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%.