It Is Well Documented That Prolonged Mechanical Ventilation Time Increases the Risk Of

Overview:

It is well documented that prolonged mechanical ventilation time increases the risk of ventilator associated pneumonia (VAP), and length of stay in ICU and hospital (LOS). According to the Surviving Sepsis 2008 guidelines and multiple other randomized control trials, weaning protocols utilizing daily spontaneous breathing trials (SBT) and daily awakening trials (DWT), (often performed by non-physicians), are known to decrease ventilator time and cost, and improve outcomes.

It is also been demonstrated that implementation gaps exist in intensive care. In MHH MICU between May 2008 and April 2009, 547 patients were ventilated for a mean time of 141.4 hours. During that time, only 65% of MICU patients are placed on a weaning protocol utilizing daily SBT. A subset of 312 (43%) of patients were on ventilators between 48 and 336 hours (2 -14 days) and was selected as the focus for the initial intervention. Their mean time on a ventilator was 139.9 hours.

The daily sedation holiday used in the Kress, et al trial decreased ventilator time by up to 2.4 days (60 hours). Within 48 hours of extubation, there was a 17.6% re-intubation rate in the intervention group and a 30% re-intubation rate in the control group. The “wake up and breath” protocol from Girard and Kress et al, using both SBT’s and sedation holidays reduced ventilator time by 3.1 days.

Previously at our institution orders for sedation holidays were written at the discretion of the residents on a day to day basis. A protocol for daily SBT’s existed but not fully implemented, moreover,there was no place for documentation in our electronic medical record (EMR, CARE4/Centricity®). As our off-set parameter, we intend to maintain the re-intubation rate close to the national average of 10%.

Since the initial implementation in the Medical ICU in 2009, we have extended the daily SBT protocol to other ICU’s including the Transplant ICU (TSICU), Neuro-Trauma ICU (NTICU), the Heart and Vascular Institute (CCU and CVICU), Shock-Trauma ICU (STICU), and Burns ICU. We now have 3 years of follow up data.

Aim Statement:

•Decrease mean ventilator time for patients by 10%.

•Extend the protocols into other ICU’s

•Decrease the frequency of ventilator associated pneumonia (VAP)

Measures of Success:

•Increased percentage of patients on weaning protocols

•Decreased ventilator time for targeted patient population

•Increased percentage of patients receiving daily sedation holiday

•Decreased ICU length of stay for selected patients

•Maintain re-intubation rate (target <10%)

•Track Compliance with wean protocols

•Improved documentation in the EMR

Use of Quality Tools:

Check sheets tracked observations of compliance to key factors of protocol bundle including all-or-none compliance.

A Measurement System Analysis (MSA) and a 2 x 2 table further detailed discrepancies in compliance and documentation.

A fishbone identified causes of non-compliance and led us to focus on technology modifications.

Brainstorming sessions gathered staff input into process breakdowns and improvement areas.

Detailed process maps using Swim-lanes, clarified existing processes and identified solutions.

Histogram of length of time on ventilator narrowed the subset of patients to focus on for this project

Interventions:

•Educated RNs and RT’s to highlight problems and clarify processes

•Linked SBT protocol daily to the ventilator order set to ensure the task was created and followed daily

•Demonstrated at the critical care counsel the data entry sheets to the entire intensive care faculty.

•Over 2 academic years extend the pilot program from the MICU to each of the other ICU’s at MHH-TMC

•Educated the entire RT staff in all units to the importance of SBT’s and the appropriate documentation of the process

•Identified process difficulties and technology limitations

•Removed residents from decision making/ordering sedation holiday

•Standardized definition of “on” and “off” protocol

•Required a daily sedation holiday for all patients that qualify (allow the timing varies by ICU)

•Created sedation holiday to be an automated computer task for the RN’s

•Changed sedation holiday from one-time physician order to unit protocol which is nurse driven

•Updated sedation holiday form in CARE4 and clarified exceptions

•Educated nursing staff how to document “not indicated” for sedation holidays rather than “not done”. Efforts have continued for appropriate documentation because now sedation holiday are electronically tracked rather than on paper

