A multidisciplinary quality improvement approach to ventilator management results in decreased ventilator times and a reduction in ventilator associated pneumonia Gillian eton MD, teven Johnson MBA, Gabriele Baragoshi RN, Earl Fulcher RRT MAE, Judy Larsen RN BN, Andi Jones RN, Edward Kimball MD, Peter Liu MD, Raminder Nirula MD, Richard Barton MD
Introduction NQIP showed that the University of Utah was a high outlier in 2008-2010 for patients receiving >48 cumulative hours of mechanical ventilation. Table 1: NQIP O/E ratio for general and vascular surgery patients in University of Utah ICU Ventilator >48hrs Pneumonia Unplanned intubation Year Rate O/E Rate O/E Rate O/E 2008 2.31% 1.42 1.00% 0.71 0.95% 0.78 2009 2.79% 1.53 1.79% 1.12 1.93% 1.46 2010 2.43% 1.48 1.34% 1.01 1.49% 1.26
Methods: Quality improvement project Goal: reduce ventilator time & ventilator associated pneumonia (VAP) without an increase in re-intubation Multidisciplinary team All ventilated patients included to assess the unit s standards Compared unit s standards with national best practices
Methods Areas of intervention, fully implemented by June 2011 Ventilator protocol revisions imple visual workplace management tools pontaneous breathing trials timed with sedation vacations Protocol prompts incorporated into electronic charting (RT & MD charting) Multidisciplinary education
pontaneous Breathing Trials (BT): RT and RN should collaborate to conduct daily 30-minute BT during a sedation vacation. Avoid RN/RT shift change (6:00 7:30 AM/PM) Expect sedation vacation during rounds. Exclusions include: Open belly or chest Patient on paralytics MD order Assess for BT when all these criteria are met: 1. FiO2 < 50% 2. PEEP < 5 3. RR < 30 4. Patient on P mode 5. Hemodynamically stable 6. No active bleeding BT Assessment Cycle ICU Ventilator Protocol Revision Date: June, 2011 TART: Assess for BT w/ edation Vacation Is patient alert? i.e. w/ Riker of 4? Reduce sedation Reassess w/in 60 min Return to previous rate Is patient triggering additional breaths? Reduce vent rate to 6 Wait 10-15 min Triggering additional breaths? Can patient follow commands or lift head? Reassess w/in 60 min Assessment complete, perform BT Weaning Extubation Parameters: Physician must approve extubation regardless of parameters. Acceptable parameters for extubation or initiation of T-piece trials (tracheostomy patients): 1. RR < 30 2. Vt > 5 ml/kg 3. VC > 10 ml/kg 4. MIF more neg. than -30 cmh2o 5. RBI < 100 Weaning Cycle Put patient on P 5 / PEEP 5 PONTANEOU BREATHING TRIAL Wait Tolerating 20-40 P 5 and min PEEP 5? TOP: Move to Minimum Vent upport Cycle for 8-24 hours Return to previous settings Get weaning parameters on P 0-5 / PEEP 5 Are parameters acceptable to MD? Consult with MD, then extubate to supplemental O 2 RT and MD should consistently work to minimize the patient s ventilation support: Maintain po2 > 90% Maintain proper acid-base balance Always maintain an appropriate PEEP to FiO2 relationship according to this table: FiO2 40% 50% 60% 70% 80% 90% 100% PEEP 5-8 8-10 10 10-14 14 14-18 18-24 When increasing support, start FiO2 at 50% and move up the table as needed. When decreasing support, decrease FiO2 to 60%. Then move down the table alternating between PEEP and FiO2 adjustments. PEEP decreased no more than 2 cmh2o at one time, no more than 2 changes in 24 hrs to maintain adequate lung expansion. Minimum Vent upport Cycle TART Vt 5-7 ml/kg and RR < 30 Vt < 5 ml/kg or RR > 30 Assess Vt and RR: Vt > 7 ml/kg and RR < 30 Has an BT been tried in last 8 hrs? Increase P to maintain Vt of 5-7 ml per kg of ideal body weight and RR < 30 Decrease P to maintain Vt of 5-7 ml per kg of ideal body weight and RR < 30 If P>20 cmh 2 O is required, see MD for alternate weaning plan Consider PEEP adjustment TOP: Move to BT Assessment Cycle Reassess Vt and RR in 2-6 hrs
Results: Outcome Improvement ICU ventilated patients June-ept 2010 June-ept 2011 Improvement p- value Vent >48hrs 104/277 (37.6%) 77/283 (27.2%) 27.7% 0.009 Mean vent time (hours) VAP >1 intubation 86.7 61.3 29.3% 0.029 14/277 (5.1%) 34/277 (12.3%) 3/283 (1.8%) 22/283 (7.8%) 65.0% 0.033 36.6% 0.077
Proportion of intubated patients 80% 70% 60% 50% 40% 30% 20% 10% 0% 61% 51% Intubation Duration Before intervention (n=277, June-ept 2010) After intervention (n=283, June-ept 2011) 12% 11% 8% 4% 6% 4% 4% 3% 6% 1% 3% 1% 0-24 24-48 48-72 72-96 96-120 120-144144-168168-192 >192 <48hrs >48hrs 1% 1% Cumulative hours of intubation 13% 8% 62% 73% 38% 27% Before After
Cost analysis: Respiratory Therapy Total RT Expense (four months) $2,286,942 Total RT Expense (annual) $6,860,826 Paid Hours 50,743 Paid Hours, Worked 43,731 Office Hours, Worked 3,359 Direct Productive Hours 40,372 Cost per Labor Hour $56.65 Labor Cost of 12 hour shift (1 person) $680 Average Number of Therapists in ICU 2.0 Average pts on vent at any given hour (before project) 8.1 Vented pts per therapist, any given hour 4.05 Average min per shift attention paid per vent pt 94.0 Average min per shift attention paid per non vent pt 17.5 Minutes per shift (1 RT) of attn paid to Vented pts. 380 Minutes per shift (1 RT) of attn paid to Non-Vented pts. 104 Direct Cost of an Hour of Mech. Vent. $10.99 Weighted Portion of Direct Cost Non-Vented pts $2.05
Cost Analysis Reduction of mean time of ventilation (61.3hrs compared to 86.7hrs) = reduction of 7,162 ventilator hours. Our estimation of an hour of mechanical ventilation based on average RT labor is $10.99 of direct cost. ubtract hourly labor cost of non-intubated patients: $10.99 - $2.05 = $8.94 avings of $ 64,028 in four months.
Discussion NQIP outcome data can be used as both an individual and institutional performance guide A systematic approach to improving daily ventilator care can reduce overall ventilator dependence and the risk of ventilator associated pneumonia without increasing re-intubations Improvement in clinical outcomes can directly lower hospital costs.