The Science Journal of the American Association for Respiratory Care
Background: Therapist driven protocols have been used to extubate or wean patients in the ICU setting. Barlow Respiratory Hospital (BRH), a 49-bed long-term acute care (LTAC) facility, has functioned as a center for weaning patients from prolonged mechanical ventilation (PMV). A therapist-implemented patient specific (TIPS) weaning protocol was developed at BRH to standardize weaning from PMV in the post-ICU setting.
Methods: A weaning protocol incorporating the procedures and pace of LTAC weaning was developed using available scientific evidence, and expert consensus. After training of staff, data gathering, and analysis of pilot data, a major revision incorporated steps to accelerate weaning; the protocol was then implemented to include all ventilator-dependent patients. It was monitored for outcome, variance, and RCP and MD compliance.
Results: 46 RCPs worked with four pulmonologists treating 103 consecutive patients admitted for weaning from PMV (a total of 4,115 ventilator days) over an eight month period. Eight patients were excluded from the protocol following initial evaluation. Of the remaining 95 patients, 93 have reached outcome. In the table below, results are compared to 238 patients treated by the same physicians in the two years prior to protocol weaning. The decrease in weaning duration was statistically significant for the TIPS patients vs. controls (p = .022). Outcomes, scored at discharge, are: W=weaned; V=ventilator-dependent; D=Died. Results are median values.
|n||Age||APS*||PVT**||Outcome - %||Weaning duration|
|TIPS||93||74||34.5||27 days||54||19||27||20 days|
|Control||238||71||33.5||30 days||58||11||31||29 days|
|*APS=APACHE III APS score; **PVT=Prior ventilator time (in ICU)|
|Physician compliance summary:|
|Steps not followed||45 episodes in 31 patients|
|Hold/resume orders||46 episodes in 29 patients (mean days held per episode = 5.2)|
|Hold/discharge orders||35 patients with modified goals or failure to wean|
|RCP compliance summary:|
|Steps not followed||39 episodes in 27 patients|
|Procedure not done||16 episodes (12 ABG, 3 RSBI, 1 telemetry)|
|Documentation omitted||6 episodes|
Experience: A therapist implemented protocol for weaning patients from PMV was instituted and refined with a high degree of resultant physician and RCP compliance, with patient safety maintained. The protocol both organizes and objectifies the patients' weaning efforts, providing a valuable weaning history for treatment, utilization review, and discharge planning decisions. The expected benefit of enhanced interdisciplinary communication was also realized.
Conclusions: Weaning duration was significantly shorter using a protocol in this setting as compared to an historical control. Weaning outcome data during the period following implementation of the TIPS protocol are in fact attributable to the protocol's use.