1. Night-time extubation does not increase the risk of
reintubation, length of stay, or mortality:
Experience of an anesthesia-based airway management model
in a large urban teaching hospital
Kelly Kathleen Everhart MD MS  University of Washington Medical Center
5 May 2017
Before I embarked on the study of medicine, I was a geologist by training. At Harborview, our TICU is located on the 9th floor, offering an excellent view of Rainier on a clear day. This particular profile was sketched by a member of the Charles Wilkes USGS Cascade volcano expedition in 1841.

2. Seattle, Washington Washington DC
Connecting with friends and colleagues in Washington DC, I now realize that we have so much in common. Not only do we share the name of our illustrious founding father, we both enjoy a magnificent display of cherry blossoms in front of pointy state icons. It is an honor and a pleasure to be here speaking with you today.

3. Sarah M Khorsand MD Nita Khandelwal MD MS Margaret Lind MPHc
University of Washington Medical Center
Nita Khandelwal MD MS
Harborview Medical Center
Margaret Lind MPHc
University of Washington
Aaron M Joffe DO FCCM
I would like to take a moment to thank my project collaborators, without whom this project could not have succeeded. This is another sketch of Rainier from the same expedition.

4. BACKGROUND
Extubation failure is common in the intensive care unit (ICU) and may increase morbidity, resource consumption, length of stay (LOS), and mortality1.
Night-time extubation in patients requiring mechanical ventilation (MV) for longer than 12 hours may confer increased risk of ICU and hospital mortality2.
It is unknown if night-time extubation confers additional risk of morbidity, mortality, LOS, and resource consumption in care models in which experienced airway managers are available 24/7.
Harborview Medical Center (HMC) is a Level I Trauma and Burn Center serving AK, MT, ID, WY, WA. HMC capacity includes 88 ICU-level beds.
Extubation failure is common in the intensive care unit (ICU) and may increase morbidity, resource consumption, length of stay (LOS), and mortality1.
Night-time extubation in patients requiring mechanical ventilation (MV) for longer than 12 hours may confer increased risk of ICU and hospital mortality2.
It is unknown if night-time extubation confers additional risk of morbidity, mortality, LOS, and resource consumption in care models in which experienced airway managers are available 24/7.
Extubation failure is common in the intensive care unit (ICU) and may increase morbidity, resource consumption, length of stay (LOS), and mortality1.
Night-time extubation in patients requiring mechanical ventilation (MV) for longer than 12 hours may confer increased risk of ICU and hospital mortality2.
Extubation failure is common in the intensive care unit (ICU) and may increase morbidity, resource consumption, length of stay (LOS), and mortality1.
1.Predictors of reintubation in critically ill patients. Miu T, Joffe AM, Yanez ND, Khandelwal N, Dagal AH, Deem S, Treggiari MM.Respir Care Feb;59(2):
2.Association Between Overnight Extubations and Outcomes in the Intensive Care Unit.Gershengorn HB, Scales DC, Kramer A, Wunsch H.JAMA Intern Med Nov 1;176(11):

5. AIM
To investigate the relationship between night-time extubation and risk of reintubation, hospital LOS, and mortality within the 24-7 anesthesia-based airway management model at HMC.

6. METHODS Retrospective cohort study Inclusion criteria:
Multivariate analysis performed with STATA v14
Adjusted for age, sex, BMI, Charlson Comorbidity Index using Poisson regression
Inclusion criteria:
Adults (age ≥ 18 years)
Underwent MV at HMC
Study period 7/1/2015 to 12/31/2016
Exposure Outcome
Night-time extubation Reintubation rate
Defined 1900 to Hospital LOS
Mortality
Exclude routine post-operative MV
Defined as extubation within 24 hours

7. RESULTS Extubations at HMC N 2683 Extubations at HMC N 2539
Initial Study Population
Extubations at HMC
7/1/2015 to 12/31/2016
N 2683
Exclusion
Duplicate/Incomplete
N 22
Pediatric Patients
N 122
Study Cohort
Extubations at HMC
7/1/2015 to 12/31/2016
N 2539

8. RESULTS Extubations at HMC N 2539 Extubations at HMC N 2208 (187)
Study Cohort
Extubations at HMC
7/1/2015 to 12/31/2016
N 2539
Routine Post-operative MV
N 331
Subset
Extubations at HMC
7/1/2015 to 12/31/2016
N 2208 (187)
Of 2208 patients who underwent extubation outside of routine post-operative care, 187 were extubated overnight.

9. CONCLUSIONS
Within a care model in which experienced airway managers are available and responsible for all out-of-operating room airways:
Within a care model in which experienced airway managers are available and responsible for all out-of-operating room airways:
Night-time extubation was not associated with an increased risk of reintubation or hospital mortality
Night-time extubation was significantly associated with a shortened hospital LOS.
In healthcare systems with care models similar to ours, night-time extubation appears safe and may improve resource utilization in select patient cases.
Within a care model in which experienced airway managers are available and responsible for all out-of-operating room airways:
Night-time extubation was not associated with an increased risk of reintubation or hospital mortality
Within a care model in which experienced airway managers are available and responsible for all out-of-operating room airways:
Night-time extubation was not associated with an increased risk of reintubation or hospital mortality
Night-time extubation was significantly associated with a shortened hospital LOS.

10. Questions?
Thank you.