Clinical Safety & Effectiveness Decreasing Ventilator Days in the Medical Intensive Care Unit Department of Critical Care Medicine

Prolonged Mechanical Ventilation What is the definition of PMV? Like any good scholar, the first place I went was google. The answers you get are all over the map…And of course it’s important to have standard definitions for research purposes. But from a quality perspective, or even a patient perspective, maybe that definition should be different. In fact, from OUR perspective, maybe any extra time a patient spends on the ventilator because the healthcare team could have done an even better job should be considered prolonged mechanical ventilation? Any of you who have worked in ICU know that we spend much of our time frustrated, because despite our best efforts, patients often have poor outcomes due to their underlying disease processes. Failure to wean certainly can fall into that realm. But there is some strong evidence out there showing us things we can do to get patients weaned faster, yet a huge disparity in our practices– not just in the US but around the world. Like many evidence based practices, these are taking their time to infiltrate our ICU’s, and the consequences of that are substantial.

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, 8:242 Zilberberg et al. Crit Care Med 2008. 36(5): 1451-1455

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 Doesn’t include LTAC/SNF costs $

Prolonged Mechanical Ventilation Ventilator Associated Pneumonia Deconditioning Airway Trauma Costs to the patient… Mortality exceeds 50% in the first year for patients on prolonged mechanical ventilation. Increased Mortality

Our baseline = 6.62 days/patient Aim statement “To decrease ventilator days in Medical Intensive Care Unit patients by 10%, by June 30th, 2011” Nisha Our baseline = 6.62 days/patient

Involve everyone involved: 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? Nisha Large Unit with 150 nurses, 10 MLP’s, 10 ICU faculty, 13 RT’s, and 30-50 patients Find the root cause: What are the barriers to achieving this goal? 7

Ishikawa(Fishbone)Diagram Nisha The highlighted items are all related to SBT’s and sedation holidays

Flow Chart of Weaning Process Probably a lot like other hospitals where the SBT is the central process that weaning protocol revolves around

Sedation Holidays & Spontaneous Breathing Trials What 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) p=0.01 1 year mortality (from 58% to 44%) p=0.02 “daily interruption of sedatives can reduce the duration of mechanical ventilation without compromising patient comfort or safety” As I mentioned before, there is strong evidence that having this protocol driven by nurses and RT’s on a daily basis

Our Current Sedation Protocol December of 2007, time of sedation holiday became a default order

How were we doing in our Intensive Care Unit? Baseline Data How were we doing in our Intensive Care Unit? Wendi

Average Ventilator Days in the Medical Intensive Care Unit at the MD Anderson Cancer Center before our intervention… 6.62 days per patient Nathan

Wendi Looking back 12 months (February 2010 to February 2011) 14

Process Map One of the problems we identified after brainstorming sessions was that we were taking a really long time to extubate patients– and that was creating difficulty for the beside nurse who was often left with an awake, combative patient Average time to extubation after passing a Spontaneous Breathing Trial PRIOR to starting our project…

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) Wendi

starting February/March 2011 Our Interventions starting February/March 2011 Nisha

Refreshments will be served SBT & Sedation Holiday Educational Meetings “A Collaboration at Bedside” Mandatory for ICU RN’s & Therapists (days and nights) When: 2/21 through 2/25 Time: 7:00 AM (15mins) Location: ICU Classroom Presented by: Dr. Rathi Refreshments will be served Nishao Able to get almost all 150 nurses(night and day shift) and all ICU RT’s by the end of the week Pointed out where we were at, and where we needed to be, and the reasons why it was important. We got a lot of important feedback from people as well that influenced our interventions.

Pair Spontaneous Breathing Trials with Sedation-Analgesia 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 8:30 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 Nisha

Keeping the Momentum Going… Bedside quizzes with prizes Raffles Inservices (RT and RN) Emails/staff meetings Nisha

Nisha Buttons for the staff

sedation/analgesia holiday today? WAKE UP and BREATHE Nisha Screen savers Have you done your sedation/analgesia holiday today?

Post Intervention Data How are we doing? Post Intervention Data

Intervention Estella 24

Estella p = 0.116

Intervention Estella 26

Estella p = 0 .117

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 Estella RASS improved with education at night by -3.5 Baseline Average

Respiratory Data Post-intervention

Clarence

Clarence

Clarence

Made it mandatory that Physicians provide justification for not extubating a patient who passed an SBT

Ventilator Days Decreased by 0.78 or 12% Intervention Clarence Insert p value Baseline = 6.62 days/pt; Post intervention Average = 5.84 days/pt Ventilator Days Decreased by 0.78 or 12%

MICU LOS Decreased by 1.24 days or 13% Intervention Clarence Baseline = 9.46 days/pt; Post intervention Average = 8.22/pt MICU LOS Decreased by 1.24 days or 13%

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 Nathan These were true hospital costs not charges

Potential Cost Savings… $3,488,627.28 per year Nathan

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

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

p value 0.012

Intervention Estella 41

Intervention Estella 42

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. Dee Cano Edward Scott, B.S, 43 43