Decreasing Duration of Mechanical Ventilation by Implementing Evidence Based Protocols in the Medicine ICU

TEAM

• Team Members Edward Best, RRT, RCP, MBA, MSHA,

Director Respiratory Care, Parkland Health & Hospital System Dean Holland , RRT, RCP

Respiratory Care Educator Parkland Health & Hospital System Harold Wey, RRT, RCP

MICU & CPICU Clinical Team Leader, Parkland Health & Hospital System Pheba Abraham, RN, MSN, CPHQ

PI Project Manager, Parkland Health & Hospital System Alayne Royster, RRT,RCP

Respiratory staff Martin Flores RN, CCRN MICU Peter Hoffmann, MD, M Phil

SVP Chief Quality Officer, Parkland Health & Hospital System

• Physician Champion Craig S. Glazer, MD, MSPH

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 14 bed ICU 4720 total patient days FY 2011 4736 total patient days FY 2010

MICU Physician Staffing Two attending pulmonologists and one pulmonary fellow

together oversee and round with 4 MICU teams MICU teams are composed of a resident, an intern and a

rotating PM call intern

Physician Staffing Rotations Attending faculty rotate off service every two weeks The fellow and the residents rotate off every four weeks Interns rotate off service every calendar month on the first

MICU

Nursing and Respiratory Care Staffing There are no travelers or agency staff used for nursing or

respiratory care

Nursing Staff Consistently staff with the number of nurses needed

based upon census and acuity of the patient population Staffing ratio of 1:1 or 2:1

Respiratory Care Staffing 2 MICU therapists assigned per shift

Measure of Success

Goal Measure Baseline Target

Decrease the duration of

ventilation for each ventilated

patient

Duration of ventilation

Jan- April 2010MICU vent days =

6.1(147.51 hours)

Decrease by 1 dayMICU vent days =

5.1(122.4 hours)

Maintain or decrease current re-intubation rate

Re-intubation rate = # of re-intubations

within 48 hrs of extubation / # of

patients intubated

Jan- April 2010Re-intubation rate

MICU= 6.9 %

*5-10% ( best practice / literature)

100% protocol compliance for all disciplines

Protocol compliance = # compliant with protocol / # of patient audits

Oct 2010 – Jan 2011

MD Orders - 57%RN SAT - 18%

RT Screen - 75%

100%

Fishbone Diagram

Physician Directed Flow Map

Cause and Effect Analysis

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% decrease32% decrease in VAP rate

Discussion

Protocol driven process decreased the duration of MV in our MICU by 2.1 days in the first six months of protocol implementation Difference in rate of reintubation was not significant

House-wide ventilator days were reduced by 17% when comparing FY 10 to FY 11

House-wide rate of VAP was reduced by 32% (7.8 vs. 5.3) when comparing FY 10 to FY 11 30 fewer patients developed VAP in FY 2010 vs 2011

Lessons Learned

Multidisciplinary team is key for success

Automated protocol in EMR streamlines the process

Implementation in phases leads to difficulty in protocol compliance

Next Steps

Data collection automated in EMR

Year to year comparison for further analysis to determine sustainability

Investigate the impact of protocols on VAP

Special Thanks

Carlos Girod MD Professor Internal Medicine UT Southwestern Medical Center , Medical director MICU Parkland Health & Hospital

System

Sanjuana Wilhoite RN PI & PS Specialist, Surgical Services

Mary Lynn Fancher RRT Manager Respiratory Care

Alissa Lockwood PharmD. Clinical Pharmacy Specialist

Carol HirschKorn RN, MSN, ACNP, CCRN Nurse Practitioner in the trauma ICU

Paul A Carlson PHD Application System Analyst/Program-SR

Jennifer De La Garza RRT, RCP Respiratory Therapist

Sarah Clemente RN,CCRN Unit Manager MICU & CPICU; Manager PICC Service

Billy J Moore PHD Chief Biostatistician, Centers for Clinical Innovations

Vicki Crane MBA, FASHP, RPh Senior Vice President Clinical Support Services

QUESTIONS?