Harbor:ED Extubation Checklist

• Harbor-UCLA Adult Emergency Department Extubation Checklist (for non-palliative patients ages 18 and above)
  • Pre-Extubation Assessment (Physicians and Nursing)
    • There is resolution of the initial intubation indication (e.g. Improved mentation after acute intoxication, completion of procedure, head trauma with improving mental status and negative neuroimaging)
    • The patient is alert and following commands
    • The patient is hemodynamically stable
    • The intubation was uncomplicated
    • The anticipated hospital course does not require mechanical ventilation (no upcoming procedures, surgeries, etc.)
    • The patient is low risk for laryngeal edema (if not, a cuff leak is present)
    • Patient passed a 15min Spontaneous Breathing Trial [RSBI <75 breaths/min/L] (Rapid shallow breathing index [RSBI] is calculated as Tidal Volume/respiratory rate)
  • Preparing for Extubation (Physicians)
    • Airway supplies are at bedside (airway tray, glidescope, suction, BVM, EtCO2)
    • Post-extubation supplemental oxygen is at bedside (e.g. NRB, HHFNC, BiPAP)
    • Physician, Nurse and Respiratory Therapist Huddle is complete with:
      • Discussion of patient pre-extubation assessment
      • Plan for sedation medications
      • Plan for post-extubation oxygen therapy
    • DHS ED Extubation Order set is placed in FirstNet
    • All unnecessary sedation medications are turned off per Huddle plan
    • Do NOT extubate unless someone who can immediately intubate is aware/in room.
• DO NOT PROCEED TO EXTUBATION UNLESS EVERY BOX ABOVE IS CHECKED
  • Extubation (RT)
    • Time out with Physician, Nurse and Respiratory therapist is complete
    • Ventilator FIO2 to is increased to 100%
    • All unnecessary sedation medications are turned off per Huddle plan
    • In-line ETT suction performed
    • ETT balloon is deflated
    • Patient is asked to cough while ETT (and OG tube if present) is removed
    • Patient’s mouth is suctioned
  • Post Extubation (Nursing)
    • Patient is placed on supplemental oxygen per Huddle plan
    • Nurses should re-assess every 5-15 minutes stay in the room for at least the first 15 minutes. Then every 30 -60 minutes. Cont with routine assessments until pt is stable.
    • Continue to assess for HDS, mentation, stridor and ability to oxygenate and ventilate closely for (at least) 1 hour. The first hour post-extubation is critical, and reassessments should be very frequent and clearly documented.
    • 30min Post-extubation POC VBG performed
    • Notify Physician of any concerning features including (increased RR, increased work of breathings, stridor, decreased oxygen saturation, tachycardia, bradycardia, hypotension, and decreased mentation)
    • Physician will determine if patient requires re-intubation or other advanced airway interventions