this population (Pashikanit & Von Ah, 2012). The findings from the literature review were that the early mobilization of medical-surgical patients can improve patient outcomes (Pashikanit & Von Ah, 2012). This article is useful as evidence for early extubation because the earlier they are extubated the earlier you can get them moving, which has been found to improve patient outcomes (Pashikanit & Von Ah, 2012).The last article I reviewed was Mobilization of Intensive Care Cardiac Surgery Patients on Mechanical Circulatory Support. This article was published in Critical Care Nursing Quarterly in 2013. This article details how to get critical post-op cardiac patients progressively mobile (Freeman & Maley, 2013). It also documents and reiterates the complications that follow prolonged intubation such as pulmonary emboli, pressure ulcers, pneumonia and deconditioning (Freeman & Maley, 2013). This article is useful because it outlines specifically what early mobilization of cardiac patients looks like. Cardiac patients post-op often have a lot of equipment that needs to be moved with them and this article discusses how to coordinate safe mobility in this population (Freeman & Maley, 2013).Recommendations to Improve Quality and SafetyBased on the evidence I have seen in regards to prolonged ventilation and thus prolonged immobility, it is my recommendation that an early extubation and progressive mobility protocol be established. The risks of prolonged immobility have been well documented throughout nursing literature in recent years. It goes to follow that the longer you keep someone intubated, the longer they will remain immobile. Because we know from the literature that either prolonged intubation or immobility does not promote positive patient outcomes, effort should be made then to change our practices to reflect the evidence. Early, progressive mobility is now considered the standard for intensive care patients (Freeman & Maley, 2013) and effort should be made at the local level to adopt this standard.Nurses will be on the front line of adopting an early mobilization and extubation protocol. It will be up to the nurses providing direct patient care to ensure patient safety remains a priority during this process. By encouraging early extubation and mobilization in post-op cardiac patients, nurses will be protecting patients from further complications. Care must be taken that these efforts are undertaken with care and focus on safety to protect the patient from additional harm as the patient gradually grows stronger. Quality of care will be evident in the decrease in cost of treatment and prevention of readmission. Management could meet with cardiologists to develop the extubation guideline and perhaps a policy could be written that is reflective of this process. This could help it to be adopted as a formal standard of care.ConclusionProlonged intubation following cardiac surgery can lead to a host of problems such as pressure ulcers, pneumonia, deconditioning and pulmonary embolism because it requires patients to be immobile (Freeman & Maley, 2013). Evidence is mounting for early extubation and mobilization programs in surgical patients. In an effort to ensure we are practicing to the current standards of care we must look at this evidence and see how it relates to our patient populations. We must look critically at this evidence and apply it to our own current practice. In this case, the evidence supports early extubation and mobilization in patients to prevent further health complications and control costs.ReferencesFreeman, R., & Maley, K. (2013, January-March). Mobilization of intensive care cardiac surgery patients on mechanical circulatory support. Critical Care Nursing Quarterly, 36, 73-88. , C., Foxcroft, D., & Yerrell, P. (2010, March 19). Clinical guideline for nurse-led early extubation after coronary artery bypass: an evaluation. Journal of Advanced Nursing, 2038-2049. Retrieved from CINHALNieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Upper Saddle River, NJ: Pearson.Pashikanit, L., & Von Ah, D. (2012, March/April). Impact of early mobilization protocol on the medical-surgical inpatient population: an integrated review of literature. Clinical Nurse Specialist, 87-94. Retrieved from ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download