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

Ventilator Management Description

Description of the QI Activity

Six Areas Identified

1. Present Protocol

The first activity involved a literature review of best practice guidelines and published standards with regard to the ventilator management protocols that were in use in the intensive care unit. We determined that our practices were consistent with published best practices. We did find however, that our written protocols were too lengthy and somewhat difficult to follow. Based on that evaluation, a summary diagram of our ventilator protocol was created that includes the relationship of positive end expiratory pressure (PEEP) and fraction of inspired oxygen (FiO2) to achieve oxygenation goals and minimize oxygen toxicity, algorithms for minimizing ventilator support, weaning the ventilator and the performance of spontaneous breathing trials. The diagram also includes specific criteria for, and contraindications to, the performance of a spontaneous breathing trial. Finally the diagram includes the specific weaning criteria that need to be met for extubation to occur. The new protocol was streamlined and reformatted so that it fit onto a single page (Figure 1). The protocol page has been laminated and placed at every bedside for reference and review.

Figure 1. SICU Ventilator Protocol

SICU Ventilator Protocol

2. Spontaneous Breathing Trials

For those patients deemed medically eligible for weaning from the ventilator, the nurse and respiratory therapist collaborate in order to evaluate the patient and prepare for a spontaneous breathing trial (SBT). The initial steps for an SBT was termed “SBT Assessment Cycle” which begins with a sedation vacation. Sedation medications are titrated downward and the patient’s level of alertness is frequently evaluated and targeted to a Riker Scale value of 4. The sedation vacation is timed so that the 30 minute SBT, followed by weaning parameters, occurs every morning at 5:00 am in appropriate patients, so that the information is available for morning rounds and qualifying patients can be extubated.

3. Formal Assessment for Extubation

The SBT, followed by formal weaning parameters, is undertaken and the patient may then be extubated after physician examination, review of weaning parameters and approval. For those unable to be extubated, the patient is evaluated for the “Minimum Ventilator Support Cycle” arm of the protocol.

4. Merge Protocol with Chart Documentation

The protocol was incorporated into the respiratory charting system, termed Medilinks. Documentation by respiratory therapy (RT) was in turn linked to the electronic medical record, so that clinicians could review recent changes. In order to decrease the ventilator time for uncomplicated postoperative patients, the frequency of evaluation by respiratory therapy and step-wise decrease in support was shortened to 6 hours or less.

5. Computerized Plan for Ordering Care

A computerized care plan for routine physician orders (for example, patient positioning, daily oral chlorhexidine, orogastric or nasogastric tube use, post-intubation chest x ray, etc.) and an electronic progress note template, which incorporated basic prompts for respiratory failure diagnosis and planned interventions, was created and implemented. These interventions were designed to maximize the strengths of an electronic medical record for communication, accurate medical coding, and database design.

6. Education

Nursing and respiratory therapy review sessions reiterated the changes to the ventilator protocol for both experienced and new staff. With frequent resident physician turnover, a repeating schedule of teaching conferences was designed to explain terminology, physiology, and expected use of the protocol to improve compliance.