Transcript Slide 1
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
Decrease the
duration of
ventilation for
each ventilated
patient
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)
Jan- April 2010
Re-intubation rate
MICU= 6.9 %
*5-10% ( best
practice /
literature)
Oct 2010 – Jan
2011
MD Orders - 57%
RN SAT - 18%
RT Screen - 75%
100%
Re-intubation rate =
Maintain or
# of re-intubations
decrease current
within 48 hrs of
re-intubation rate
extubation / # of
patients intubated
Protocol
100% protocol
compliance = #
compliance for
compliant with
all disciplines
protocol / # of
patient audits
Fishbone Diagram
Physician Directed Flow Map
Cause and Effect Analysis
100%
50%
100%
94%
45%
90%
87%
40%
80%
70%
Category
35%
70%
30%
60%
25%
50%
20%
40%
35%
15%
30%
10%
20%
5%
10%
35%
35%
17%
7%
6%
People
Method/Process
Measurement
Machine/Equipment
Environment
0%
0%
Protocol Directed Flow Map
Project Timeline
EMR Charting for SBT
Physician Order
Results
Jan – Apr 2010
Jan – Apr 2011
Results
SAT/SBT Ordering and Screening Compliance -MICU
Audit: 10/30/10 - 5/31/11
Oct -Jan (N=109)
Feb - May (N= 40)
100%
90%
P<.01
P<.01
100%
P<.01
100%
80%
85%
70%
75%
60%
50%
57%
40%
30%
20%
10%
18%
0%
MD ORDER
RN SAT SCREEN
RT SCREEN
Results
Ventilation days decreased by 2.1 days (34.6% ) in the MICU
(P = .04)
Rates of Reintubation
Rate (Number of reintubations per 100 intubations)
Comparison of Rates of Reintubation
10
9
8
7
6.9
P = .44
6
5
4.4
4
3
2
1
0
January - April 2010 (n=116)
January - April 2011 (n=90)
Results
17% decrease in Vent
Days as compared to
2010
Results
32% decrease in
32% decrease
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?