American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

A Multidisciplinary QI Approach to Ventilator Management Results in Decreased Ventilator Times and a Reduction in Ventilator-Associated Pneumonia

University of Utah Health Sciences Center, Salt Lake City, UT

General Information

University of Utah Health Sciences Center, Salt Lake City, UT
Richard G. Barton MD

What Was Done?

Problem Addressed

Global Problem

Prolonged mechanical ventilation carries multiple risks for the surgical patient. These risks include ventilator-associated pneumonia (VAP), increased length of hospital stay, morbidity, and mortality. Conversely, premature discontinuation of ventilator support (extubation) that leads to re-intubation and further prolongation of ventilator support also increases the risks of pneumonia and mortality.

Prolonged mechanical ventilation is more common among patients with a higher severity of illness, chronic pulmonary disease, and respiratory failure due to pneumonia.  Further, prolonged ventilator support, along with advanced age (greater than 70), decreased level of consciousness, aspiration and sepsis is a risk factor for ventilator associated pneumonia.1,2

Because of the risks associated with prolonged mechanical ventilation, numerous professional organizations, including the NSQIP, have emphasized the importance of discontinuation of ventilator support and earlier extubation after surgery.3,4 On the other hand, failed extubation occurs in 2-25% of patients with associated co-morbidities and related critical care complications.4-7 Failure of extubation is an independent predictor of increased ICU length of stay, discharge to a long-term facility, and a seven-fold risk of death.8 Thus the emphasis on early extubation needs to be balanced against the risks of failed extubation.

Costs of care related to the need for prolonged ventilatory support are high, with national estimates suggesting that one incident of VAP cost $40,000.9 Aside from the cost of care for treatment within an ICU, there are numerous other benefits to transitioning patients out of critical care settings as soon as medically feasible.

Identification of Local Problem:

Compared to the NSQIP average, the incidence of prolonged mechanical ventilation in our 20-bed Surgical Intensive Care Unit (SICU) was excessive during the years of 2008, 2009, and 2010. Local NSQIP outlier data values prompted a multidisciplinary quality improvement project focused on reducing the duration of mechanical ventilation in all SICU patients while minimizing reintubation rates.

How Was the QI Activity Put in Place?

Context of the QI Activity

The SICU at the University of Utah is a 20-bed, multispecialty unit that admits more than 1,400 patients a year. The University of Utah is a tertiary care hospital with a well-established Level 1 trauma designation. The University serves patients from five surrounding states and has the largest geographic catchment area of any academic medical center in the country.

The University of Utah was an early member of the ACS NSQIP program with much of the early research carried out at the Salt Lake City Veteran’s Medical Center.

The SICU staff has attempted to address the issue of prolonged ventilator times previously by examining and comparing sedative agents used for patient comfort and developing protocols for sedation and analgesia, creating algorithms for sedation vacations to assess patient neurological status and attempting to link sedation vacations temporally to spontaneous breathing trials and the attainment of ventilator weaning parameters. The SICU team is made up of physician intensivists, nurses, pharmacists, residents, fellows, advance practice clinicians, social workers, nutritionists, physical and respiratory therapists, and from this group a ventilator management core group was created in order to develop algorithms and procedures to reduce the duration of time each patient spends on the ventilator.

Planning and Development Process

The core ventilator group consisted of intensivist physicians from the primary specialties of surgery, anesthesiology and emergency medicine, a general surgery resident, a respiratory therapist (RT), nurse educators, a research nurse, and quality improvement staff (NSQIP nurse and MBA). The core group was assembled in October 2010. After review of the current ventilator protocol and strategies the group identified 6 areas that would require focused review in order to streamline and improve ventilator management.