1997 OPEN FORUM Abstracts
Standardization of Technology: A Case Study
Celeste Beal, RRT, Monday, December 8, 1997
Many larger institutions utilize both advanced ventilators and ventilators with limited capabilities. In addition, several different makes and models are available which may serve to confuse the decision making further. When a patient's condition deteriorates and the ventilator currently used is not able to support the patient, there may be unnecessary delay while another more appropriate ventilator is found. Standardization of ventilators results in a continuum of care regardless of patient condition. It may also improve understanding and correct utilization of the modes available on the ventilator. Additional benefits to standardized ventilator equipment are: i) ease of maintenance for the biomedical department, ii) less inventory of spare parts and preventive maintenance kits, iii) increased familiarity among nurses and physicians, iii) more rapid training of new respiratory staff. Standardized equipment may also result in improved outcomes secondary to the possibility of protocol development utilizing the ventilatory modes available on the equipment. In 1977 we started to utilize pressure control ventilation (PCV) with the Servo Ventilator 900B and found that PCV had some advantages compared to IMV and volume control (VC). In the early 1980's PCV became a standard mode of ventilation as discussions of baro/volutrauma started to surface. Weaning modes such as pressure support (PSV) was introduced in order to speed up the weaning process. In recent years yet another pressure mode of ventilation was introduced, pressure regulated volume control (PRVC). During this time our institution has continuously utilized one make of ventilators that have offered these modes. Additionally, since 1993, our ventilation management protocols mandates that patients with peak airway pressure greater than 38 cm H2O are switched from SIMV + PSV to either PRVC or PCV. To evaluate the impact of this strategy we retrospectively reviewed the outcomes in terms of ventilator length of stay (VLOS) and possible cost savings. A meta analysis of published results of ventilator outcomes variables was also utilized to compare our results to other institutions of similar size.
Methods: Retrospective review of 2363 patients entered into the respiratory department data base and ventilated according to protocols during years 1993 - 1996. Using 1993 as baseline year changes in VLOS and mortality in respiratory failure patients were analyzed. Comparisons of VLOS and mortality between this study and patient groups of similar severity and age, coming from institutions of similar size was made.
Results: Ventilator length of stay in days was reduced in all years except 1996 (Table). Our average length of stay for the years 1993-96 was 6.4 days compared to 10.1 days for the meta-analysis. In terms of mortality (Table) there was a significant difference (p < 0.0001) between our data (21%) and data obtained from the meta-analysis (51%).
YEAR 1993 1994 1995 1996
NO of PAT 566 591 628 578
VLOS 8.2 6.2 6.8 5.9
MORTALITY 25 22 18 19
Conclusion: Although the reduction of ventilator length of stay was not statistically significant, there may be a real financial impact. Compared to the meta-analysis our VLOS is approximately half of the published average. When comparing mortality, many confounding factors such as severity of respiratory failure, traumatic injuries or surgery may cloud the results. In our mortality comparison we include all patients ventilated for 24 hours or more. Thus, our mortality number may be skewed due to less severe respiratory failure compared to those in the meta-analysis. However, the mortality in our group of patients have decreased over the last 4 years. We contribute the reduction in VLOS and mortality to standardized equipment, efficient use of available modes and protocol driven approach to ventilatory management.
AARC 50th Anniversary, December 6 - 9, 1997, New Orleans, Louisiana.