2005 OPEN FORUM Abstracts
BEDSIDE END-TIDAL CARBON DIOXIDE (ETCO2) MONITORING:IT TAKES A TEAM
Authors: Cheryl Hoerr, BS, RRT, CPFT, RCP; Ann Petlin, RN, MSN, CCRN, CCNS; Marin Kollef, MD, FACP, FCCP; Donna Clayton, BS, RRT, RCP; Donna Prentice, RN, MSN, CCRN, BC; Robin Kidder, BS, RRT, RCP; Barnes-Jewish Hospital, St. Louis, MO
Background: End-tidal carbon dioxide monitoring (ETCO2) is becoming a standard of care for intubated patients requiring mechanical ventilation. ETCO2 verifies endotracheal tube placement, assures that the patient is ventilating and helps in the assessment of the patient's response to therapy. In spite of these advantages, we were not using ETCO2 continuously or consistently on all invasively ventilated patients. Our hospital has two different monitor systems in use throughout our six intensive care units and four observation units. Non-standardized systems did not encourage compliance and made staff education and competency assurance a challenge. We lost cables and airway adapters, staff nurses were busy with other monitoring priorities, and we did not train the respiratory care practitioners (RCPs) to set up or troubleshoot the equipment.
Method: A work group made up of the manager of respiratory care services, a critical care clinical nurse specialist (CNS), the medical director of respiratory care services, a respiratory care supervisor and clinical instructors met to evaluate our current practice and identify performance improvement opportunities with the ultimate goal of increasing patient safety. We agreed that our practice of ventilator management must include ETCO2 monitoring before ventilator initiation was considered complete. We developed and implemented a plan to educate all RCPs on how to set up ETCO2 on both monitor systems. Training was also provided on minor troubleshooting. The CNS made a small laminated reference card with the set up steps for each monitor. These laminated cards are clipped to the hospital staff identification badge for easy reference. We revised the bedside documentation to record ETCO2 with other ventilator data. We updated the hospital policy and procedure to reflect the partnership between nurses and the RCPs to ensure that ETCO2 monitoring is done. The Respiratory Care Services department incorporated ETCO2 monitoring into their annual skills validation process.
Results: Audits show that ETCO2 is now consistently ready before our patients are connected to a ventilator or, during a crisis, within a few minutes of intubation and ventilator initiation.
Conclusion This project promotes our policy that initiation of invasive mechanical ventilation is not complete until ETCO2 is monitored with display of an acceptable waveform. The enhanced collaboration between nursing and respiratory therapy ensures that we use this vital monitor on all mechanically ventilated patients. Ultimately, patient safety is improved due to consistent use of appropriate monitoring.