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Perspectives
SUCCESSFUL VENTILATOR WEANING:
A COLLABORATIVE EFFORT
Suzanne Rogers, MA RN CRRN CNA-AMartha Ryan, AS RNLawrence Slepoy, AS RCP RRT
Teamwork can be successfully implemented. Rehabilitation nurses playeda central role as our interdisciplinary staffworked together to improve our facility's approach to weaning medically complex patients from the ventilator.
Ventilator weaning is a difficult taskthat involves many variables. It cannotbe accomplished alone-it takes encouragement, endurance, and coaching,as well as the support and example ofothers. By working together, our facility designed an educational format, ateam structure, and a set of intermediategoals that helped patients and staff focuson the progressive steps needed for discharge. As a result of our collaborativeeffort, patient outcomes have improvedand we have identified further areas formaking improvements.
A case studyConsider the case of Mr.P., who was
admitted to our hospital with a diagnosis of "failure to wean." In fact, he wasdependent on a ventilator for his everybreath. But his eyes and his attitude revealed more than that. They seemed tosay, "What's the use? I can't do this."When asked a question, Mr. P wouldshrug, look at the wall, or close his eyes.
Of course, Mr. P.'s other problemsalso contributed to his difficulties withweaning. He had a poor nutritional state,underlying sleep apnea, a body weightof more than 350 lbs, diabetes, hypertension, poor bed mobility, and-not unrelated to all of this-the beginning of asacral pressure ulcer. Most of all, Mr.P.'sspirit was broken. He had failed severalprior attempts to wean and was still unable to breathe on his own. He was demoralized, profoundly anxious, and morethan a little skeptical that weaning waseven possible for him.
Two months later, however, Mr. P.walked out of our facility with the help
of a cane. He was free of the ventilatorand decannulated, his skin was intact,and he was 50 lbs lighter. He continuedrehabilitation to increase his endurance,but his confident smile and the look inhis eyes said, "I can do this."
Mr.P. is an example of a patient whohad real difficulty weaning from a ventilator in a short-term acute hospital setting due to his underlying chronic lungdisease, weight, and a complicated medical history. At our long-term acute facility, we specialize in the care andrestoration to health of these challengingpatients.
Most of our patients come to us fromICUs in the Boston metropolitan region.Those admitted with a "failure to wean"diagnosis also have multiple underlyingchronic medical conditions. Many areolder people who lack proper nutritionand family and social support. They havehad surgery or some critical medicalevent that placed them temporarily on aventilator. However, once their acutemedical or surgical event begins to resolve, their progress slows. They oftenfail at initial attempts to wean from theventilator, and they may begin to presentmore complex discharge issues.
Examining the programOur ventilator weaning program had
been in place for several years; however, as we examined our program, weidentified some new strategies that couldimprove patient outcomes. As a result ofthis improvement process, we have created a stronger interdisciplinary approachthat has worked well, decreased the number of days patients spend on the ventilator, and increased the percentage ofpatients who wean from the ventilator andgo home.
Three major strategies were central tothis improvement project: the creation ofa dedicated team of healthcare profes-
sionals, the education and preparation ofthe team, and the deliberate structuringof the program to respond to each patient's expected progress.
Creating a dedicated teamWe determined that interdisciplinary,
closely coordinated care is essential fora program dedicated to weaning patientsfrom the ventilator. While we recognizedand honored the specialized skills eachhealthcare professional brings to patientcare, we also agreed that we must planand work together as a team of skilledprofessionals, each ofwhom knows whatthe others are doing.
We recognized that nurses, respiratory therapists, and rehabilitation therapistsall needed to assign the same staff members to work with the same patients on aroutine basis. This would enable eachcaregiver to know each of the other members of the patient's team. And when thesame professionals worked with eachother regularly, they would know who tocall and whose assessments to rely on.
Then, we wanted to avoid the following types of situations: the nurse callingthe respiratory therapist when a patientneeded to be suctioned, the respiratorytherapist attempting a wean even thoughthe patient had had a poor night's sleep,or the rehabilitation therapist schedulinga treatment time during the first few daysof weaning. We resolved to all be on thesame page-the patient's page. Each day,the plan of care would provide for the patient's primary need for that particularday. Consistency and communication became our passwords.
To accomplish these goals, severalmembers of the interdisciplinary teammet to brainstorm ideas. We includedstaff and managers from nursing, respiratory therapy, education, pulmonarymedicine, social services, psychology,and discharge planning. We drew on our
Rehabilitation Nursing> Volume 23. Number 5· Sep/Oct 1998265
Figure 1. CRICUEducational ProgramTopics
Note. These classes are taught by staff members in collaboration with the CRICU EducationPlanning Committee. Each program offers continuing education credit. Selected self-studyprograms are available by contacting the education coordinator.
