title: Advancing extubation time for cardiac surgery patients using lean work design.
abstract: BACKGROUND
  Early 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.
  
  
  OBJECTIVE
  To 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.
  
  
  METHODS
  Retrospective data analysis.
  
  
  METHODS
  Sixteen-bed intensive care unit in a mid-sized, academic community hospital.
  
  
  METHODS
  Four hundred four patients undergoing coronary artery bypass graft surgery, aortic valve replacement, or mitral valve replacement/repair.
  
  
  METHODS
  The 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.
  
  
  METHODS
  The rate of patients being extubated in fewer than 6 hours and length of intubation.
  
  
  RESULTS
  One 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.
  
  
  CONCLUSIONS
  The closely planned, coordinated, and integrated care paradigm dramatically increased the likelihood of extubation within 6 hours of arrival in the SICU.
authors.affiliation: Department of Anesthesiology and Critical Care. Electronic address: jacob.gutsche@uphs.upenn.edu.
authors.forename: Jacob T
authors.initials: JT
authors.lastname: Gutsche
authors.affiliation: Department of Family Medicine.
authors.forename: Lee
authors.initials: L
authors.lastname: Erickson
authors.affiliation: Department of Anesthesiology and Critical Care.
authors.forename: Kamrouz
authors.initials: K
authors.lastname: Ghadimi
authors.affiliation: Department of Anesthesiology and Critical Care.
authors.forename: John G
authors.initials: JG
authors.lastname: Augoustides
authors.affiliation: School of Nursing.
authors.forename: Joseph
authors.initials: J
authors.lastname: Dimartino
authors.affiliation: Department of Surgery, School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: Department of Surgery, School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: E Andrew
authors.initials: EA
authors.lastname: Ochroch
mesh_terms: D000368:Aged; D060666:Airway Extubation / Q000379:methods / Q000706:statistics & numerical data*; D006348:Cardiac Surgical Procedures; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013997:Time Factors
keywords: aortic valve replacement; coronary artery bypass graft; critical care; early extubation; extubation; lean design; mitral valve replacement; quality improvement