The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

RESULTS AFTER ONE YEAR OF USE: AUTOMATICALLY INVOKED PROTOCOL FOR VENTILATOR MANAGEMENT.

John W. Farnham, RRT; Michael S. Powers, MS, RRT. Respiratory Care Services, University of Tennessee Medical Center, 1924 Alcoa Highway, Knoxville, TN 37920.

Background:
Literature for years has indicated improved clinical and economic impact of mechanical ventilation when managed by a systematic protocol as compared to individual physician orders. Critical care bed availability was limited, and both hospital length of stay (HLOS) and ventilator length of stay (VLOS) seemed ripe for improvement. Faculty physicians expressed a need to utilize best practices for improved outcomes and to be able to teach same consistent practices to residents.

Method:
We developed a protocol for management of and liberation from mechanical ventilation. As with our treatment protocols, the mechanical ventilation protocol is automatically invoked, but has the option for the attending physician to order that no protocol be used. Once the protocol was approved by a multidisciplinary team including all services that would be using it, it was implemented in stepwise fashion until it was in place in all adult units. Physicians and respiratory therapists were heavily educated, other personnel less strenuously. Monitoring included retrospective study of approximately 100 patients for the year prior to protocol in each adult unit to establish a control population. In each unit, HLOS, VLOS, rate of reintubation in ≤ 48 hours were monitored for 12 months. We were able to monitor ventilator associated pneumonia (VAP) for 10 months in 5 of the units and for 1 year in one of the units. General cost savings were based on variable costs and were calculated very conservatively at ยป $266/day of HLOS. Salaries/wages were not included since they are paid regardless of patient being on ventilator or not. VAP costs were based on our average cost to treat each VAP patient, including medication costs, lab costs, and HLOS costs.

RESULTS:
Pre-protocol N = 585, post-protocol N = 643. Aggregate data across all units showed median HLOS decrease of 1.5 days, median VLOS decrease of 1.3 days compared to control. 4-quarter mean for patients remaining off ventilator ≥ 48 hours was 94.5% (no pre-protocol data available). VAP rate (%) went down from 21.9% to 16.2% in same period vent days went up by >2000. Annual savings from decreased HLOS were $256,557, and from decreased VAP $113,000, for a total of $369,557. Figures do not include increased revenue from increased throughput of bed usage.

Conclusions:
Use of ventilator protocol decreased HLOS and VLOS, as well as VAP, resulting in both clinical and financial benefits. Continuing adjustment of protocols is necessary. A tendency of clinicians to revert to baseline behaviors is noted. If this protocol's progress is similar to that of earlier treatment protocols, will take 2-5 years of refinement and usage to realize optimized benefits. Success of this protocol is encouraging to implementation and monitoring of protocol for acute lung injury/acute respiratory distress syndrome.

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