• Jacob T Gutsche, Lee Erickson, Kamrouz Ghadimi, John G Augoustides, Joseph Dimartino, Wilson Y Szeto, and E Andrew Ochroch.
• Department of Anesthesiology and Critical Care. Electronic address: jacob.gutsche@uphs.upenn.edu.
• J. Cardiothorac. Vasc. Anesth.. 2014 Dec 1;28(6):1490-6.

BackgroundEarly 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.ObjectiveTo 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.DesignRetrospective data analysis.SettingSixteen-bed intensive care unit in a mid-sized, academic community hospital.PatientsFour hundred four patients undergoing coronary artery bypass graft surgery, aortic valve replacement, or mitral valve replacement/repair.InterventionThe 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.MeasurementsThe rate of patients being extubated in fewer than 6 hours and length of intubation.ResultsOne 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.ConclusionsThe closely planned, coordinated, and integrated care paradigm dramatically increased the likelihood of extubation within 6 hours of arrival in the SICU.Copyright © 2014 Elsevier Inc. All rights reserved.

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