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Decreasing Duration of Mechanical Ventilation in the Medicine ICU

This project aimed to decrease the duration of mechanical ventilation in the Medicine ICU by implementing evidence-based protocols for awakening and spontaneous breathing trials. Results showed a decrease in ventilation days by 34.6% and a 32% decrease in rates of ventilator-associated pneumonia.

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Decreasing Duration of Mechanical Ventilation in the Medicine ICU

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

  2. 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

  3. 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.

  4. AIM Statement Decrease the duration of mechanical ventilation in MICU by one day by instituting a standardized approach to awakening and spontaneous breathing trials

  5. 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

  6. 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

  7. Measure of Success

  8. Fishbone Diagram

  9. Physician Directed Flow Map

  10. Cause and Effect Analysis

  11. Protocol Directed Flow Map

  12. Project Timeline

  13. EMR Charting for SBT

  14. Physician Order

  15. Results Jan – Apr 2010 Jan – Apr 2011

  16. Results

  17. Results Ventilation days decreased by 2.1 days (34.6% ) in the MICU (P = .04)

  18. Rates of Reintubation

  19. Results 17% decrease in Vent Days as compared to 2010

  20. Results 32% decrease in VAP rate 32% decrease

  21. 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

  22. Lessons Learned • Multidisciplinary team is key for success • Automated protocol in EMR streamlines • the process • Implementation in phases leads to difficulty in protocol compliance

  23. Next Steps • Data collection automated in EMR • Year to year comparison for further analysis to determine sustainability • Investigate the impact of protocols on VAP

  24. 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

  25. QUESTIONS?

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