(1508) Expansion of Emergency Department Extubation Criteria: Moving Beyond the Paradigm

Introduction: Emergency Department (ED) Extubation (EDx) is uncommon, yet expanding EDx could enhance health care delivery and reduce unnecessary ICU admissions. We developed an EDx clinical practice guideline (CPG) that assessed readiness-to-wean via a spontaneous awakening trial, spontaneous breathing trial, & Rapid Shallow Breathing Index (RSBI). We identified 5 criteria for EDx: resolved intoxication, resolved status epilepticus, intubated for safety/workup, resolution of acute respiratory failure (RARF), & palliative cases. The RARF criterion was theoretical as these patients did not typically undergo EDx before the CPG. Our objective was to analyze the clinical characteristics of the RARF subgroup.

Methods: This was a quasi-experimental study conducted at a US academic medical center. We examined outcomes of EDx for 64 months: 24 pre & 40 post (1/2019-5/2023). We identified EDx criteria, number EDx pre/post, EDx RARF subgroup & ICD-10 codes. We compared patient age, gender, comorbidities, dispositions, and length of stay.

Results: 66/130 underwent EDx CPG pre/post. EDx for RARF occurred only post-CPG in 8 patients. Primary ED diagnoses; obstruction of the upper airway, acute hypoxemic respiratory failure, bradycardia, cardiac arrest, intracranial hemorrhage, hypoxia, status asthmaticus, and hemorrhagic shock. Avg age: 51.5 years +/- 17.3. Male (2): 25%; Female (6): 75%. Avg comorbidities: 3.6/patient. Avg time intubated: 12.26 hours +/- 4.97. Avg RSBI 43 +/- 23. Disposition from ED: Med-Surg 75% (6), ICU 12.5% (1), Left Against Medical Advice 12.5% (1). Discharge destination: Home 87.5% (7), Psychiatric floor 12.5% (1). Avg days from EDx to discharge: 6.87 +/- 7.74 days. Overall length of stay: 8.12 +/- 7.75 days. No re-intubations in the ED or in-hospital mortality occurred.

Conclusions: We described a novel EDx CPG that included RARF, a population that had historically not been considered for EDx, with preliminary data supporting feasibility and safety. The study highlights the potential for EDx to improve patient care & resource utilization. Results suggest that ED physicians can safely extubate patients with RARF under a standardized CPG. This study is the first use of the RSBI in the ED we are aware of. Future studies can build on this work to further refine EDx.