The Science Journal of the American Association for Respiratory Care
BACKGROUND: Ventilator length of stay (LOS) was selected to evaluate the quality of treatment in the critical care unit of a 330-bed teaching hospital. A LOS retrospective review in 1997 included all patients in a 14-bed mixed medical/surgical critical care unit and all patients in an intermediate unit. The critical care teams was mandated to reduce ventilator LOS by 30% after the review found the average LOS in 1997 to be 9.25 days
METHOD: The multi-disciplinary team devised a process of improvement using the Institute for Health Care Improvement Rapid Cycle method and PDCA. The team revised the multiple physician-driven wean strategies process, wrote and implemented strategies and protocols for Pressure Support Wean and Oxygen Titration to 50%. Early in the process, daily team meetings were instituted to review each patient's status and empower respiratory therapists to implement protocols and procedures.
Results: By the end of year one, ventilator LOS was reduced by 39% to 5.6 days. Oxygen titration to 50% or less became practice in 97% of all appropriate cases and nosocomial pneumonia was reduced from 17.3% to 13.7%. All improvements have been sustained to date. Severity adjusted mortality and acuity was unchanged.
EXPERIENCE: Prior to the formation of the multi-disciplinary team, respiratory therapists (including LT & LVH) were not involved in patient care planning. The increase in autonomy for respiratory therapists' involvement in the care and planning of care and their contribution to problems solving has been recognized as a significant factor in the success of this process improvement.
CONCLUSION: Positive outcomes are attributed to teamwork, decrease in variation of practice, and emphasis on respiratory therapists' management of ventilated patients. JCAHO surveyors scored Saint Mary's "98". At the summary conference they cited the successful achievement of the team's objective. The team next plans to implement Lung Protection Strategies and access to new technology, such as APRV (bi-level), and Esophageal Doppler monitoring, as further improvements for mechanically ventilated patients.