Clinical Audit on Reintubation,

Weaning Criteria & Extubation Criteria

 AIM
• To decrease incidence of VAP in mechanically ventilated patients.
• To decrease length of stay in ICU of mechanically ventilated patients.
• To decrease the mobidity and mortality of mechanically ventilated
patients.
• Thus to improve health care services of Mechanically ventilated
patients by health care providers.
Audit Initiated July -2018

Responsible team members for clinical audit Dr. B.K.S.Sastry

Dr. Mustafa Afzal
Dr. Pramodini B Dandekar
Dr. Abhay R Kulkarni
Dr. Parimal B
Dr. Kushal
Sr. Jayasree,
Sr. Mamatha
Sr. Manju bhargavi
Incharge Manu Mathew
Incharge Kanakarani T
Incharge Sibi Jose
Nurse Bindu Antony
Sr. Shanthi
 Reintubation within 48hrs Audit Jan to Aug- 2018

Exclusion Criteria Inclusion Criteria

ICU No.Of pts Intubated No.of Re intubations within Audit results
48 hrs

Justified Not justified

ICCU 98 1 1 0

MICU 122 1 1 0

IMCU 32 1 1 0

NICU 50 0 0 0
Total 302 3 3 (100%) 0
Gen.Surg 730 1 1 0

Neur.Surg 405 0 0 0

CT. Surg 425 7 4 (57%) 3 (43%)

Total 1560 8 5 (63%) 3 (37%)

Over all Out come No. Of Discharge - 7 No.Of death - 4 (CT Surgery-3 , ICCU -1)
 Re intubation audit observations
• Clinical Audit of Re-intubation rate in ICUs OF CARE Hospital Nampally.
• Period: 1 year.
• Observations: High morbidity & mortality associated with mechanically ventilated
patients.
• There was no common protocol of weaning and extubation of ventilated patient in the ICU
• No particular speciality was made responsible for weaning/ extubation of patient
• Documentation of weaning and extubation was lacking in the IP records

• But disparity in the incidence of re-intubation rate.

• Audited reintubation rate was very low as compared to actually number of reintubation
done in the our hospital.
• Introduction of sub –audit: “ Designed weaning and extubation protocol” on the basis
of guidelines published by American College of Chest Physicians and American Thoracic
Society.
• Observation: Under reporting of re -intubation cases and hence incomplete explanation
of increase mortality and morbidity associated with mechanically ventilated patients.
 Introduction of the sub audit
• In order to fillup the gap of under reporting of reintubation cases but
increase morbidity and mortality of mechanical ventilated cases
compelled to introduce sub audit in the form of
“ clinical audit on weaning criteria , extubation criteria”.
Commitee of anaesthesiologist critical care specialist had multiple
meetings to decide and design the protocol for clinical audit on
weaning criteria and extubation criteria which was subsequently
finalized and sub audit started.
All the department concerned with delivery of mechanical ventilatory
care to the patient where given lecturers and training about the
clinical audit.
 Methodology

1. Infection control nurse will do the surveillance on ventilator patients in all

critical care areas daily.
2. Handing over extubation criteria forms to all concerned ICU Incharges to
fill the extubation criteria forms in co-ordination with critical care
consultants and anesthetist.
3. Handing over filled proformas to the auditors for anlysing and justifying
the extubation criteria protocol.
4. Auditor returned the forms to Infection control department for
documentation and monthly presentation in HICC Meet.
5. What ever short fall noticed while auditing were discussed and
reexplained to all ICU doctors, ICU Nurses and Respiratory therapist to
practice weaning protocol.
 Extubation criteria followed as per policy July & Aug- 2018
Exclusion Criteria Inclusion Criteria
ICU No.Of pts No.of pts No.of pts No.of pts No.of Pts No.of Compliance of Audit results
Intubated Extubated Expired Tracheostomy went on extubation following
within 48hrs done LAMA s done Extubation criteria
(Surgical
cases) Followed Not Justifie Not
follow d justifie
ed d
ICCU 19 - 6 1 2 10 10 10
(100%) (100%)

MICU 33 - 16 5 4 8 5 (63%) 3 5 3
37%) (63% 37%
IMCU 3 - 2 1 0 0 - - - -

NICU 12 - 5 4 1 2 0 2 0 2
Total 67 - 29 (43%) 11 (16%) 7 (10%) 20(30%) 15(75%) 5 5 5
(25%) (75%) (25%)
Gen.Surg 140 139 1 - - 0

Neur.Surg 99 95 1 - - 3 2 1 2 1

CT. Surg 96 93 2 - - 1 1 1

Total 335 328 4 - - 4 2 2 2 2

 Results of introducing sub audit

• Reporting of re-intubations and visibility of unreported re-intubations

were captured easily.
• Early preventive interventions could decrease the morbidity and
mortality.
• It helped us to widen the exclusion criteria for exceptional cases like
cyanotic congenital heart disease cases, Severe pulmonary
hypertension cases.
• Continuous training of medical and paramedical personnels reduces
overall morbidity and mortality due to reintubation.