2005 OPEN FORUM Abstracts
IMPLEMENTATION OF A VENTILATOR DISCONTINUATION PROTOCOL IN THE MEDICAL ICU OF AN ACADEMIC MEDICAL CENTER.
Dean R. Hess, PhD, RRT, FAARC; Robert M. Kacmarek PhD RRT FAARC; Ernie C. Chou BS RRT; Neila Altobelli BA RRT; Mary Lavieri MSN RN; Adele L. Keeley MA RN; Benjamin D. Medoff MD; B. Taylor Thompson MD. Massachusetts General Hospital and Harvard Medical School, Boston MA.
Background: Ventilator discontinuation protocols implemented by non-physicians have been shown to safely decrease the duration of mechanical ventilation and evidence-based guidelines recommend their use. However, a recent study reported no difference in the duration of mechanical ventilation with the use of a ventilator discontinuation protocol in a medical ICU that was well staffed by physicians. We conducted this study to assess the impact of a ventilator discontinuation protocol in the medical ICU of a tertiary academic medical center that is adequately staffed by physicians, nurses, and respiratory therapists. Our 18-bed medical ICU is staffed by 2 physician teams, each with a board-certified critical care attending physician, a pulmonary/critical care fellow, a senior medical resident, junior residents, and interns. There is always a minimum of at least 1 respiratory therapist present in the unit with additional coverage determined by the number of patients and acuity. A consistent group of therapists provide coverage and the primary therapist does not have an assignment outside the ICU. Nurses are assigned 1 or 2 patients depending on acuity.
Methods: The ventilator discontinuation protocol was developed by a multidisciplinary team comprised of respiratory therapists, physicians, and nurses. Although many of the details of the protocol are implemented by the respiratory therapist, the protocol stresses teamwork between respiratory therapists, nurses, and physicians. An assessment of readiness for a spontaneous breathing trial is based on commonsense criteria (resolving disease process, adequate gas exchange, hemodynamic stability, and ability to initiate a breath); weaning parameters per se are not used. The patient's sedation is assessed and the infusion of sedative medications is adjusted as necessary to avoid interference with spontaneous breathing. If the patient is deemed ready, a spontaneous breathing trial is performed by setting the ventilator to a pressure support of 0 cm H2O and a PEEP of 0 cm H2O. Mechanical ventilation is promptly re-established if the patient does not tolerate spontaneous breathing. If the patient tolerates a 1-hr spontaneous breathing trial, this is reported to the physician team and a decision is made regarding extubation. The goal is to extubate patients capable of spontaneous breathing by the completion of morning rounds (11 AM). The protocol was implemented in May 2004. We assessed the impact of the protocol by comparing patients mechanically ventilated for the last 3 months of 2003 (before protocol implementation) to the last 3 months of 2004 (after protocol implementation).
Results: 117 patients were extubated in the pre-protocol group and 113 were extubated in the post-protocol group. The protocol was associated with a decrease in ventilator days/patient from a median of 3 to 2 days (P=0.03), ICU days/patient from a median of 6 to 5 days (P=0.06), hospital days from a median of 18 to 14.5 days (P=0.01), and hospital cost/patient from a median of $47,680 to $39,004 (P=0.03). There was no significant change in re-intubation rate (17.1% to 11.5%, P=0.26) and 28-day mortality (20.5% to 17.7%, P=0.62).
Conclusions: The implementation of a ventilator discontinuation protocol resulted in reduced ventilator days and lower cost despite adequate physician staffing.