title: Clinical quality improvement: eliminating unplanned extubation in the CCU.
abstract: OBJECTIVE
  This article aims to explore coronary care unit (CCU) extubation structures, processes and outcomes. There were 13 unplanned-extubation cases (UE) among 251 intubated patients (5.2 per cent) in a cardiologist-led CCU in 2008. Seven did not require re-intubation, implying possible earlier extubation. A quality improvement project was undertaken with a goal to eliminate CCU UE within 12 months.
  
  
  METHODS
  Using the clinical practice improvement (CPI) method, the most significant root causes were missing sedation/analgesia protocol, no ventilator weaning protocol and absent respiratory therapist during the CCU morning rounds. Non-physician directed sedation/analgesia and ventilation weaning protocols were created and put on trial in Plan-Do-Study-Act cycles before formal implementation. Arrangements were made to allocate a respiratory therapist to the CCU daily for morning rounds.
  
  
  RESULTS
  For 12 months after fully implementing the interventions, UE incidence dropped from 5.2 per cent to 0.9 per cent (p = 0.006). There were no adverse outcomes, re-intubation and/or readmission to CCU within 48 hours.
  
  
  CONCLUSIONS
  Through a multi-disciplinary CPI approach, adopting non-physician directed protocols has successfully streamlined and improved airway management in mechanically ventilated patients in a cardiologist-led CCU.
  
  
  CONCLUSIONS
  There is little published data on improving intubated patient care in cardiologist-led CCUs. Previous studies centered on intensive care units managed by critical care specialists.
authors.affiliation: Department of Cardiology, Tan Tock Seng Hospital, Singapore, Singapore. powlichia@gmail.com
authors.forename: Pow-Li
authors.initials: PL
authors.lastname: Chia
authors.forename: Deanna Rapi
authors.initials: DR
authors.lastname: Santos
authors.forename: Tit Chai
authors.initials: TC
authors.lastname: Tan
authors.forename: Candice
authors.initials: C
authors.lastname: Leong
authors.forename: David
authors.initials: D
authors.lastname: Foo
mesh_terms: D060666:Airway Extubation / Q000009:adverse effects / Q000592:standards / Q000706:statistics & numerical data*; D002985:Clinical Protocols; D003325:Coronary Care Units / Q000458:organization & administration / Q000706:statistics & numerical data*; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000592:standards / Q000706:statistics & numerical data*; D058996:Quality Improvement / Q000458:organization & administration*; D015300:Ventilator Weaning / Q000009:adverse effects / Q000592:standards / Q000706:statistics & numerical data*