The Science Journal of the American Association for Respiratory Care

2009 OPEN FORUM Abstracts

THE UTILIZATION OF ELECTRONIC DOCUMENTATION TO ASSESS THERAPIST COMPLIANCE TO PERFORM DAILY WEANING ASSESSMENTS AND SPONTANEOUS BREATHING TRIALS

Kenneth J. Miller, Robert Lehsko, Angela Lutz, Matthew McCambridge; Respiratory care, LVHN, Allentown, PA

Introduction: Mechanical Ventilation is supportive and is utilized to maintain adequate gas function. After clinical stabilization has been achieved, progression to ventilatory liberation becomes a major objective. Daily weaning assessments and spontaneous breathing trials (SBT) are cardinal in evaluation of the patient’s progress towards venilatory liberation. Therapist compliance towards this important end-point sometimes is less than desire. Heavy workloads, chaotic time management, and not fully understanding role responsibilities are a few barriers to complete the required assessment and intervention. By utilizing electronic documentation we examined the practice regarding performing daily weaning assessments and spontaneous breathing trials (SBT). Methods: Utilizing traditional methods to assess if our staff was compliant with the daily documentation became impractical. We moved to adding daily check parameters to our electronic charting system Meta-Vision (iMDsoftR). A learning packet and in-services were provided to the staff to reeducate them on the importance and significance of this documentation. These parameters were placed with the daily assessment of the patient and would act as a reminder that a VWA and SBT needed to be conducted on a daily basis. At the end of each month we now have the ability to query compliance and gather the data within and hour, and can give feedback to each therapist on compliance. Results: Prior to therapist education, our data demonstrated a less than optimal compliance of daily weaning assessments (VWA) and spontaneous breathing trials (SBT). Compliance was below the desire threshold of 95% prior to re-education from January to June 2007. Post education, which included development of a learning manual, inservices, and bedside teaching the compliance level, was near 100% over a six month period from July to December 2007. Conclusion: Electronic Documentation helped our leadership team to asses our current level of therapist compliance towards to perform daily weaning assessments and spontaneous breathing trials. When standards were not at the desired level it also provided post re-education compliance levels. Electronic documentation is a non-objective way to evaluate pre and post intervention data. Our next assessment will determine if increasing the number of Daily weaning assessments and SBT will reduce our ventilator days. Sponsored Research - None

You are here: RCJournal.com » Past OPEN FORUM Abstracts » 2009 Abstracts » THE UTILIZATION OF ELECTRONIC DOCUMENTATION TO ASSESS THERAPIST COMPLIANCE TO PERFORM DAILY WEANING ASSESSMENTS AND SPONTANEOUS BREATHING TRIALS