2003 OPEN FORUM Abstracts
A RETROSPECTIVE ANALYSIS OF MECHANICAL VENTILATOR DAYS BEFORE AND AFTER IMPLEMENTATION OF A THERAPIST DRIVEN VENTILATOR WEANING PROTOCOL IN 1,772 PATIENTS
Russell T. Reid, RCP, RRT Garry Dukes, RCP, RRT Thomas Nelson, RCP, RRT Mike Scotton, RCP, RRT Roberta Braun, RCP, RRT Carolinas Medical Center, Charlotte, NC
Background: The Department of Respiratory Care at Carolinas Medical Center, an 843 bed tertiary care center, located in Charlotte, North Carolina, sought to design and implement a therapist driven ventilator weaning protocol (TD-VWP) which could be applied to the majority of patients requiring mechanical ventilation in our Level 1 Trauma Center. The primary goal of the TD-VWP was a reduction in the time patients were mechanically ventilated.
Method: A committee, including the medical director, was formed to review the available weaning literature and to design a weaning protocol. A major criterion was to design a flexible weaning protocol by using a multi-arm algorithm, which would allow physicians the flexibility of choosing from more than one weaning methodology, but allow the Respiratory Care Practitioner (RCP) to proceed with weaning once a methodology had been chosen. Once RCPs, physicians and nurses, were educated protocol implementation was undertaken. Data was collected for the 12-month period prior to, and after the implementation of the TD-VWP, in both medical and surgical patients, for hospital length of stay (LOS), patient ventilator days, All Patient Refined Diagnosis Related Groups (APR - DRG) acuity/mortality score, and age.
RESULTS: There was a statistically significant reduction in the number of days on mechanical ventilation of 1.3 days (p = 0.024), and LOS of 2.6 days (p = 0.032) after implementation of a TD-VWP. There were no statistically significant differences between the Pre TD-VWP group and Post TD-VWP group, when comparing age 54.4 vs. 54.4 years (p = 0.984) or patient acuity 3.5 vs. 3.4 (p = 0.529), respectively. All data were statistically analyzed using a Z-test for comparison of mean values. Patients being mechanically ventilated for < 48 hours and > 3 S.D. were treated as outliers and excluded from analysis. A total of 861 patients on the ventilator < 48 hours were excluded (416 Pre-VWP and 445 Post - VWP) and 123 patients > 3 S.D. (62 Pre-VWP and 61 Post - VWP) were excluded. Data was collected and analyzed for a total of 1,772 patients representing a total 19,791.3 ventilator days and 39,791.8 hospital days. This represented 930 patients (10,969.8 ventilator days) prior to TD-VWP implementation and 842 patients (8,821.5 ventilator days) after TD-VWP implementation. The mean values for patient age, patient acuity and ventilator days are shown in Table 1.
|n||Mean Age (yrs)||Mean APR-DRG Acuity Score||Mean Ventilator Days||Mean LOS (days)|
|Pre TD -VWP||930||54.4 (±18.2)||3.5 (±0.9)||11.8 (± 9.6)||23.7 (± 19.9)|
|Post TD-VWP||842||54.4 (±17.4)||3.4 (±1.1)||*10.5 (± 7.9)||*21.1 (± 16.1)|
Table 1. Mean patient values. * Statistically Significant p < 0.05
Experience: Each of the authors has multiple years of experience weaning patients from mechanical ventilation and in designing and implementing protocols.
CONCLUSION: The results of our experience lead us to conclude that the implementation of a TD-VWP can result in a significant reduction in both the number of days a patient is mechanically ventilated and the number of days a patient receiving mechanical ventilation is in the hospital. Additionally, the dedication of a clinical specialist to collect data, assist staff members, provide periodic information updates and educate medical/nursing staff increased both understanding and acceptance of the TD-VWP with current enrollment rates exceeding 90%.