Lean process streamlines cardiac surgery extubation time

Integrating a lean work design into cardiac surgery practices allowed one department to greatly increase the likelihood that patients would be extubated within six hours. The results were published in the December issue of the Journal of Cardiothoracic and Vascular Anesthesia.

Medical director Jeremy T. Gutsche, MD, and other members of the Surgical Intensive Care Unit process improvement team at the University of Pennsylvania in Philadelphia decided to apply a lean design to their unit based on a review of Society of Thoracic Surgeons data. They observed that fewer patients treated at their facility were extubated within six hours after surgery than at similar hospitals. Guidelines recommend fast-track extubation in low- and medium-risk CABG patients.

The team first went through training in lean principals. They used the training to identify barriers, redesign processes and develop guidelines to streamline fast-track extubation. For instance, the team determined that a single nurse admitted patients and replaced the practice with a “swarm” system using available nurses to admit and stabilize the patient. They also changed their sedation protocol, postoperative pain medication, ventilator weaning process and equipment process.

They also placed extubation times at the head of a patient’s bed to remind the surgery team, reviewed results after cases and provided feedback.

Their study evaluated the effectiveness of the changes using a before-after design based on 195 pre- and 171 postintervention patients who underwent CABG, aortic valve replacement or mitral valve replacement or repair.

They failed to meet the six-hour mark in 86 patients in the postintervention group. Causes for delayed extubation included hemodynamic instability, lung disease or hypoxia and oversedation. Not following the guidelines and equipment delays explained many of the cases where they missed the six-hour goal.

“If more time could have been invested in education and oversight, it is possible that these failures could have been prevented,” they wrote. “Oversedation from residual anesthetics was a common problem early in the post-intervention period. The medical director has shared feedback about FTE [fast-track extubation] failure due to residual anesthetics with the anesthesiology staff, and this problem virtually has been eliminated.”

They concluded that using the guidelines lowered extubation times to within six hours. By February of 2014, they achieved fast-track extubation in 61 percent of patients who underwent CABG, aortic valve replacement or mitral valve replacement or repair.