Dr. Dean Sandifer

Lakeland Medical Center

February 24, 2010

Jon Seiter, Michelle Payne, Ginny Temple

The things that are important to us are the monthly data that we use for our review of the SAT SBT process and the number of people who are determined to be candidates for an awakening trial and a breathing trial and the number of people who passed and the number and percentage of people who are extubated within x amount of time after their first passing of the SBT. Those are the kind of data things we are looking for.

Jon- how often did therapists perform protocols?

We had… the evolution of the process… when you start out is that there are many patients who are not properly screened and the nurse doesn’t do their part and the therapist doesn’t do their part and the doc doesn’t do their part so it’s hard to say what things made it better than any process that you work on is going to get better with time. Certainly automating things to determine whether they are done or not is certainly more accurate than somebody checking a check list or the list gets lost. I noticed on our last 2 or 3 months ICU committee meetings before we would have 70 or 80 patients who have Spontaneous Breathing Trials and I thought we’ve got 40 or 50 people on ventilators every day, that’s hundreds of days, hundreds of ventilator patients… I can’t believe we are doing 70 patients with SBT and then as we have gotten more automated that number has quadrupled because we are capturing the people that were actually doing SBT.

Prior to automating the Qualification and SBT process with Protocol Management Solution we were seeing an average of 70 patients per month now our numbers have quadrupled.

Jon- What do you attribute increase to:

I think it is the automation I mean its reminding people to do it, having them answer some questions that they can’t just gloss over. But we are also working… I mean the nurses are out of the loop with the computerization with the pulmonary program… they are doing better… they’re identifying patients, they are doing their safety screens, documenting their safety screens… so every aspect of it is better.

The increase in numbers are due to the automation. The automation reminds people to do the Qualification and Trial. They have to answer questions and can’t just gloss it over.

Jon- RTs More consistent with assessment?

Absolutely, we are doing it more often and you get a feel each day when you work 2 or 3 shifts and an RT doesn’t come up to you and say “Hey, I’ve got someone who’s 2 hours on a SBT and here are their parameters do you want to extubate or not?” There were times you would go 3 or 4 days and not hear that and then we’d have some refocus. The last 6 or 8 weeks that’s a constant part of your daily practice that the therapist calling or coming up to you and you swoop by and extubate them. It’s a part of the day that needs to stay a part of the day.

We are more consistent with our assessment. Before Protocol Management Solution it would be 3 or 4 days before an RT said that a patient passed the trial and asked us if they could extubate the patient. The last 6 or 8 weeks it’s now a constant part of our daily practice. Therapist’s are calling or coming up to you to extubate a patient. It’s a part of the day that needs to stay a part of the day.

Jon- Prior to solution, what data were you using?

All the data is the same. It’s just the data is accurate and more robust now. Before we were recording how many SBTs were done, how many were passed, what % that had a SBT passed, % and number of people who passed the SBT were actually extubated. Those kinds of nuts and bolts info were what we were looking for we were just collecting it a different way. The latest change was when we started out we wanted to know when… we hoped that people that people that passed their SBT would be extubated at a pretty high rate. But we knew there were other factors besides passing the SBT so we kind of globally, initially said let’s see what % of people were extubated within 72 hours of their first pass of the SBT. We have consistently been in the 85% range so we decided at our last ICU meeting to tighten that up and look at it again and see how many people were extubated with 48 hours. Ideally we will get to the point that we have targets that are same day. We are approaching it in a gradual way so we can see how we are doing.

Jon- Were you tracking the 72 hour time period before?

We started out 40 to 50% and then we got to 60 or 70 and then the last 6 or 8 months we have been above 80% and that’s what prompted us to narrow the range because of our consistent success over the 72 hour period.

Jon- to what do you attribute the success?

We are doing about 3 or 4 big ICU protocols and they all have in common that they are complex and involve a lot of people in different disciplines and they require repetition and they push people to incorporate things in to their daily practice that they didn’t use to do. That human process is rewarded by a restaurant gift card or by an e-mail that says this nurse or therapist did a really great job with this exercise and here’s how it went. Sometimes it is a constructive criticism i.e. we had this person that met the criteria for an awakening breathing trial and yet they didn’t because of a reason that’s really not a reason. So repeating and analyzing and having one on ones and reinforcing it in nursing and respiratory meetings are the kind of things that gradually allow big groups of people to take on these new tasks. And certainly any part of it can be computerized that makes the person answer questions… is this patient a candidate, did this pt have a safety screen, yes or no…did you answer those questions … if you don’t have a computer people can wad up the piece of paper and throw it in the trash or they can say they lost the paper or say I didn’t think of that…so the more computerized it can be the less it can hide. You have to address it.

It is difficult for any hospital to do this. There are people who write these articles but you go talk to them at a meeting and they are not doing it with any reliable frequency. It takes a lot of effort to sustain these big projects. The computerization can help us do it even better in the future.

Jon- Reintubation rate impact with PMSol?

The last time we looked at it we were about 15% and we felt that it was in the ballpark range of where we should be if we were being appropriately aggressive. And we talked about …. We are going to get more up to date data about reintubation rate.