•Developed a new form in CARE4 to document SBT in a clear, consistent format

•Designed new process to ensure RN and RT collaboration

•Updated SBT protocol documentation

•In CARE4, directly connected SBT screen result to the form for the actual SBT

•Ensured that all intubated patients were screened for SBT on a daily basis

•Added a field in Vent Data Base to track results

•Eliminated paper documentation which allows repeated viewing of the results of SBT’s

Results:

WITHOUT TRACH PATIENT EVENTS

FY 2008 / FY 2009 / FY 2010 / FY 2011 / FY 2012
Total Ventilator Events / 17,052 / 18,723 / 16,238 / 14,969 / 14,476
Number of re-intubations 48 hours / 104 / 84 / 113 / 111 / 143
Percent / 0.66 or <1% / 0.44 or < 1% / 0.69 or < 1% / 0.74 or < 1% / 0.98 or < 1 %
Number of re-intubations 24 hours / 28 / 21 / 42 / 18 / 55
Percent / 0.16 or < 1% / 0.11 or < 1% / 0.25or < 1% / 0.12 or < 1% / 0.37 or < 1%

Revenue Enhancement /Cost Avoidance /Generalizability:

We recognized that even though protocols exist, frequently they are not used appropriately or to their full extent. We must standardized documentation and definitions to ensure full usage of protocols. Implementation of electronic documentation not only eliminated the former paper process but assured that results are available to any caregiver at anytime.

Utilizing a weaning protocol with daily spontaneous breathing trials and daily sedation holidays did not increase the rate of re-intubations and so far is less than the rate identified in the JP Kress, et al study from University of Chicago in 2000.

Combing both daily SBT’s with daily awakening trials will significantly decrease the number of days on the ventilator. A VAP adds an estimated cost of $57,000 to a hospital admission. At our institution in the MICU, we estimate a cost avoidance in fiscal year 2009 (between July 2009 and July 2010) of $901,000. In most of the ICU’s we have decreased the mean ventilator time by about 1 day which equates to 1 day save in the ICU per patient admission which saves about $1500 per patient ICU stay. Since this is happening in multiple ICU’s simultaneously, the cost avoidance is multiplied.

We also decreased the amount of drugs delivered and decreased the daily cost of drugs in the ICU but we did not put a dollar amount on this since the sedation holiday portion of the project is still evolving and will be reported separately

Conclusions and Next Steps:

Since the initial pilot project in the MICU, we have standardized the protocols and the documentation. We have extended the use of the SBT protocol into the rest of the ICU’s. We are now seeing, slowly, the decrease in the ventilator time we anticipate. We expect continued success and the protocol is being considered to extend system wide to the 9 hospitals in the Memorial Hermann system.

With investigation, we discovered multiple areas for improvement around our use of daily sedation holidays and SBT’s. First, we eliminated resident physician decision making, allowing daily sedation holidays in all patients who met set criteria. By streamlining the system and allowing for electronic documentation of events, we were able to improve compliance with the protocol and decrease the total time on the ventilator and the length of stay in the MICU. We continued to expand our project by education of all respiratory therapists in all ICU’s in our hospital and now allow for standardization of documentation of results. We intend to monitor full implementation for follow-up and data collection. Eventually, we plan implementation and utilization of forms and protocols throughout all ICU’s at MHH and system wide. We are currently exploring delays in extubation. We are no documenting patient passing his/her SBT but not immediately getting extubated. If we can identify the causes, we can continue to decrease vent days.

Appendixes

Measurement System Analysis 2 X 2
Documented on Protocol
No / Yes / Total
Observed on Protocol / No / 7 (9%) / 23 (28%) / Correctly Documented / 45 (55%)
Yes / 14 (19%) / 38 (46%) / Incorrectly Documented / 37 (45%)
19 (23%) / 61 (74%) / 82 (100%)

References

Ely, EW, Baker, AM, Dunagan, DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. New England Journal of Medicine 1996; 335:1864-1869

Kollef, MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Critical Care Medicine 1997;25:567-674

Kress, JP, Pohlman AS, O’Connor MF, Hall, LB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine 2000;342:1471-1477

Hooper MH and Girard TD. Sedation and Weaning from Mechanical Ventilation: Linking Spontaneous Awakening Trials and Spontaneous Breathing Trials to Improve Patient Outcomes. Critical Care Clinics 2009;25:515-525

Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing controlled trial): a randomized controlled trial. Lancet 2008;371:126-132