Decreasing Duration of Mechanical Ventilation by Implementing Evidence Based Protocols in the Medicine ICU
TEAM • Team Members v Edward Best, RRT, RCP, MBA, MSHA, v Director Respiratory Care, Parkland Health & Hospital System v Dean Holland , RRT, RCP v Respiratory Care Educator Parkland Health & Hospital System v Harold Wey, RRT, RCP v MICU & CPICU Clinical Team Leader, Parkland Health & Hospital System v Pheba Abraham, RN, MSN, CPHQ v PI Project Manager, Parkland Health & Hospital System v Alayne Royster, RRT, RCP v Respiratory staff v Martin Flores RN, CCRN MICU v Peter Hoffmann, MD, M Phil v SVP Chief Quality Officer, Parkland Health & Hospital System • Physician Champion v Craig S. Glazer, MD, MSPH v Associate Professor, Division of Pulmonary & Critical Care Medicine, University of Texas Southwestern Medical Center
Problem Statement Patients receiving mechanical ventilation are at increased risk for pneumonia, airway trauma, and iatrogenic lung injury. To minimize risk, patients should be liberated from mechanical ventilation as quickly as possible.
AIM Statement Decrease the duration of mechanical ventilation in MICU by one day by instituting a standardized approach to awakening and spontaneous breathing trials
MICU Unit Description v 14 bed ICU v 4720 total patient days FY 2011 v 4736 total patient days FY 2010 MICU Physician Staffing v Two attending pulmonologists and one pulmonary fellow together oversee and round with 4 MICU teams v MICU teams are composed of a resident, an intern and a rotating PM call intern Physician Staffing Rotations v Attending faculty rotate off service every two weeks v The fellow and the residents rotate off every four weeks v Interns rotate off service every calendar month on the first
MICU Nursing and Respiratory Care Staffing v There are no travelers or agency staff used for nursing or respiratory care Nursing Staff v Consistently staff with the number of nurses needed based upon census and acuity of the patient population v Staffing ratio of 1: 1 or 2: 1 Respiratory Care Staffing v 2 MICU therapists assigned per shift
Measure of Success Goal Measure Baseline Target Duration of ventilation Jan- April 2010 MICU vent days = 6. 1 (147. 51 hours) Decrease by 1 day MICU vent days = 5. 1 (122. 4 hours) Re-intubation rate = # of re-intubations Maintain or decrease current within 48 hrs of re-intubation rate extubation / # of patients intubated Jan- April 2010 Re-intubation rate MICU= 6. 9 % *5 -10% ( best practice / literature) Protocol compliance 100% protocol = # compliant with compliance for all protocol / # of disciplines patient audits Oct 2010 – Jan 2011 MD Orders - 57% RN SAT - 18% RT Screen - 75% 100% Decrease the duration of ventilation for each ventilated patient
Fishbone Diagram
Physician Directed Flow Map
Cause and Effect Analysis 100% 50% 100% 94% 45% 90% 87% 40% 80% 70% 35% 70% Category 30% 60% 25% 50% 20% 40% 35% 15% 30% 10% 20% 5% 10% 0% 35% 17% 7% 6% People Method/Process Measurement Machine/Equipment Environment 0%
Protocol Directed Flow Map
Project Timeline
EMR Charting for SBT
Physician Order
Results Jan – Apr 2010 Jan – Apr 2011
Results
Results Ventilation days decreased by 2. 1 days (34. 6% ) in the MICU (P =. 04)
Rates of Reintubation
Results 17% decrease in Vent Days as compared to 2010
Results 32% decrease in 32% decrease VAP rate
Discussion v Protocol driven process decreased the duration of MV in our MICU by 2. 1 days in the first six months of protocol implementation v Difference in rate of reintubation was not significant v House-wide ventilator days were reduced by 17% when comparing FY 10 to FY 11 v House-wide rate of VAP was reduced by 32% (7. 8 vs. 5. 3) when comparing FY 10 to FY 11 v 30 fewer patients developed VAP in FY 2010 vs 2011
Lessons Learned v Multidisciplinary team is key for success v Automated protocol in EMR streamlines the process v Implementation in phases leads to difficulty in protocol compliance
Next Steps v Data collection automated in EMR v Year to year comparison for further analysis to determine sustainability v Investigate the impact of protocols on VAP
Special Thanks v Carlos Girod MD v Professor Internal Medicine UT Southwestern Medical Center , Medical director MICU Parkland Health & Hospital System v Sanjuana Wilhoite RN v PI & PS Specialist, Surgical Services v Mary Lynn Fancher RRT v Manager Respiratory Care v Alissa Lockwood Pharm. D. v Clinical Pharmacy Specialist v Carol Hirsch. Korn RN, MSN, ACNP, CCRN v Nurse Practitioner in the trauma ICU v Paul A Carlson PHD v Application System Analyst/Program-SR v Jennifer De La Garza RRT, RCP v Respiratory Therapist v Sarah Clemente RN, CCRN v Unit Manager MICU & CPICU; Manager PICC Service v Billy J Moore PHD v Chief Biostatistician, Centers for Clinical Innovations v Vicki Crane MBA, FASHP, RPh v Senior Vice President Clinical Support Services
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