Extubation in the Critical Care Setting: Evaluating Evidence Based Medicine and Cost Analysis

Abstract

Background:

Several critical care arenas continue to extubate patients to low-flow cool aerosol mask when at low risk for requiring elevated support to NIPPV or HFNC. A lack of literature offering evidence that extubation to specific low-flow oxygen device is best practice over another. In terms of healthcare quality, overuse occurs when a service is provided with no evidence of providing value to the patient. Efficient healthcare avoids unnecessary waste including equipment, supplies, time, and energy. Current cultural practice in the ICUs at UC Davis Health requires extubated patients requiring low-flow oxygen, to cool aerosol mask prior to transitioning to nasal cannula or room air (RA). As this is not established in EBM, an assessment need was identified by respiratory care leadership as a QI project.

Methods:

449 Acute care surgery and trauma critical care surgery patients extubated between 2018 and 2019 were evaluated under an IRB approved QI project. A cohort of 184 patients identified as requiring low-flow oxygen were extubated to aerosol mask, with a secondary extubation device documented as nasal cannula or RA were evaluated to assess time to secondary device. Cost analysis of delivery devices were performed as well as workflow analysis of time to setup of delivery device equipment. The current practice of extubating to an aerosol mask setup included the following equipment: one humidifier, one aerosol adapter, three feet of large-bore corrugated oxygen tubing, and one aerosol mask.

Results:

Eighty-five patients (46%) were extubated to aerosol mask and transitioned to nasal cannula in 3.01 hours on average. Ninety-nine patients (54%) who were extubated to aerosol mask transitioned to RA in 2.39 hours on average. The cost of the aerosol mask set-up at UC Davis is $4.25 per set-up compared to $1.29; a cost savings $2.96/occurrence. Time to initiation of an aerosol mask was 10 minutes, between gathering equipment, set-up, and placing patient on the device as compared to 5 minutes with a nasal cannula.

Conclusions:

Current efforts are being made to identify patients requiring supportive needs with NIPPV and HFNC after extubation. However, necessary steps are needed to look at efficient healthcare in those being treated with unnecessary low-flow oxygen delivery devices. Additionally, newer ventilator models that incorporate not only NIPPV, but HFNC, will provide added cost savings benefits, value, and decreased waste when extubating all patient populations and differing levels of care.