The Science Journal of the American Association for Respiratory Care

2006 OPEN FORUM Abstracts

SAW II (Short-Term Accelerated Weaning): A Combined Ventilator Liberation & Sedation Evidence Based Project

Wayne Wallace RRT, Jacqueline Redeemer CNS, Todd Weiss RRT, Christina Judan RN, Juan Lombard, RN

Kaiser Permanente West Los Angeles Medical Center, Los Angeles CA

Background: Kaiser Permanente West Los Angeles Medical Center is a mid sized community hospital which provides critical care services in an urban setting. Prior to the advent of continuous sedation, the medical center enjoyed an excellent average ventilator LOS of slightly under 3.0 days per ventilator patient.  After FY 2000, ventilator LOS steadily climbed and reached its zenith in the 4th quarter of 2002 of 6.2 ventilator ALOS.  Moreover, there were an increased number of patients requiring ventilator care being admitted to the hospital (293 ventilator patients in FY 2000 vs. 420 ventilator patients in FY 2003). This created a bottleneck in the critical care unit and overwhelmed the staff. A literature review demonstrated that sedation and ventilator protocols were able independently to reduce ventilator ALOS. However, it was unclear if a combined protocol would show a further synergistic effect.

Method: Utilizing the IOWA EBP Model, a combined nursing-driven sedation protocol and a respiratory care-driven ventilator protocol called SAW II was implemented in phases which would allow observation of each protocol's relative contribution to the reduction of ventilator ALOS over the traditional physician-driven ventilator liberation attempts. Key patient safety, severity of illness, and other key indices were monitored to ensure that SAW II was at least as safe as the traditional physician driven weaning.

Results: Physicians were able through their own efforts to reduce the ventilator ALOS from 6.2 days to a range between 5.5 to5.0 days.  The Respiratory Care driven protocol was able to drive ventilator ALOS from 5.0 to 4.2 days.  The Nursing driven sedation protocol thus far appears to drive ventilator LOS from 4.2 to 3.7 days.  55 SAW II ventilator patients totaling 216 ventilator patient days were reviewed from August 6-October 12, 2005.  The outcomes were 72% liberated, 22% Died, and 6% ventilator dependent at discharge. There has been no change in severity of illness as measure by APACHE II scores, increases in untoward events, or increases in VAP during the entire time period. EXPERIENCE: SAW II appears to be a safe and effective strategy to reduce ventilator ALOS and achieve roughly the same patient outcomes. There appears to be a sustained downward trend in ventilator ALOS back to the previous acceptable levels. A more systematic approach to ventilator liberation was evidently needed to handle the increased number of ventilator patients efficiently.

Conclusion:
Thus far, SAW II appears to have a synergistic positive effect on ventilator liberation while promoting interdisciplinary cooperation and collaboration over traditional physician-driven ventilator liberation attempts.  However, more study is required to confirm this provisional conclusion.

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