2001 OPEN FORUM Abstracts
A Ventilator Management Performance Improvement Program
C Haas RRT, MKonkle RRT, R Dechert RRT, L Folk RRT, P Loik RRT, L Stapp RRT, V StevensonRRT, A Andrews RRT, C Lane RRT, S Lawrence RRT, L Young RRT, A Benschoter RRT, K Marecle RRT, T Behm RRT, S Mack, S Gay MD, JG Weg MD Respiratory Care Department, Universityof Michigan Health System, Ann Arbor Michigan
Background:An improvement team composed of Respiratory Care management, staff therapists,and medical director was formed in 1999 to determine improvement opportunitiesfor adult mechanical ventilation (MV). The purpose of this abstract is to presentan overview of the improvement project process.
Methods: A macro-flowchartidentified 8 major time points associated with MV: 1) MV initiated; 2) ventilatorsettings suggest a wean assessment (FIO2 <0.5 , PEEP <5cm H2O, VE <15 L/m); 3) initial wean assessment done; 4)patient ready to begin weaning (meets #2 criteria and MIP <-20 cmH2O, f/VT <105); 5) wean begins; 6) patient ready for MV to stopor extubation (meets #4 criteria and can protect airway, successful spontaneousbreathing trial (PS <5 cm H2O, CPAP <5 cm H2O),minimal secretions, stable hemodynamics, acceptable ABGs); 7) patient extubatedor MV stopped; and 8) time of reintubation or initiation of other support within48 hrs. Type of intervention noted. ICU MV-related outcome was noted. Data wascollected by the bedside respiratory therapists. Thresholds were establishedfor the following segments: 1) 4-hrs from when ventilator settings suggest anassessment until it was done (Gap 1); 2) 4-hrs from when patient was ready tobegin weaning until it started (Gap 2); and 3) 1-hr from when patient was readyto be extubated/stop MV until it was accomplished (Gap 3). Perceived reasonsfor deviation from thresholds for Gap 1 & 3 were collected.
Results: 1948patients were monitored from 7/1/99 through 6/30/00. The thoracic ICU accountedfor 41% of the patients, while the remaining 59% were associated with our otherICU?s (surgical=20%, medical=15%, trauma/burn=12%, neuro=8% and coronary=4%).Aggregate (all cases) duration of ventilation was 72.9 + 127 hrs (median=21.6hr). Duration [in hrs] of Gap 1=18.3 + 41.1 (7.0); Gap 2=3.1 +18.7 (0); and Gap 3=7.34 + 31.9 (0.8). Percent of patients and perceivedreasons for exceeding a gap threshold are: Gap 1=54% (44% sedation, 14% timeof day, 14% unstable patient, 16% unknown, 12% other); Gap 2=8.4% (reasons notpart of collection tool); and Gap 3=34% (25% MD availability, 15% MD decision,12% airway, 8% time of day, 19% unknown, 21% other). Cause and effect diagramswere generated for each of the major segments of MV using the gap informationand brainstorming techniques. An action plan was developed to address itemswithin our control. Survival curves (SC) demonstrated a descending stair-steppattern in several MV segments, indicating major progress every 24 hrs. SCsalso showed that when the initial set of parameters were obtained, 65% of thepatients were ready to wean and that the RCP immediately began the wean 70%of the time. In addition, 6.4% of the patients did not stay off MV for 48 hours.Of those requiring support, 78% were reintubated, 7% used NPPV, 6% used trach-BiPAP,and 5% had a tracheostomy and were placed back on MV. ICU outcome showed that85.6% stayed off MV, 12.1% expired, 1.1% were discharged on MV or BiPAP, and1.3% were classified as ?other?. Unit specific reports of the initial findingswere shared with each ICU medical director and nurse managers. Strategies weredeveloped to improve each major segment of the MV process, including: a genericwean protocol, multiple MV and extubation policy changes, development of a RCcare-plan tool, and RCP inservices.
Discussion: Continuedassessment and re-evaluation will provide an opportunity to examine the impactof protocol changes on duration of MV in our adult population.