From the 2019 HVPAA National Conference
Mrs. Holly Zurich (Yale New Haven Health)
Background
Optimal recovery after thoracic (lung) surgery is achieved by a patient’s ability to participate in a rigorous regimen of pulmonary hygiene and mucus clearance. Such optimization reduces the risk of pneumonia and/or respiratory failure requiring intubation. In patients who cannot clear airway secretions, performance of an early bronchoscopy to manually clear secretions may mitigate the progression of poor pulmonary toilet to respiratory failure. This procedure was performed in the operative room (OR), intensive care unit (ICU), and stepdown unit (SDU) with variations in the process and standards of care. Trainees, APPs and RNs familiarity with the procedure was variable.
Objective
Develop safe practice guidelines for the performance of bedside bronchoscopy following thoracic (chest) surgery. Demonstrate that bedside bronchoscopy is a clinically effective tool to reduce postoperative complications, facilitate discharge, and to optimize resource utilization.
Methods
Following best-practice guidelines, the clinical redesign team developed a safe and effective means of performing bedside bronchoscopy procedures in a monitored (SDU without conscious sedation. The collaboration of regulatory staff, pharmacy, anesthesia, thoracic surgeons, APPs, RNs, respiratory therapists, and pulmonary medicine enables the clinical redesign team to establish a clear procedural policy, including the following: 1.) standardized procedural documentation, 2.) concise EMR Order Set with appropriate medications and orders, 3.) Standard Policy and Procedure which was linked directly to the Thoracic Bedside Bronchoscopy Order Set for easy access to all staff, 4.) Bedside Bronchoscopy dashboard to monitor metrics and compliance.
Results
Thoracic surgery piloted 10 bedside bronchoscopy procedures following our project’s standardized protocol from May 2018-Mar 2019 on SDU. Patients with an oxygen requirement of <4L nasal cannula were deemed appropriate candidates. Patients were required to be awake and alert, demonstrating competency to sign consent. Indications for bedside bronchoscopy included atelectasis, mucus plugging, or inability to clear airway secretions as deemed by the surgical team. All procedures occurred postoperative day 2 to day 4. No conscious sedation was utilized. Use of benzodiazepines or other such medications that might impair respiratory drive were contraindicated. All patients were given local anesthesia with nebulized 1% Lidocaine as well as atomized Lidocaine to the vocal cords, followed by bronchoscopic Lidocaine to the tracheal carina. Bronchoscopy was performed by both a faculty member and an APP or senior resident. No complications or transfers to ICU were identified. Of these patients, the median LOS was 7.5 days (mean LOS 7.1 days). Post-hoc analysis identified smoking history of >30 years to be strongly associated with postoperative secretions requiring bronchoscopic intervention. Surgical approach of thoracotomy also appeared to be a risk factor. Historical controls included 14 post-lung resection patients Jan 2016-Nov 2017 (not having early bronchoscopy) transferred to ICU for clinical decompensation associated with respiratory failure requiring reintubation were evaluated. Of these 14 patients, the median LOS was 15.5 days (mean LOS 20.3 days)
Discussion
We demonstrated the safety and feasibility of a standardized protocol for early intervention bedside bronchoscopy on the SDU of our primary thoracic oncology floor, driven by clinical and/or radiographic findings concerning for poor pulmonary toilet.
Implications
Collaborative interdisciplinary teamwork was used to create a standardized, best-practice bedside procedure and policy. Bronchoscopy can now be performed in a consistent, safe and effective manner at the bedside, and no longer requires utilization of the operating room, a procedural suite and/or intensive care resources.
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