Using the DMAIC Process to Examine Variability in Extubation Practices in Different Intensive Care Units Relating to Management Teams

Background:

In our intensive care units (ICU) there was a perception of a between a successful spontaneous breathing trial (SBT) and the time to which the patient is extubated. An SBT is used to predict a mechanically ventilated patient's ability to breathe on their own and is our standard of care for assessment in the process of extubation. Evidence suggests using a protocol to assess a patient's readiness for extubation. In our ICUs, a Ventilator Liberation Guideline (VLG) was used daily to assess the patient's readiness for extubation. SBT practices were reviewed in three Medical ICUs (MICU) and two Surgical ICUs (SICU), primarily managed by either Advanced Practice Practitioners (APP) or Medical Resident (MR) during the first phase of the DMAIC (Define, Measure, Analyze, Improve, and Control) process. The goal of the study was to examine variability in SBT practices across different ICU management teams.

Methods:

SBT practices from 12/1/17 - 4/30/18 were reviewed. Data points included start time of ventilation, time of successful SBT, time of extubation order entry, and time of extubation. Inclusion criteria were patients with the following characteristics: orally intubated, charted successful SBT, extubation order entry, and charted extubation time. A total of 487 intubations were examined. Patients were excluded if inclusion criteria were not met, the patient self-extubated, care was withdrawn, or if the patient had a tracheostomy. Data was entered into SPSS 24.0 and analyzed using analysis of variance (ANOVA) with Tukey's post-hoc analysis.

Results:

Table 1 below lists each unit's mean times for each process in the extubation process. The greatest mean difference was from a successful SBT to order entry. The results of the ANOVA indicate differences within the units for each of the measurements. Tukey's post-hoc analysis indicated that the MICU and SICU unit's mean time differences for all measured time points were statistically significant (P<0.05). Further analysis indicated there were no statistically significant differences in times in management team.

Conclusions:

The DMAIC process is used for operational improvement, identifying root causes, and proposing solutions. Variability in practices suggests room for improvement in the extubation process and investigating causal factors for length of time from a successful SBT to order entry.

Disclosures:

None.

Table 1: SBT Practices Recorded in Minutes

(MICU: n=349; SICU: n=138)

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