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Average vent duration drops from 4.7 days to 2.9
An innovative set of ventilator protocols has helped case managers at Nash General Hospital in Rocky Mount, NC, cut length of stay (LOS) for ventilator patients by 34% and overall LOS in the intensive care unit by one-fourth.
The average duration of mechanical ventilation dropped 38% (4.7 days vs. 2.9 days), and ventilator patients averaged savings of $35,000 in hospital charges. During the first nine months of implementing the ventilator protocols, the intensive care unit reported no cases of ventilator-associated pneumonia, down from a previous average of 12.9 infections per 1,000 ventilator days. (See pp. 153-154 for a sample protocol and pathway.)
The protocols’ success is due in large part to enthusiastic physician support, says Pam Johnson, BSN, RN, CCRN, clinical educator for critical care services. An internist/pulmonologist served as the initial physician champion for the protocol project. "With all the changes we made in implementing the protocols in incremental steps, he was the one who would initiate those changes first with his patients," Johnson says. "That was how we got our benchmark data out to the other physicians. They saw how well his patients were doing, how quickly they were weaning [from ventilators], and the decrease in the cost of care for his patients compared to theirs, and that’s how we won physician support."
At that time, in 1996, most physicians at Nash used a standard order set in dealing with ventilator patients. While the order sets were useful, members of the ventilator collaborative team believed they didn’t go far enough in standardizing care or addressing unnecessary costs. They also provided little flexibility to the bedside nurses and respiratory therapists in initiating the weaning process, Johnson says.
The first major difference between the existing order sets and the new protocols had to do with the number of autologous blood gases (ABGs) performed to check a patient’s breathing status after ventilator changes are made. "With the new protocol sets, we limited the ABGs to once a day and any time a change in the patient’s status warranted it," Johnson says. Previously, an ABG was performed each time a ventilator change was made, an expensive trend given that ABGs cost about $100 each to perform. "If you’re trying to wean a patient and you’re checking three or four times per day, the cost is driven up," she says. When possible, nurses use pulse oximetry instead, which costs less and is less invasive for patients.
Other elements of the ventilator protocols include:
• Initiating tube feeding immediately after the patient is placed on the ventilator, pending a physician’s approval. Before, patients may have gone a day or two before they were fed.
• Giving drugs for sedation if the patient becomes restless.
• Performing chest X-ray right after a patient is placed on a ventilator to make sure the tubing is in place.
• Taking sputum cultures to determine a baseline for organism growth and the need for antibiotics.
• Weaning the patient at certain oxygen levels.
Patient readiness to leave ICU rated
Another helpful aspect of the protocols has been the implementation of a daily rating system for ICU patients that helps determine when patients need to be moved out of ICU, Wells says. An "A" rating means the patient is on a ventilator or drips and needs to stay in the ICU. A "C" rating means the patient is off the ventilator and drips, is stable, and is ready to move to a regular floor. A "B" rating means the patient is at a point in between and should stay in the ICU until becoming stable.
The ventilator protocol project began with a goal to decrease the average number of ventilator days by 25%, decrease the costs associated with providing mechanical ventilation by 25%, and decrease the incidence of ventilator-associated pneumonia in the ICU — all of which the hospital accomplished within nine months of implementation. The protocols themselves, however, were implemented in incremental stages, beginning with a respiratory-driven protocol designed to wean ventilator patients from mechanically supplied oxygen.
The second stage involved the reduction of ABGs in favor of pulse oximetry. A by-product of this stage was the reduced incidence of nosocomial pneumonia among the ventilator patients.
"We then started looking at the nutritional aspects of our patients," Johnson says. A protocol was developed in which parenteral nutrition was started within 24 to 48 hours. "That way, when the physicians ordered the vent protocols, we were able to initiate the tube feedings at that point," she says.
The final step was to standardize medications used to promote tolerance of the ventilator, including sedatives and analgesic agents. "Before, physicians would use whatever medications [they wanted]," Johnson says.
A standard set of ventilator orders is included in every patient’s chart, and the ventilator protocol is posted in the unit. Johnson says the standardization improves patient care and makes staff education much easier. "Before, the nurses and therapists had to work with 30 different physicians with 30 different ways to wean," she says. "Now there’s less stress for the staff, and it’s easier for them to learn."
Johnson goes over the protocol with nurses during new staff orientation, touches on the topic in monthly inservices for existing staff, and discusses treatment options during daily rounds. She also participates in interdisciplinary rounds twice a week. Physicians receive a manual with the protocols, and the nurses constantly remind them to think about weaning patients.
"We continuously monitor the protocols to make sure that we’re still on track with the data," Johnson says. "We have had a lot of turnover with respiratory staff and nursing staff, so we began to see some of the gains we had made in the management of ventilator patients decline. We re-examined that and went back to re-educate new staff and new therapists to get them back up to speed." As a result, Johnson says, the numbers are gradually moving back in line with expectations.
Meanwhile, the ventilator protocols continue to evolve. "We’re planning to revisit the issue of nutrition in the vent patients and fine-tune that process a little more," Johnson says. "We’re also looking at the implementation of kinetic therapy for the patients."
For more information, contact Pam Johnson, BSN, RN, CCRN, clinical educator for critical care services, Nash General Hospital, 2460 Curtis Ellis Drive, Rocky Mount, NC 27804. Telephone: (252) 443-8723.