Jon- Change before and after with PMSol.

Our reintubation Rate must be up because we before just sat on people and we didn’t extubate until everybody and their brother thought they were ready to extubate. And so we didn’t have that many re-intubations. Reintubations were rare because we were so unaggressive at extubating.

Jon- How was your VLOS after PMSol

Question of how we’re are going to measure that… how do we mearsure that … the numbers I have in my head are based on ICU sheets from all of the ICUs during the hospital stays the nurse kind of checks when the pt went on vent, when they were extubated... if they went back on the ventilator… if they were extubated they kind of count total number of days on the vent per stay. By the strict definition some of those people may have had 3 vent stays of 10 days verses 1 ventilator stay of 30 days. But this method that we have historically used does not break down vent days in to sub groups like that. And ideally if we are going to compare our numbers to other centers we have some strict rules… that if you are reint within 48 hours that is a failed ext. and the vent day count continues. If you are int. 4 days later that is a new intubation. A new day #1. I’d love to have our computerization do that for us… that in itself would lower our vlos. Now that being said our overall vlos is only about 4.2 days and it certainly has been in the 5 and 6 range 2 or 3 years ago before we got aggressive with our program. It might be even lower if we had some breakdown of some of those reintubation ______.

Michelle- comments to Dr. S. Confirmed that we could calculate the vlos however they would like to.

That would be great.

Jon- Reports on the numbers.

I think without a doubt, the VLos is getting a shorter. But it is that multi-pronged reason it’s getting shorter but whether PMSol is 60%, 30% can’t say.

This is proven therapy. If you evaluate every vent pt with an awakening trial and alter their sedation so that they can interact with you if they need to, if sedation needs to be altered, and then following with a breathing trial and following with extubation … if you do those things your los is going to go down there’s no doubt about it. Using the avail tools to help you do that there’s no question that when the players have to address these issues because the computers won’t let them do the next step until they do, that is a huge plus. If we could have the nurses in a computerized way, that would be even better but we are a long way off from having a computerized process throughout with the drs. And the nurses and it’s helpful.

I would use the highlighted area as is.

Jon- Do you use PMSol to determine the multi-disciplinary plan of care.

There seems to be many additional opportunities with data and info that we could utilize that we’re not utilizing and we started out with the idea that we’re gonna take the day to day RT process and computerize it so we could track a lot of different things. But to date our focus has been on SBT and our ability to extubate based on that. But there’s lots of other stuff in there that we can tap and tweak it’s just that we are so focused on this plan A deal that we haven’t gotten to plan B but the hope is that we’ll be able to mine lots more data and make changes elsewhere when we get this under our belt.

Jon- Anything else?

It’s been interesting to see the conversion of the therapists who have not been using any computer activity… and then they are asked to use this to manage their day and delineate their time and the general attitude of disgust and frustration that has gradually turned into part of their day and part of their life and you never hear that negatively that you did before. It’s been interesting to see how that works and trying to streamline data entry and make it as easy for them to improve workflow. Seems like we’ve made progress in those areas because you don’t hear them complaining like you used to.

Jon- Was implementing a challenge?

That’s not to be underestimated. HUGE deal , always received… even those who are gung ho and positive at first are overwhelmed by the changes in their day and takes weeks, months to really make it a part of your day and make it something you do verses some extra thing that is killing you.

Michelle’s offer to change calculating length of stay.

If we can go back and do some of that because I think in 6 mo or a year we will have a data set of…. SBT, SAT, extubation data… that will be extraordinary that we can publish in abstract form at least if not more. I really have that as a goal by t he end of the year … cuz everyone I talk to they do this in one ICU or doing it reasonably well but there are not 70 ICU beds doing this process with this magnitude. We would have some very attractive data to publish.

Michelle- observations already in system, just need to reconfigure report.

Jon- Asks about publishing case study.

The kind of things that ICU docs and directors are interested in the process, how successful was a private hospital at implementing this proven therapy and what kind of impact did it have on the key variables? This is nuts and bolts critical care is the implementation of proven therapy in day to day practice. We were invited to an international congress because of our work with sepsis and the next big publishable process is this SAT SBT. There are lots of hospitals that say that yeah that’s a good idea and I would love to do it but… how the hell did you do that? If you go to all t hat trouble, how much does it really help?? We can help answer some of those questions. We can do it and we don’t have residents or interns. And by doing it here is the kind of impact we had on our vlos. Those questions are yet to be answered and we can help answer them.

·  As we have become more automated with our SBT protocols, our number of patients who ______(don’t know how to word it) quadrupled.

·  It is proven therapy that if you follow SBT protocols, your Ventilator Length of Stay will go down. Automating the process, however, requires all players to address each issue and does not allow them to move on to the next step until they comply. This is a huge benefit to our patients as well as gathering critical data.

OR:

·  It is proven therapy that if you follow SBT protocols, your Ventilator Length of Stay will go down. Automating the process, however, requires all players to address each issue and does not allow them to skip steps in evaluating the patient until they comply. This is a huge benefit to our patients as well as gathering critical data.

·  The RTs are assessing the patients more often and the automated assessments are consistent and thorough.