The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts

EVALUATION OF SPONTANEOUS BREATHING TRIALS AND SEDATION VACATION PROTOCOLS IN DURATION OF MECHANICALLY VENTILATED PATIENTS

Elester Stewart RN RRT MSN FNP-C, John Sabo MS RN RRT, Joy Hargett BS RRT, Mary Lou Warren MSN RN CNS-CC CCRN, Greg Laine MS RPh, and Patrick Herlihy MD. St. Luke's Episcopal Hospital, Houston, Texas

Background: The clinical outcomes of patients requiring mechanical ventilation were evaluated related to coordination of Spontaneous Breathing Trials (SBT) and Sedation Vacations (SV). The Institute For Healthcare Improvement (IHI) advocates the implementation of the "Ventilator Bundle" to improve outcomes of mechanically ventilated patients. The ventilator bundle (VB) incorporates specific aspects of care used in tandem to improve the overall quality of care and decrease complications related to mechanical ventilation. The VB includes five components 1) daily assessment of readiness to wean and extubate, 2) sedation vacations, 3) patient positioning (head of the between 30-45°), 4) Peptic Ulcer Disease (PUD) prophylaxis, and 5) Deep Vein Thrombosis (DVT) prophylaxis. The simple to implement VB components were patient positioning, PUD and DVT prophylaxis. The implementation of the SBT and SV protocol were not as simple. Through a collaborative effort between Respiratory Care, Nursing, Pharmacy and Pulmonary Medicine a strategy was developed to decrease the duration of mechanical ventilation. This strategy coordinated the SBT and SV components. The SBT and SV protocols were developed, approved by the pulmonary physicians, and implemented. Decision-making algorithms were used to ensure consistency. The SBT protocol utilized Rapid Shallow Breathing Index (RSBI) as the predictor of readiness to extubate. The Drager Evita 2 (Drager Medical, Telford, PA) RSBI function in the CPAP mode was utilized to monitor this predictor. The SV Protocol foundation was the Richmond Assessment Sedation Scale (RASS). This scale assesses the depth of sedation of the ventilated patient. According to protocol the level of sedation was titrated and was suspended prior to the SBT. Effectiveness of the SBT was dependent on the coordinating with the suspension of the sedation.

Method:
A two-phase prospective non-randomized observational study was used to evaluate the impact of the SBT and SV protocols. The pilot was restricted to a 20 bed Medical/Surgical ICU. All patients were coded DRG 475. There was classroom training of therapists and nurses regarding the protocols. Advanced Practice Nurses (APNs) provided additional bedside training and coordinated implementation of the protocols between the physicians, therapists and nurses. The effectiveness of the protocols was evaluated by length of ventilation (LOV), ICU length of stay (ICU LOS), and tracheotomy rate. Patient safety was evaluated by self-extubation rates.

Results:
The initial pilot was evaluated by comparing the Pre Protocol Phase (n=56) and the Proto col Phase (n=40). Outcomes demonstrated LOV decreased 13%, ICU LOS decreased 13% or 7.9 to 6.7 days and the tracheotomy rate decreased 9%. In the medical patient sub-population the tracheotomy rate decreased 84%. The self-extubation rate was 7% and 6% respectively. Due to the positive outcomes of the protocols a plan was developed to adopt "VB" as the standard of care. The plan included the use and coordination of the SBT and SV protocols within the entire mechanically ventilated patient population. Plan implementation included 1) A multidisciplinary VB management workshop conducted by physicians, therapists and nurses. 2) APNs "rounding" with physicians and continued bedside training and coordination. 3) VB components became quality monitors on the Patient Care Units.

Conclusions:
After the initial pilot,theprotocols were expanded to all patient care units which ventilator patients are assigned. After expansion an evaluation of outcome data for the ventilator patient population was conducted. The comparison groups were pre pilot (n=97) and post pilot (n=45) periods. Results were similar to the initial pilot group, LOV decreased 21%, ICU LOS decreased 10%, hospital LOS decreased 11%, mortality decreased 28% and tracheotomy rate decreased 28.7%. 18 of 40 patients did not require further sedation after their SV. These clinical interventions resulted in a cost decrease of 25%. Coordinating SBT and SV has a positive impact on the quality and financial bottom lines.

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