2003 OPEN FORUM Abstracts
IMPLEMENTATION OF A LARGE SCALE WEANING PROTOCOL REDUCES VENTILATOR TIME BY TWENTY EIGHT PERCENT
Theodore Stryker, BA, RRT, University of Washington Medical Center, Seattle, WA
Background: Mechanical ventilation beyond that which is necessary is dangerous to patients and incurs unnecessary expense. Respiratory Care Practitioner (RCP) and Nursing directed protocols have been demonstrated to be safe and effective in facilitating the extubation of patients. We believed that an interdisciplinary team of a Doctor, Nurses and RCP's could create and implement a RCP and Nursing directed protocol that could reduce the overall median ventilator hours by 30% without increasing the reintubation rate.
Methods: In June of 2000, we formed an interdisciplinary team consisting of a Doctor, Nurses and RCP's to review the literature on extubation protocols. This team then developed and tested a protocol to be used on all ventilated patients in the facility. This protocol involved a daily screening of parameters on all patients on .50 fio2 or less, and positive end expiratory pressure (PEEP) of 8 or less. Patients passing the daily screen were advanced to a spontaneous breathing trial (SBT). After 30 minutes, an arterial blood gas was obtained and physicians were notified of the results. A pilot test program was begun on only the medical intensive care patients then expanded to all ventilated patients in the facility. Doctors, Nurses and Respiratory Therapists were trained on the use of the protocol. Six months of baseline data was collected from September 1999 thru February 2000. To minimize outliers, patients ventilated over 217 hours were excluded. Also excluded were tracheostomy patients, patients who expired or self-extubated. The median hours of ventilated patients were tracked every month along with the reintubation rate and the average number of ventilators running per month.
RESULTS: Our six months of baseline data included 401 patients with a median ventilation time of 18.2 hours. The median from November 2002 thru April 2003 is 13 hours and includes 423 patients. This is a reduction of 28%. The reintubation rate did not increase, varied from 1% to 10% monthly but averaged 4% overall.
Conclusions: Although we did not meet our goal of a 30% reduction in ventilator hours, we came very close. Our reintubation rate did not increase. We expected that our length of stay and ventilator associated pneumonia rate would decrease but, monitoring these parameters was beyond the ability of our small group. We attempted to find a reason for our failure to meet a 30% reduction by analyzing staffing, overuse of a lung protective ventilation strategy and ventilator census. We were unable to demonstrate a relationship between staffing and ventilator hours even though we know staffing shortages caused unnecessary delays in extubations. In October of 2002, 28% (27 of a total of 94) ventilated patients were on a tidal volume of less than 500cc leading us to suspect that use of a lung protective protocol may greatly exceed the number of patients with Acute Respiratory Distress Syndrome (ARDS). This could be contributing to prolonged ventilation times, as use of this protocol seems to require higher fio2's, higher PEEP and greater amounts of sedatives. The average number of ventilators per month and the median ventilators hours appeared to closely follow each other leading us to believe that either a higher acuity lead to higher ventilator census and longer ventilator hours and/or a higher ventilator census did not allow adequate staffing to focus properly on more timely extubations.