Practitioner led extubation in recovery: a report into viability in the post anaesthetic care unit.
Abstract: Patients entering recovery often have a requirement for their airway to be managed. This can be performed in a variety of ways: either by having an airway adjunct placed in-situ, or by airway manoeuvres performed by recovery practitioners (Scott 2012). One of the adjuncts that patients may have is the endotracheal tube [ETT]. Traditionally patients have been extubated before leaving the operating theatre, with trained anaesthetic assistants helping the anaesthetist to remove the airway in a safe and controlled environment. Alternatively the anaesthetist extubates in recovery with experienced recovery practitioners.

KEYWORDS Extubation / Recovery / Extended roles
Article Type: Report
Subject: Professional development
Author: Harvey, Paul
Pub Date: 09/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Sept, 2012 Source Volume: 22 Source Issue: 9
Accession Number: 309315285
Full Text: However, there has been a drive in my employing trust to allow the recovery practitioners to extubate in recovery, without the anaesthetist present. The rationale for this was to improve the throughput of patients and relieve the anaesthetist to move on to the next patient, therefore improving productivity and efficiency. I also think that there was an element of providing a more substantive element of professional development opportunities for those that work in the postoperative field. With this in mind, I was asked by the principal Operating Department Practitioner to explore the viability of this practice by approaching another local trust that was known to extubate in recovery area. I contacted the other trust and asked them whether this procedure was still practised and if so, what the guidelines and criteria were that directed their practice.

The Association of Anaesthetists of Great Britain and Ireland (AAGBI 2002) does provide some guidance on this practical concept, clearly stating that 'the removal of tracheal tubes from patients in the recovery room is the responsibility of the anaesthetist'. However they also declare that the standards require continuous updating and reviewing and this particular guideline document is currently being reviewed (AAGBI 2002). Whilst the Association for Perioperative Practice [AfPP] does not have any direct guidance, I contacted them directly. Through an emailed response their professional advice service stated strongly that they felt that practitioner led extubation is an unsafe practice and has significant risk associated with it and that there should be the essential equipment (anaesthetic machine, monitoring etc) and experienced practitioners close by. However, AAGBI (2002) further states that the provision of good quality of care during recovery from anaesthesia and surgery relies heavily on investment in the education and training of recovery room staff. Arguably then, this could offer new and exciting opportunities for recovery practitioners to develop clinically and professionally, especially as intensive care nurses frequently extubate in the ICU without doctors present.

Having emailed the other local trust with the request, I decided that it might be prudent to explore what other trusts nationally practised. I sent 156 emails to all the trust PALS departments, discounting children's hospitals and received 48 emails back with definitive answers. This was a response rate of only 30%. Whilst this was disappointing, it did enable me to provide a good idea of the current practice nationwide. I sorted through the answers and split the responses into three groups: practitioner led extubation was practiced/practitioner led extubation was not practiced/extubation in recovery was practiced with an anaesthetist. The table below demonstrates the responses.

The trusts were asked to provide the incidence of practitioner led extubation in recovery. I also enquired about what criteria they set to extubate and what staff training or experience was required before extubation could be practised.

For several of the trusts that did practice extubation in recovery, it was deemed essential that staff had at least 5 years experience. Some other trusts insisted on staff having undertaken a dedicated recovery course with extubation as a definite competency within it, or an in house training course with theory and practice assessed by consultant anaesthetists.

Several trusts responded that they used to extubate but, in line with the AAGBI (2002) guidelines, they had changed their practice reverted back to ensuring that the anaesthetist retains the responsibility of extubation. One trust questioned whether the anaesthetist was properly discharging their authority and responsibilities by handing over the patient to the recovery staff before the patient was extubated.

One trust provided evidence, through an internal audit of anaesthetic complications, that there was a bigger risk from removing laryngeal masks than ETTs. They also suggested that their anaesthetists were keen on the practice of practitioner led extubation as this 'freed' them up for the next case. However, anaesthetists would remain present if there was any indication of difficult or complicated airway.

The largest amount of comments was about competence. Several replies argued that there needed to be a definitive training programme to ensure that the staff obtained competence. Equally there needed to be an explicit protocol to ensure that staff remain competent after training.

Therefore, in order to ensure that the Nursing and Midwifery Council and the Health Professions Council codes of conducts are not breached, there are several issues that need addressing before the practice of practitioner led extubation in recovery occurs:

* Training of staff and anaesthetists. Anaesthetists need to be aware that there is a protocol in place and that not all patients can be brought into recovery intubated and then extubated by recovery staff. Recovery staff also need to be aware that this is a new practice and be prepared to develop themselves and their practice.

* Staff need to gain competence and, once gained, ensure that competence is maintained i.e. that there are sufficient numbers of qualified extubations to ensure that competence is maintained.

* Communication. There will need to be better handovers from theatre staff/ODPs and anaesthetists to recovery staff.

In order to resolve the above issues there needs to be a significant change in the following:

* Theatre policies and procedures need to clearly define the criteria for when, where and by whom patients are to be extubated.

* A definitive training package needs to be in place to ensure that recovery staff become competent.

* An audit needs to be carried out to monitor how many patients require extubation in a regular working week.

Overall, I think that the practice of practitioner led extubation in recovery is a good idea in principle. It will expedite the recovery process, freeing up the anaesthetist faster, increasing the throughput of patients in theatre and making the theatre much more productive. It also will allow recovery practitioners to develop new skills and enhance their own professional development. However, there does need to be several important safeguards in place to protect both patients and recovery staff.

References

Association of Anaesthetists of Great Britain and Ireland 2002 Immediate Postanaesthetic Recovery London, AAGBI

Scott B 2012 Airway management in post anaesthetic care Journal of Perioperative Practice 22 (4) 135-8

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Correspondence address: Paul Harvey, Recovery Nurse, Burton Hospitals NHS Foundation Trust, Queens Hospital, Belvedere Road, Burton-on-Trent, DE13 0RB.

Email: p.a.harvey@sky.com

About the author

Paul Harvey

BSc (Hons), PGCE, RN (Adult)

Recovery Nurse, Burton Hospitals NHS Foundation Trust, Queens Hospital, Burton-on-Trent

No competing interests declared
Nurse led          Nurse led          Extubation in
extubation         extubation         recovery with
IS                 IS NOT           anaesthetist
practiced          practiced

N           % of    N           % of    N         % of
            total              total             total

11             23  20             42   17           35

Total Responses = 48
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