Clinical Safety & Effectiveness

1. Clinical Safety & Effectiveness Decreasing Ventilator Days in the Medical Intensive Care Unit Department of Critical Care Medicine

2. ProlongedMechanicalVentilation

3. A glimpse at the future… Projected Annual Hospitalization Days in 10-year Increments Spent by a Patient on Prolonged Acute Mechanical Ventilation (PAMV) in Various Strata of Hospital Care. ICU is intensive care unit. MV is mechanical ventilation. Y is year. Zilberberg et al. BMC Health Services Research 2008, 8:242 Zilberberg et al. Crit Care Med 2008. 36(5): 1451-1455

4. Prolonged Mechanical Ventilation in the United States On any given day, 7000 to 11,000 PMV patients… 300,000 patients per year Annual costs exceed 20 billion dollars $

5. Prolonged Mechanical Ventilation Ventilator Associated Pneumonia Deconditioning Airway Trauma Increased Mortality

6. Aim statement “To decrease ventilator days in Medical Intensive Care Unit patients by 10%, by June 30th, 2011” Our baseline = 6.62 days/patient

7. Brainstorming Involve everyone involved: Nurses, Nursing Leadership, Respiratory Therapists, Physicians, Mid-level providers, Pharmacists Ask the question: How can we work together to get patients off the ventilator sooner? Find the root cause: What are the barriers to achieving this goal?

8. Ishikawa(Fishbone)Diagram

9. Flow Chart of Weaning Process

10. Sedation Holidays & Spontaneous Breathing TrialsWhat is the evidence? • Nurse and RT driven • Significant decrease in: • Ventilator free days • Hospital length of stay • ICU length of stay (from 12.9 days to 9.1 days) p=0.01 • 1 year mortality (from 58% to 44%) p=0.02 “daily interruption of sedatives can reduce the duration of mechanical ventilation without compromising patient comfort or safety”

11. Our Current Sedation Protocol

12. Baseline Data How were we doing in our Intensive Care Unit?

13. 6.62 days per patient Average Ventilator Days in the Medical Intensive Care Unit at the MD Anderson Cancer Center before our intervention…

15. Process Map

16. Baseline Average Richmond Agitation Sedation Scale (RASS) for intubated MICU patients between 7pm and 7 am +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and Calm -1 Drowsy -2 Light Sedation -3 Moderate Sedation -4 Deep Sedation -5 Unarousable -3.5 Target (Our Average)

17. Our Interventions starting February/March 2011

18. SBT & Sedation HolidayEducational Meetings“A Collaboration at Bedside” Mandatory for ICU RN’s & Therapists (days and nights) • When: 2/21 through 2/25 • Time: 7:00 AM (15mins) • Location: ICU Classroom Presented by: Dr. Rathi Refreshments will be served

19. Improve Nursing Compliance with Automatic Sedation-AnalgesiaHolidayProtocols Measure of success: Automated individualized compliance reports through PICIS Pair Spontaneous Breathing Trials with Sedation-Analgesia Holidays 30 minute goal to decision to extubate after SBT RT-MD Rounds 8:30 am Communicate Individual MD rates of deferred extubation Improvement In RASS scores at night to an average goal of 0 to -2 Improve Nursing and RT communication of SBT readiness

20. Keeping the Momentum Going… • Bedside quizzes with prizes • Raffles • Inservices (RT and RN) • Emails/staff meetings

22. WAKE UP and BREATHE Have you done your sedation/analgesia holiday today?

23. How are we doing? Post Intervention Data

24. Intervention

25. p = 0.116

26. Intervention

27. p = 0 .117

28. Improvement in RASS (sedation score) at night post-intervention +4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and Calm -1 Drowsy -2 Light Sedation -3 Moderate Sedation -4 Deep Sedation -5 Unarousable Target -1.2 post intervention -3.5 Baseline Average

29. Respiratory Data Post-intervention

34. Intervention Baseline = 6.62 days/pt; Post intervention Average = 5.84 days/pt Ventilator Days Decreased by 0.78 or 12%

35. Intervention Baseline = 9.46 days/pt; Post intervention Average = 8.22/pt MICU LOS Decreased by 1.24 days or 13%

36. Costs of Project: Payroll + materials = $18,062.50 ICU Costs: Cost of ICU/Day = $3872.00 Respiratory Costs/Day= $3133.00 ACTUALReturn on Investment$ $ Decrease in Average ICU LOS for ventilated patients since March 1st, 2011 = 1.24 days (13 % decrease) Decrease in Average ventilator days since March 1st, 2011 = 0.78 days (12 % decrease) March 1st to June 30th 2011: Savings in ICU LOS $782,608.64 +Savings in Vent Days $398,329.62 = $1,180,938.26 Costs of Project - 18,062.50 TOTAL NET COST SAVINGS = $1,162, 875.76

37. Potential Cost Savings… $3,488,627.28 per year

38. Upcoming Challenges • Maintain gains and continue improvements • Ongoing education (new staff) • Continue to improve practitioners’ variability • Implement initiatives in the Surgical ICU

39. Upcoming Challenges • Maintain gains and continue improvements • Ongoing education (new staff) • Continue to improve practitioners’ variability • Implement initiatives in the Surgical ICU

40. p value 0.012

41. Intervention

42. Intervention

43. Additional Team Members Laura Withers, MBA, RRT, CPFT Quan Ngyuen, BS, RRT Mick Owen, BSN, RN James Darden, RN, BSN Enedra McBride, RN, BSN Mary Lou Warren, RN, CNS, CCRN, CCNS Rhea Herrington, RN, BSN, CCRN Natalie Clanton, RN Jennifer Harper, RN Fallon Benavides, RN, MSN Jeffrey Bruno, PharmD, BCNSP, BCPS Gregory Botz, MD, FCCM Sajid Haque, MD Hetal Brahmbhatt, MHA, CPhT Lora Washington, MHA, JD Andrew Dinh, BS Hollie Lampton, B.S. Rose Erfe, B.S. Dee Cano Edward Scott, B.S, The Wean Team • CS & E Class Participants • Nisha Rathi, MD. • Clarence Finch, MBA, MHA, RRT, FCCM • Estella Estrada, BS • Nathan Wright, MD • Wendi Jones, MSN, ACNP-BC • Facilitator and Sponsor • Joseph Nates, MD, MBA-HCA, FCCM 43