The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

EVALUATION OF THE EFFECT OF A THERAPIST-DRIVEN WEANING PROTOCOL ON LENGTH OF VENTILATION, RE-INTUBATION RATES AND HOSPITAL COSTS

Cecilia Herlitzke RRT, NPS; Robert Milisch Med, RRT; Daniel Deetz MD. Franciscan Skemp Medical Center, La Crosse, Wisconsin.

Background: The use of respiratory care protocols has been shown to decrease unnecessary treatment and reduce health care costs. We sought to design a program whereby ventilated patients are evaluated for ability to be weaned on a daily basis. Patients who passed the daily wean screen (WS) could then be automatically weaned from mechanical ventilation per a protocol and extubated if they successfully completed the weaning process. The assumption was that a systematic approach would decrease ventilator days, the number of ICU days, re-intubation rates and also reduce costs.

Method:
Physicians were given the option of having their patients have daily WS. Daily WS parameters were established for patients on mechanical ventilation. These parameters include PaO2/FIO2 >200, PEEP < 5, f/Vt < 105, MIF > -20, sedation score, evaluation of hemodynamic stability and vasopressor use. Patients passing the WS were placed on a T-piece for a period of 1 hour. Patients experiencing difficulties with T-piece breathing were placed on pressure support and slowly weaned. Patients failing both T-piece and pressure support trails were returned to full mechanical ventilation and evaluated the next morning. Physicians not wanting the daily wean screens weaned their patients with written orders for each step of the weaning process.

Results:
During a 22 month period, 321 patients were mechanically ventilated. Of these patients, 56 were either transferred, expired while on mechanical ventilation or were self-extubated. 108 patients were weaned and extubated by direct physician order (without use of the protocol). The remaining 67 patients were ordered on the WS protocol. The average ventilator days, ICU days and re-intubation rate are shown below:

Type of weaning Number Average Vent. Days Average ICU days Re-intubation rate
Without protocol 108 3.61 6.90 6.5%
With protocol 67 2.0 4.34 1.5%

Conclusion: The patients who were weaned per protocol had a significant reduction in ventilator days (1.6 days), ICU days (2.56 days) and had a lower re-intubation rate (5% reduction). The reduction in ventilator days and ICU days resulted in cost savings of $ 115,000.00 for the 67 patients in the protocol group. The reduction in the ICU days resulted in a cost savings of $90,908.00 when comparing the cost of ICU care versus care on a general medical floor. This represents a savings of $3251.00 per patient weaned per protocol or a total savings of $217,830.00 for all patients during this time period. The significantly lower re-intubation rate also represents a positive impact of the use of the protocol. We concluded that the use of the WS protocol represents a significant reduction of both ventilator and ICU days and costs while reducing the risks and trauma of being mechanically ventilated.

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