Trachs: Different kinds, different care needsUnderstanding blood gasesThe patient with COPD and blood gas disturbancesPhysical assessment for nurses and respiratory therapistsKnowing what you are seeing: Important observations for CNAsPneumonia: The benefits of nutritional interventions for outcomesUnderstanding EKGs: A two-part series (1 hour for each part)Weaning the ventilated patient who is receiving dialysisCardiopulmonary lecture: A case study
wide range of experiences to identify theneeds of these patients. We determinedthat our patients typically need dailymedical attention; management of nutritional status; attention to skin integrity;bowel and bladder management; management of secretions and ventilator settings; assistance with communication,swallowing, mobility, activities of dailyliving (ADLs); and help in dealing withfeelings of frustration, anger, and loneliness. Patients and their families alsoneed support and education.
During this brainstorming session, wetalked about the patient's needs, notabout each discipline's scope of service.We drafted a vision statement-a brief,nontechnical description of the ideal program within the continuum of care. Thenwe began planning for the best way toshare and implement this vision.
Getting startedOnce we agreed on a basic descrip
tion of our program, we reviewed thedata we already had to determine benchmarks for later improvements. Our cardiopulmonary department had maintained a database of patient outcomes inrelation to respiratory status, successfulweans, and eventual discharge. During1996, we provided care for 57 ventilated patients. In the course of that year, wehelped 19 of those patients wean fromthe ventilator and discharged 14 of themto their homes. The other 5 patients wereweaned from the ventilator and discharged to nursing homes. While thesestatistics are by no means impressive,they were a starting point.
To better allocate resources, we decided to cluster patients according to specific categories. We began by placing allnon-ICU patients who Were ventilatordependent on the same cardiorespiratory intermediate care unit (CRICU). Weunderstood that not all staff memberswould want to work on this unit everyday, so we selected staff who had a particular interest in this area.
Perspectives
We recognized that all caregivers hadto be aware of the new vision of care andthat they also had to be trained in the additional skills required to care for thesepatients. Then we created a staffing andcare delivery system that clustered thesame set of interdisciplinary caregiverswith the same patients. We called this ourprimary team model.
Educating the teamNext, we worked together to design
training modules for all staff, includingRNs, LPNs, CNAs, physicians, respiratory therapists, physical therapists, occupational therapists, speech-languagepathologists, swallowing specialists,pharmacists, dietitians, social workers,psychologists, and case managers.Everyone was involved in identifyingcontent, attending or presenting classes,and evaluating the usefulness of theclasses. One-hour educational sessionswere given on the unit and were presented by staff members who volunteered to teach specific topic areas. Thecurriculum continues to evolve as we develop greater expertise and as new staffjoin the program (see Figure1).
Structuring the programAs we developed this program, we
found that we wanted to move patientsalong a continuum even within our fa-
cility. Thus we deliberately structuredthe program to respond to the patient'sexpected progress. Patients are admittedfirst to our ICU, where we establish theirmedical stability and familiarize themwith the program. Some patients also begin weaning from the ventilator at thispoint; however, the standard plan is toprepare them to move to the CRICU,where most of the weaning is carried out.
As patients successfully maintain independent ventilatory efforts off the ventilator, they are transferred to the Central2 Unit, a less intense unit where staff prepare patients for discharge. This unit'sstaff focus on teaching ADLs, increasingpersonal responsibility for learning, andgetting the family involved. Prior to thisphase of care, there is too much work related to ventilator weaning to be done andpatient anxiety is too high to add discharge teaching to the mix of tasks.
Our original plan called for movingpatients to this less intense unit in orderto reduce the possibility of infections;however, we found that patients responded positively to this move-it gavethem a sense of graduating. Once on thisunit, they are expected to be more mobile and can focus their energy on planning to go home, surrounded by otherswho are doing the same. We now use thisgraduation terminology when preparingpatients for this move.
266 Rehabilitation Nursing > Volume 23, Number 5· Sep/Oct 1998
Getting patients through this continuum is truly a matter of highly individualized care. There is no magic formulaor protocol other than assessing the pa-
Perspectives
tient's responses to interventions, comparing assessments across disciplines,and helping the patient see that we are aunified team focused on our goals. We
pay attention to all team members' assessments on an ongoing basis. And welisten to the patient's own assessment ofhis or her progress.
