Develop a Standardized Multidisciplinary Process for Safe Adult Extubation

Background: Inova Fairfax Medical Campus (IFMC) has utilized physician-ordered extubation in most Adult ICUs/ED. The team of physician, resident, pharmacist, nurse and respiratory therapist participates in multidisciplinary rounds and formulates a plan to extubate a patient. Physician would write the order for Extubation, RT acknowledges the order, verbal communication among team takes place and procedure would be performed. A physician/Advanced practice provider (APP) would be close by to assure skilled personnel is available to reestablish artificial airway if needed. In 2017, an extubation was performed prematurely on an adult patient due to different interpretation of a verbal communication about the order and the timing of the extubation. We identified the root cause to be the lack of a clear closed loop communication among all team members. It was an opportunity to improve patient safety. Our institution has embarked on a 9No harm, high reliability9 organization journey with focus on patient safety by linking our cultural beliefs to patient safety. In addition, IFMC employees have learned TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) to improve Teamwork, Better communication and Patient Safety. Methods: A multidisciplinary team (consisting of Respiratory Care Services, intensivists, CMO, Nursing) collaborated to develop a safety pre-procedure pause before adult extubation. The pre-procedure pause includes patient identification, order for procedure, assurance that the required team members and equipment are available prior to start of the procedure. Team performs Time- out with physician in the patient9s room. Closed loop communication is expected to assure a mistake is not being made. Physician must be present in the room or in the unit when extubation is performed. A SMART phrase was created in EHR documentation. Education to all team members was done in person, through critical care committees and via email. Results: Initial post implementation data was 72%. We reeducated and one-on-one follow up with RT showed improved compliance. EHR documentation of pre-procedure pause shows compliance of 72-97 % to date. Our goal is to achieve 100% compliance. Conclusions: Our result shows compliance with a pre-procedure pause to establish a standardized process to extubation of adult ICU patients and improve patient safety. References provided upon request.