An evaluation of the development and implementation of a clinical guideline for nurse led extubation of adult coronary artery bypass graft patients

Abstract

Research Question Does standardising nursing practice through the implementation of a clinical guideline for extubating adult cardiac surgical patients early improve patient care? Aims Evaluate the development and implementation of a clinical guideline for nurse-led extubation of adult cardiac surgical patients at one centre in the United Kingdom. Objectives Methods 1. Provide a systematic overview of the evidence base for early extubation (Hawkes et al., 2003). 2. Quantify the impact on professional practice of standardising care through the use of the guideline (interrupted time series (ITS». 3. Explore the results of the ITS and identify important factors for the successful implementation of the guideline (qualitative study). A mixed methods approach in a single case study was used. New evidence in the form of a systematic review, including a meta-analysis, of existing evidence for early extubation was used to meet Objective One. An ITS study was used to quantify the impact of implementing the guideline. The third objective was met through a qualitative study drawing on applied practitioner ethnography. The last two parts contribute unique evidence because there was no such existing evaluation of a nursing guideline for extubating cardiac surgical patients. Analysis The systematic review's meta-analysis used relative risk and weighted mean differences. The ITS analysis used exponential models to compare predicted values with actual values to assess the impact of the guideline. Qualitative data were analysed to identify themes, using the framework approach (Ritchie and Spencer, 1994). Results Early extubation reduces intensive care unit and hospital length of stay; the evidence for its impact on mortality and morbidity is weak. Evidence to support various decision making processes for early extubation is also lacking. The ITS demonstrated no changes in the outcomes studied. The guideline developed was a consensus of existing practice. However, while it did not change patient care, it maintained standards in a changing environment