The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

PROCESS BASED MEASUREMENT OF EXCESS VENTILATOR DAYS IN A CARDIAC INTENSIVE CARE UNIT WITH IMPLICATIONS FOR PATIENT AND FINANCIAL OUTCOMES

Clifton Hunt, MD, Thomas Blackson, RRT, Lisa Racine, RRT, Danielle Martino, RCP, Dave Conomon, RCP, Paula Stillman, MD, Christiana Care Health Services (CCHS), Newark, DE

Background: Identification of the correct time to liberate a patient from mechanical ventilation (MV) or to remove their artificial airway (AA) continues to be an elusive target.  Premature and delayed withdrawal of support is associated with increased mortality and morbidity. Previous attempts to quantify the impact of ventilator liberation and extubation protocols have been primarily intensive care unit (ICU) based rather than patient based. ICU based determinations of excess ventilator days (VDE ) are often inadequate to quantify the financial implications of, or personnel resources needed for, successful protocol implementation.

Purpose:
To create a patient-based process to define and quantify VDE and to quantify the potential financial impact of, and personnel resources needed for, successful implementation of an evidence-based MV and AA liberation protocol. 

Methods:
We developed a well-defined patient assessment protocol (PAP) with time and performance specifications for evaluation of mechanically ventilated patients prior to withdrawal of ventilatory support. The protocol was implemented in a cardiac ICU in two stages. The baseline stage (BS), was conducted over a 2 week period. It consisted of a daily evaluation of MV patients independent of the staff respiratory therapist's (RCP) evaluation. Results of these patient evaluations were used to compare care provided by the RCP to the protocol guidelines for care. All ICU care providers and decision makers were blinded to the protocol guidelines during this stage. A delay in care (DC) was defined during the BS as failure to liberate or extubate the patient by noon in cases where the protocol guidelines would have directed the RCP to do so. The protocol implementation stage (PS) was conducted over a 4 week period. During this stage the protocol was implemented by one experienced RCP and 2 senior respiratory care students trained to implement the protocol. In addition to results of daily spontaneous breathing trials, vital capacity and negative inspiratory force measurements, data collection during both stages included the number of ventilator patients/day (VD), the time required to perform daily patient assessments, the number of extubations and re-intubations, as well as the number of patients liberated from MV in whom the AA was not removed. VDE was defined as the number of days of DC per total ventilator days during each stage. Financial data for the cost of a ventilator day was supplied by the Hospital’s Finance Department.

Results:
Implementation of the protocol resulted in a decrease in VDE, by approximately 80%, relative to current practice, 0.036 and 0.186 respectively (P< 0.05). The extubation rate during the protocol increased significantly, (p< 0.05) relative to the baseline period. The re-intubation rate during the protocol period was considered acceptable at 11%. There were no significant patient complications attributed to implementation of the protocol.
*p < 0.05

Stage(weeks) VD total VD average (± SD) DC total VDE Extubations
Baseline 2 43 4.3 (± 1.2) 8 0.186 * 5 *
Protocol 4 84 4.3 (± 1.3) 3 0.036 * 18 *

Conclusions: It is possible to define VDE using a best practice, patient-based protocol for weaning. Patient-based determination of VDE may offer increased utility when compared to previous unit-based approaches with respect to financial planning and personnel resource utilization. Implementation of the PAP at CCHS will require investment in additional staff RCP’s with an expected return on investment of > 1000%.

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