P-2 EXTUBATION CHECKLIST - A CALL FOR 'MANDATORY' IMPLEMENTATION Collins, Donna 1

Transcription

1 P-2 EXTUBATION CHECKLIST - A CALL FOR 'MANDATORY' IMPLEMENTATION Collins, Donna 1 1 Quality Risk Management, Critical Care Education, Crystal Clear Transitional Care Inc., Saint John, New Brunswick, Canada Introduction: There are a large number of extubation failures that could be prevented. According to leading American authors, an extubation checklist is required to improve extubation success (Cavallone, & Vannucci 2013; Howie & Dowie, 2012; Tobin, 2006). With this many deaths, it is critical that we improve patient outcomes by perhaps using a different system (i.e. checklist) to improve patient outcomes and to pull people back from the brink of death. Objectives: The objective of the research is to identify gaps in clinical practice so as to improve patient outcomes pertaining to extubation failure (i.e. reduce preventable premature death) in intensive care units. Improvement in patient outcomes and ensuring that clinicians have done all that we can to improve patient outcomes will lead to increased confidence in healthcare delivery. It may also reduce litigation and contribute to the sustainability of the Canadian healthcare system. Methods: Using a clinical case review coupled with evaluation of current research in the field of extubation (Tobin, 2006), gaps in clinical service were identified. While Hutton and Dowie (2012) provide a template to assist with extubation, this is clearly not comprehensive enough and would have missed gaps identified in the clinical case reviewed. Results: It is clear, based on the evidence that an extubation checklist needs to be implemented in critical care units as a matter of patient safety. To my knowledge, there is currently no checklist in Canada. Further the mandatory checklist implemented by Hutton & Dowie is clearly not comprehensive enough and would not have overlooked gaps in extubation failure. It is also clear, based on the evidence, that opiate overdose is being mismanaged in the ICU. Specifically, the signs and symptoms of opiate overdose are being overlooked. The reversible causes checklist needs to include "Opiate" and narcan as the treatment option. Further the ACLS algorithm needs to be reviewed and updated to consider 'respiratory failure' as the precursor to cardiac arrest. Conclusion: There is a clear need for an extubation checklist to improve patient outcomes in the intensive care units in Canada. While the checklist submitted may be extensive, it begs the question: is your life worth it? This added safety tool is intended to provide a double-check list system before extubation is initiated. ICU NPs may be able to further 'tailor' the checklist to make it more user-friendly and efficient. Other tools need to be reviewed and revised to prompt and signify changes in the treatment of opiate overdose. Clinicians need to be informed of deadly drug-drug interactions and patients need to be assured that clinicians are double checking for lethal drug-to-drug interactions (i.e. References: Cavallone, L. F., & Vannucci, A. (2013). Extubation of the Difficult Airway and Extubation Failure. Anesthesia & Analgesia, 116(2), Howie, W. O., & Dutton, R. P. (2012). Implementation of an evidence-based extubation checklist to reduce extubation failure in patient with trauma: A pilot study. AANA Journal, 80(3), Retrieved from Laghi, F., & Tobin, M. (2006). Indications for mechanical ventilation. In M. J. Tobin (Ed.), Principles & Practice of Mechanical Ventilation (2nd ed., pp ). New York: McGraw-

2 Hill. Naxolone: Drug information. ( ). Retrieved from Tobin, M. J. (2006). Principles & practice of mechanical ventilation (2nd ed.). New York: McGraw-Hill.

3 Patient Label Patient s Age: Gender: M / F Reason for Intubation: Circle High Risk Extubation? Extubation Checklist Patient s Weight = Indicate Value/Comment Trauma/COPD/Asthma/Head Injury/other (i.e. sudden LOC) Neck Surgery If yes, consider removal in O.R. Pre-extubation tests Patient Assessment Medication Review Lab Review Airleak test Chest x-ray (Opiate?, A, B, C, D ) CT Scan MRI Echocardiogram Other state (3T MRI, etc.) Awake Follows commands Agitated Cooperative Muscle relaxant reversed Analgesia (i.e. opiates - Fentanyl, morphine) Benzodiazepines Lasix (Consider K+ replacement, drug interactions) IV medications Antibiotics (Consider for lengthened QTc interval) K+ (WNL) Hbg (WNL) Urea (WNL) Creatinine (WNL) LKC s (WNL) PT/PTT/aPPT Blood gas interpretation Pass/Fail Naloxone (Narcan ) - autoinject* - intramuscular - intravenous - subcutaneous - endotracheal - intranasal - sublingual Current value/date Other (cultures pending) Respiratory Rate < 20 bpm Temperature C If febrile, consider sepsis or other Heart Rate WNL (<100 bpm) If tachycardia, correct/consult

4 Blood Pressure WNL (Canadian guidelines) Value/Comment Pain Scale Pain quality/location Urine Output 0.5 ml/kg/hr ECG rmal sinus rhythm Arrhythmias within last 24 hours Ectopic beats QTc interval examined ETCO2 <21 SPO2 >90% on 30% FiO 2 Fluid balance (consider perfusion notes if applicable) Hemodynamically Stable: Sputum Production Positive (liters) Negative CVP (2 mmhg 12 mmhg) PA Pressure (8-13 mmhg) Cardiac Output (4-8 L/min) Intra-arterial pressure (readings are at least 10mmHg higher than cuff BP readings) Color Amount (sm, med, lg, copious) Stage of Weaning Stage 1 Stage 2 (think about extubation) Stage 3 Stage 4 Stage 5 Stage 6 Stage 7 Weaning Technique T-tube trial PS Intermittent Mandatory Ventilation (IMV) Combination of above date If yes, consider cardiac consult >500 ms 4-fold increase in sudden death Minute Ventilation normal is about 6L/min = V e <10 L/min Rapid Shallow Breathing Index <105 (RSBI) = f/v t ratio VC mls/kg IBW NIF -20 to -30 cmh 2 0 minimum acceptable in adult population Respiratory Rate bpm Other Caloric balance restored Consults initiated (state) See additional sheet ICD-10 classification Comments Discharge Teaching Drug-drug interactions ( CPR/First Aid; Signs & Symptoms of Opiate/Methadone overdose fridge magnet; Signs & Symptoms of Anaphylaxis fridge magnet; medical alert tag Organ retrieval: criteria met: yes or no Peer Death Review: / Chart referred to DNP or

5 Date Consult Initiated Department Consults Physician/NP Allied Healthcare Professional Reason for Consult Follow-up Outcome