2000 OPEN FORUM Abstracts
QUALITY IMPROVEMENT PROGRAM IDENTIFIED FROM THE USE OF RESPIRATORY CARE PLANS IN THE ICU SETTING
John W. Salyer, RRT, MBA, FAARC, Kay Lockhart RRT., Karen K. Burton RN, RRT. Respiratory Care Services and Outcomes Research Service, Primary Children's Medical Center, Salt Lake City, UT
Introduction: We suspected that there were deficits in ventilator management in our NICU. We sought to improve measurement and standardization of ventilator care in the NICU through the development of ventilator care plans. These forms became part of the medical record and served to improve communications between all clinical disciplines involved in ventilator management and also acted as physician orders. Care plans were to be completed by RCP's in collaboration with MD's and NNP's within 24 hours of patient admission. They contained such information as ventilator settings, desired blood gas ranges and other weaning parameters. Design: A prospective study was conducted by collecting copies of all ventilator care plans on ventilated patients admitted to the NICU between December 1999 and April 2000. In addition, all blood gas results and ventilator flow sheets were concurrently reviewed. We randomly selected a subset of these care plans to analyze. The data gathered were entered into a database. We evaluated how many days the care plan was followed, not followed, and the number of days the care plan was not updated when it should have, e.g. following surgery or failed extubation. We identified over-weaning, under-weaning, and not weaning as ways in which the care plans were not followed. We further analyzed how many times patients with a care plan experienced a setback in ventilator management, e.g. the patient had a subsequent increase in ventilatory support within 12 hrs of following or not following the care plan. Results: There were a total of 185 care plans gathered on 67 patients. We reviewed 107 of these care plans, spanning 435 ventilator days, and involving 39 patients. Care plans were followed on 49% of ventilator days reviewed, not followed 46% of ventilator days, and not properly updated on 5% of ventilator days. Of the patient days when the care plan was not followed, the distribution of types was; 78% overweaned. 19% not weaned, 3% under-weaned. Among patients who did not have their care plans followed, 23% experienced a ventilatory setback. However, even among patients who did have their care plans followed, there were 22% who experienced a ventilator setback. When pts were overweaned it was most often done by RCP (57%). Discussion: We found deficits in ventilator management, such that nearly ½ of the time we are not following our care plans, with over-weaning being the most prevalent departure. However, our observation that 1 in 5 of patients experience ventilator set-backs irrespective of whether or not the care plan was followed suggest that the care plans may not be reflecting optimal ventilator management guidelines. Two possible problems are that the care plans were not updated often enough, or were too restrictive, such as allowing only very small changes in ventilator settings. Thus, RCP's who were more aggressive in weaning than the care plans allowed, may have been using more current information about the pt than was described by the plan. Possible improvement interventions include, updating care plans more frequently, making weaning guidelines in the care plans less restrictive, and requiring RCP's to follow the care plans as written.