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

2. 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.

3. 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 (5):

4. 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 $

5. 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

6. 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

7. 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 patients
Find the root cause:
What are the barriers to achieving this goal? 7

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

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

10. 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

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

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

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

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

15. 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…

16. 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

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

18. 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.

19. 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

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

21. Nisha
Buttons for the staff

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

23. Post Intervention Data
How are we doing?
Post Intervention Data

24. Intervention
Estella 24

25. Estella
p =

26. Intervention
Estella 26

27. Estella
p =

28. 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

29. Respiratory Data
Post-intervention

30. Clarence

31. Clarence

32. Clarence

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

34. 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%

35. 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%

36. ACTUAL Return on Investment $ $
Costs of Project:
Payroll + materials = $18,062.50
ICU Costs:
Cost of ICU/Day = $
Respiratory Costs/Day= $
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, Savings in Vent Days $398,329.62
= $1,180,938.26
Costs of Project ,062.50
TOTAL NET COST SAVINGS = $1,162,
Nathan
These were true hospital costs not charges

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

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

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

40. p value 0.012

41. Intervention
Estella 41

42. Intervention
Estella 42

43. 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