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

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

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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.
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AIM Statement

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

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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

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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 11 or 21
• Respiratory Care Staffing
• 2 MICU therapists assigned per shift

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Measure of Success
Goal Measure Baseline Target
Decrease the duration of ventilation for each ventilated patient 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)
Maintain or decrease current re-intubation rate Re-intubation rate of re-intubations within 48 hrs of extubation / of patients intubated Jan- April 2010 Re-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
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Fishbone Diagram
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Physician Directed Flow Map
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Cause and Effect Analysis
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Protocol Directed Flow Map
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Project Timeline
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EMR Charting for SBT
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Physician Order
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Results
Jan Apr 2010
Jan Apr 2011
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Results
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Results
Ventilation days decreased by 2.1 days (34.6 )
in the MICU (P .04)
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Rates of Reintubation
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Results
17 decrease in Vent Days as compared to 2010
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Results
32 decrease in VAP rate
32 decrease
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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

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Lessons Learned

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

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Next Steps

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

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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

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QUESTIONS?