DRAFT - University of Texas System



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Overview:

It is well documented that prolonged mechanical ventilation time increases the risk of ventilator associated pneumonia (VAP), and length of stay in ICU and hospital (LOS). According to the Surviving Sepsis 2008 guidelines and multiple other randomized control trials, weaning protocols utilizing daily spontaneous breathing trials (SBT) and daily awakening trials (DWT), (often performed by non-physicians), are known to decrease ventilator time and cost, and improve outcomes.

It is also been demonstrated that implementation gaps exist in intensive care. In MHH MICU between May 2008 and April 2009, 547 patients were ventilated for a mean time of 141.4 hours. During that time, only 65% of MICU patients are placed on a weaning protocol utilizing daily SBT. A subset of 312 (43%) of patients were on ventilators between 48 and 336 hours (2 -14 days) and was selected as the focus for the initial intervention. Their mean time on a ventilator was 139.9 hours.

The daily sedation holiday used in the Kress, et al trial decreased ventilator time by up to 2.4 days (60 hours). Within 48 hours of extubation, there was a 17.6% re-intubation rate in the intervention group and a 30% re-intubation rate in the control group. The “wake up and breath” protocol from Girard and Kress et al, using both SBT’s and sedation holidays reduced ventilator time by 3.1 days.

Previously at our institution orders for sedation holidays were written at the discretion of the residents on a day to day basis. A protocol for daily SBT’s existed but not fully implemented, moreover, there was no place for documentation in our electronic medical record (EMR, CARE4/Centricity®). As our off-set parameter, we intend to maintain the re-intubation rate close to the national average of 10%.

Since the initial implementation in the Medical ICU in 2009, we have extended the daily SBT protocol to other ICU’s including the Transplant ICU (TSICU), Neuro-Trauma ICU (NTICU), the Heart and Vascular Institute (CCU and CVICU), Shock-Trauma ICU (STICU), and Burns ICU. We now have 3 years of follow up data.

Aim Statement :

• Decrease mean ventilator time for patients by 10%.

• Extend the protocols into other ICU’s

• Decrease the frequency of ventilator associated pneumonia (VAP)

Measures of Success:

• Increased percentage of patients on weaning protocols

• Decreased ventilator time for targeted patient population

• Increased percentage of patients receiving daily sedation holiday

• Decreased ICU length of stay for selected patients

• Maintain re-intubation rate (target ................
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