Postoperative Emergent Reintubations or Unanticipated Prolonged Intubation: A Quality Improvement Project Author: Sarah Clift, RN, BSN, DNAP Candidate Committee: K. Arndt DNP, CRNA , S. Barenklau DNP, CRNA Support from Dr. Adam Reese MD, Assistant Professor KU Background KUMC safely performs 30,000 general anesthetics every year, however there is still concern over the number of emergent reintubations in the PACU and patients that require an unanticipated postoperative ventilator. Intervention Ø Chart reviews were performed to seek trends and identify areas for improvement. Ø Key areas for improvement: ideal technique for monitoring neuromuscular blockade depth and proper dosing of paralytic reversal agents. Ø The Institute of Healthcare Improvement Model for quality improvement methodology was used to bundle the most effective techniques to prevent CREs. Ø A PowerPoint presentation was given to student nurse anesthetists, along with a one-page cognitive aid containing the key concepts from the lecture. Ø 5 months later CRE re-evaluated to seek trends and improvement post intervention. Project Goal reduce the number of CREs by 25% in five months through education of best practices. Outcome Ø Pre-intervention: 33 CRE Ø Post intervention: 7 CRE Surpassed goal of 25% reduction Lessons Learned Ø Overdose of the paralytic reversal, neostigmine, may have contributed to CRE. Ø Replacement of this drug by sugammadex may have prevented this problem reducing CRE. Ø Education & Cognitive Aid likely helpful and unlikely harmful References Ø Bridion (sugammadex): annotated prescribing information. (2016). Merck & Co., Inc. Retrieved from http:// www.merck.com/product/usa /pi_circulars/b /bridion /bridion_pi.pdf Ø Dorsch J. & Dorsch, S. (2011). Neuromuscular transmission monitoring. In A practical approach to anesthesia equipment. (pp. 500-516). Philadelphia: Lippincott Williams & Wilkins. Ø Nagelhout, J. (2014). Neuromuscular blocking agents, reversal agents, and their monitoring. In Nagelhout, J. & Plaus, K. (Eds.), Nurse anesthesia (5th ed.) (pp. 158-185). St. Louis: Elsevier Inc. Ø Pelt, M., Chitilian, H., & Eikerman, M. (2016). Multi-faceted initiative designed to improve safety of neuromuscular blockade. APSF Newsletter, 30, 51-52. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx http://www.xavant.com/products/nms450

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Page 1: Postoperative Emergent Reintubations or Unanticipated ... · reintubations in the PACU and patients that require an unanticipated postoperative ... Ø 5 months later CRE re-evaluated

Postoperative Emergent Reintubations or Unanticipated Prolonged Intubation: A Quality Improvement Project

Author: Sarah Clift, RN, BSN, DNAP Candidate

Committee: K. Arndt DNP, CRNA , S. Barenklau DNP, CRNA Support from Dr. Adam Reese MD, Assistant Professor KU

Background

KUMC safely performs 30,000 general anesthetics every year, however there is still concern over the number of emergent reintubations in the PACU and patients that require an unanticipated postoperative ventilator.

Intervention

Ø Chart reviews were performed to seek trends and identify areas for improvement. Ø Key areas for improvement: ideal technique for monitoring neuromuscular blockade

depth and proper dosing of paralytic reversal agents. Ø  The Institute of Healthcare Improvement Model for quality improvement methodology

was used to bundle the most effective techniques to prevent CREs. Ø A PowerPoint presentation was given to student nurse anesthetists, along with a

one-page cognitive aid containing the key concepts from the lecture. Ø  5 months later CRE re-evaluated to seek trends and improvement post intervention.

Project Goal reduce the number of CREs by 25% in five months through education of best practices.

Outcome Ø  Pre-intervention: 33 CRE Ø  Post intervention: 7 CRE

Surpassed goal of 25% reduction

Lessons Learned Ø  Overdose of the paralytic reversal, neostigmine, may have contributed to CRE.

Ø  Replacement of this drug by sugammadex may have prevented this problem reducing CRE.

Ø  Education & Cognitive Aid likely helpful and unlikely harmful

References

Ø  Bridion (sugammadex): annotated prescribing information. (2016). Merck & Co., Inc. Retrieved from http://www.merck.com/product/usa /pi_circulars/b /bridion /bridion_pi.pdf

Ø  Dorsch J. & Dorsch, S. (2011). Neuromuscular transmission monitoring. In A practical approach to anesthesia equipment. (pp. 500-516). Philadelphia: Lippincott Williams & Wilkins.

Ø  Nagelhout, J. (2014). Neuromuscular blocking agents, reversal agents, and their monitoring. In Nagelhout, J. & Plaus, K. (Eds.), Nurse anesthesia (5th ed.) (pp. 158-185). St. Louis: Elsevier Inc.

Ø  Pelt, M., Chitilian, H., & Eikerman, M. (2016). Multi-faceted initiative designed to improve safety of neuromuscular blockade. APSF Newsletter, 30, 51-52.

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

http://www.xavant.com/products/nms450