title: A protocol-driven approach to early extubation after heart surgery.
abstract: OBJECTIVE
  We assessed the effectiveness of standardized protocols in decreasing postoperative mechanical ventilation time to <6 hours.
  
  
  METHODS
  In 2061 patients undergoing coronary bypass, the proportion extubated in <6 hours was calculated for 3 sequential time periods. During period 1 patients were weaned per baseline practices; during period 2, per a protocol developed by a multidisciplinary committee; and during period 3, as in period 2 but with paralytic reversal and extubation performed at lower body temperatures and an extubation reminder sheet prominently displayed. We used a χ(2) test to examine differences in ventilation times among the 3 time periods and logistic regression modeling to control for independent risk factors for prolonged ventilation. As measures of patient safety, we examined rates of reintubation and rates of patient shivering following paralytic reversal.
  
  
  RESULTS
  Twelve percent of patients were extubated in <6 hours during period 1, 24% during period 2 (P < .01), and 38% during period 3 (P < .01 compared with both periods 1 and 2). After controlling for 12 risk factors, patients were more likely to be extubated in <6 hours during period 2 (odds ratio, 2.39; 95% confidence interval, 1.84-3.10) and period 3 (odds ratio, 5.05; 95% confidence interval, 3.65-6.99) than during period 1. There was no difference in reintubation rates across periods, and the rate of patient shivering did not increase with paralytic reversal at lower body temperature.
  
  
  CONCLUSIONS
  The standardized protocols outlined in this article dramatically improved early extubation performance.
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md. Electronic address: zwfitch@gmail.com.
authors.forename: Zachary W
authors.initials: ZW
authors.lastname: Fitch
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Orlando
authors.initials: O
authors.lastname: Debesa
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Rika
authors.initials: R
authors.lastname: Ohkuma
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Damon
authors.initials: D
authors.lastname: Duquaine
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Jochen
authors.initials: J
authors.lastname: Steppan
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Glenn J R
authors.initials: GJ
authors.lastname: Whitman
mesh_terms: D060666:Airway Extubation / Q000592:standards*; D006348:Cardiac Surgical Procedures; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000592:standards*; D011446:Prospective Studies; D012307:Risk Factors; D013997:Time Factors