Clinical Safety

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Clinical Safety Effectiveness

• Decreasing Ventilator Days
• in the Medical Intensive Care Unit
• Department of Critical Care Medicine

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ProlongedMechanicalVentilation
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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, 8242
Zilberberg et al. Crit Care Med 2008. 36(5)
1451-1455
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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

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Prolonged Mechanical Ventilation
Ventilator Associated Pneumonia
Deconditioning
Airway Trauma
Increased Mortality
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Aim statement

• To decrease ventilator days in Medical Intensive
  Care Unit patients by 10,
• by June 30th, 2011

Our baseline 6.62 days/patient
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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?
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Ishikawa(Fishbone)Diagram
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Flow Chart of Weaning Process
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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)
  p0.01
• 1 year mortality (from 58 to 44) p0.02

daily interruption of sedatives can reduce the
duration of mechanical ventilation without
compromising patient comfort or safety
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Our Current Sedation Protocol
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Baseline Data

• How were we doing in our
• Intensive Care Unit?

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Average Ventilator Days in the Medical Intensive
Care Unit at the MD Anderson Cancer Center before
our intervention

• 6.62 days per patient

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Process Map
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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

Target

• -3.5

(Our Average)
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Our Interventions

• starting February/March 2011

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SBT Sedation Holiday Educational MeetingsA
Collaboration at Bedside

• Mandatory for
• ICU RNs Therapists
• (days and nights)
• When 2/21 through 2/25
• Time 700 AM (15mins)
• Location ICU Classroom
• Presented by Dr. Rathi
• Refreshments will be served

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Improve Nursing Compliance with Automatic
Sedation-Analgesia Holiday Protocols 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 830 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
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Keeping the Momentum Going

• Bedside quizzes with prizes
• Raffles
• Inservices
• (RT and RN)
• Emails/staff meetings

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WAKE UP and BREATHE
Have you done your sedation/analgesia holiday
today?
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How are we doing?

• Post Intervention Data

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Intervention
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p 0.116
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Intervention
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p 0 .117
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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
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Respiratory Data

• Post-intervention

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Intervention
Baseline 6.62 days/pt Post intervention
Average 5.84 days/pt Ventilator Days Decreased
by 0.78 or 12
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Intervention
Baseline 9.46 days/pt Post intervention
Average 8.22/pt MICU LOS Decreased by 1.24
days or 13
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ACTUAL Return on Investment

• Costs of Project
• Payroll materials 18,062.50

• ICU Costs
• Cost of ICU/Day 3872.00
• Respiratory Costs/Day 3133.00

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
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Potential Cost Savings

• 3,488,627.28
• per year

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Upcoming Challenges

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

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Upcoming Challenges

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

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p value 0.012
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Intervention
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Intervention
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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

• 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.

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