Figure 2. VencorHospitaI-Boston's North Shore VentilatorWeaningClinical Staircase
Anticipated Outcome forPatient with Underlying COPD:Discharge home, off ventilator (from admission at ICU Level to CRICU discharge)
Intermediate Outcome DischargeExpectationAspect of Care Specific Interventions Done (Ready for CRICU) Met (Readyfor Central2 Unit)
Functional health • Prehospital status • Expected level of assistance at • Able to begin retraining ofstatus • All assessments within discharge identified basic ADL functions at pre-
48 hours • Initial discharge plan agreed to hospital levelby patient and family • Medically stable
Nursing needs • Assessment of skin • Skin intact • Skin intact, bowel regimencare needs and resting • Special resting surface effective, able to performsurfaces, medication • Bowel regimen identified and transfers to and from bedregime, bowel protocol effective or commode with minimal
• Baseline medical problems stable assistance, oriented,participates in self-care
Respiratory status • Baseline ABGs, EKG, • Patient beginning trach collar • Trach collar: Tolerating offsputum culture, ventila- wean up to 2 hours a day, on ventilator for 48-72 hourstor settings, number of night ventilation • Normal pulse and whiteprevious weans • Secretions managed with suction- blood cell count, chest clear
ing 3 times a day• Pulse oximetry at 90%-95%
white blood cell count withinnormal limits
Patient and family • Expectations • Home evaluation • Education begun concerningteaching • Contact person • Informal daily contact with home preparation: Medica-
caregivers: Information about tions, respiratory needs atprogress, medical needs home, pacing, lifestyle
Rehabilitation • Assessment of patient • Patient able to transfer out of bed • Able to participate in low-therapies (e.g., phys- goals with minimal assistance, tolerate intensity daily therapy,ical, occupational, • Swallowing evaluation sitting up to 4 hours a day beginning ambulation withspeech) • Direct supervision of meals respiratory equipment
Nutrition • Recent albumin or • Adequate caloric and nutritional • Eating modified diet withprealbumin intake distant supervision
• Caloric needs • Adequate oral intake
Discharge planning • Psychosocial assessment • Focus on necessary intermediate • Daily teaching and focus• Community support goals, ventilator weaning, transi- on community reentry
services tion to Central 2 Unit preparation
Variance/change inplan
Rehabilitation Nursing> Volume 23, Number 5· Sep/Oct 1998 267
Perspectives
We drafted a description ofthe idealprogramwithin the continuum ofcafe and made plans
to share and implement this vision.
Measuring outcomes:Does it work?
A comparisonof thefirst6 monthsof1996with the first6 monthsof 1997underscores the success of this approach.From January to June 1996, we discharged 4 patients home who had beenweanedfrom the ventilator. In the same
time period in 1997, we discharged 13patients.The percentageof patientswhowere weaned off the ventilator and discharged home increased from 12% in1996 to 50% in 1997.Another measureof successcan be foundin thedecreasedaverage numberof daysrequiredto weana patient from the ventilator-this number dropped from 38 days in 1996 to 27days in 1997.
We are now designing a clinical"staircase" for these patients, as a wayto predict patient needs, progress, andgoals (seeFigure 2). Wedefinedthe following seven major aspects of patients'care needs from admissionto dischargeandalsoallowedspaceto documentvariances in and changes to the plan:
• functional health status• nursing needs• respiratory status• patient and family teaching• rehabilitationtherapies• nutrition• dischargeplanning
Each of these categorieshas its own discharge goals and corresponding intermediate goals. The intermediate goalsindicate patients' readiness to progressto less complex settings and then to return home. The intermediate goals also
provide each discipline with an opportunityto plan,coordinate, andfocuscare.
This typeof designis differentfrom aclinicalpath, in whichmany of the caregiving activities are identified to reachpredetermined outcomesin a predictableperiod of time. In our plan, intermediateand even dischargegoals may be modi-
fiedbasedon thepatient'sprogressand expectations. Tomakechangestogoals, the pa-tient,family, and
entire teammust be involved. Weevaluate each patient'sprogresson a dailybasis, adjustingventilatorsettings,extending weaning times, monitoring pulseoximetry, assessing levelsof anxietyandstress, and sharingour assessmentswiththe team and the patient.
We use understandable, concreteterms to explain to patients and familiestheprogressthathasbeenmadeandwhatwe expect, so that the patient may become free of the ventilator and returnhome. Our clinicalstaircaseis goal-specificbutnot time-specific. It helpsus describe to patients, families, physicians,caregivers, and case managers what toexpect in this program.So far, however,we havenotbeenableto predicton a daily or evena weeklybasishowlongit willtake each patientto progress,what complicationsmayarise,or whatadaptationswill be necessary.
Making a differenceManaged care has prompted all
healthcare professionals to ask and answer the question, "How do you knowwhen the patient is ready?" By showingexternal case managersour plan, we areable to share our general expectationsand to show the specific intermediate
goals we are planning.While we cannotpredict the total time it will take any patient to completethe weaningprocess oreven which patients will succeed, ourplanhasprovideda kindof roadmap.Aspatients achieve specific intermediateoutcomes, we are better able to predicthowmuch longer it will takefor them toreach their dischargegoal.
Havewe madea difference? We thinkso. Ask Mr. P.,who is now at home andfree from the ventilator. Ask our staff,who now must be selected from a waiting list to workon our unit. Ask the areavisiting nurses and external case managers who follow these patients and tellus how well theydo. Weare a team, andgoal-oriented teamworkdoesmakea difference.
All ofthe authors are affiliated with Vencor Hospital-Boston's North Shore inPeabody, MA. Suzanne Rogers is the director ofnursing, Martha Ryan isa nursemanager ofcritical care, and LawrenceSlepoy is the manager of cardiopulmonary care. Address correspondence toSuzanne Rogers, MA RN CRRN CNA-A,Vencor Hospital-Boston 's North Shore,15 King Street, Peabody, MA 01960.
AcknowledgmentThe authorsacknowledge the support
of Della Underwood, RN, Administrator, Vencor Hospital-Boston's NorthShore.
Editor's noteThis article is based on a paper pre
sentation thatwasgivenat the 1997ARNAnnualEducationalConferencein Baltimore.
268 Rehabilitation Nursing' Volume 23, Number 5· Sep/Oct 1998