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

Ventilator Management Resources

Resources Used and Skills Needed

  • Physicians: Richard G. Barton, MD; Edward Kimball, MD; Peter Liu, MD; and Raminder Nirula, MD
    • Resident: Gillian Seton, MD
    • Respiratory Therapy: Earl Fulcher, RT, MAE
    • Nursing: Andi Jones, RN
    • Quality Improvement: Judy Larsen, RN, and Steven Johnson, MBA
    • Research: Gabriele Baraghoshi, RN

What Were the Results?

Two timeframes of 4 months each were compared in order to ascertain if there was an improvement, pre-protocol to post-protocol implementation. During the pre-implementation period (June-September 2010), 277 patients were intubated during their SICU stays. Of these, 104 patients (37.6%) required mechanical ventilation for > 48 cumulative hours, including patients who were clinically ineligible for extubation (such as patients with open abdomens or patients with a second planned procedure within 24 hours). Mean ventilator time was 86.7 hours and 14 out of 277 developed VAP.9-11 Thirty-four patients (12.3%) required reintubation within 48 hours of extubation during their ICU stay.

In comparison (Table 1), there were 283 intubated patients in the post-implementation period (June-September 2011). A total of 77 patients (27.2%) required ventilation for more than 48 cumulative hours. This represented a statistically significant reduction in ventilator time of 27.7% (p=0.01) (Figure 2). Mean ventilation time had an improvement of 29.3%, from a mean of 86.7 to 61.3 hours (p=0.01). The number of VAP cases was reduced from 14 to 5 (or 5.1% to 1.8%), a decrease of 65% (p=0.03). There was a non-significant reduction in re-intubation rates, from 12.3% to 7.8% (improvement of 36%, p=0.08), suggesting that extubations were timed appropriately relative to the patients’ condition.

Table 1. Comparison of Ventilator Outcomes Pre-Intervention to Post-Intervention

 

Time Period

 

 

Outcome Variable

Jun-Sep 2010

Jun-Sep 2011

Percent Improvement

P-Value*

Ventilated > 48 hr % (n)

37.6 (104/277)

27.2 (77/283)

27.7%

0.01

Ventilator time (hr)
(mean ±standard deviation)

86.7±149

61.3±123

29.3%

0.01

Ventilator-Associated Pneumonia %, (n)

5.1 (14/277)

1.8 (5/283)

65.0%

0.03

Reintubation %, (n)

12.3 (34/277)

7.8 (22/283)

36.6%

0.08

Chi-Square for categorical variables with Fisher’s Exact for expected values <5: Mann-Whitney U Test for continuous variables

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

Figure 2. Intubation Duration

Intubation Duration

The cost analysis was based on respiratory therapy hours for ventilated and non-ventilated patients. At our institution, the estimated direct cost per hour of respiratory therapy care for a ventilated patient was $10.99; the cost per hour for non-ventilated patients was $2.05. Based on the reduction of the mean time of ventilation (61.3 hours from 86.7), this translates to an average reduction of 7,162 ventilator hours. After subtracting the hourly labor costs of non-intubated patients ($10.99 - $2.05), the cost savings equaled $8.94 per hour or a savings of $64,028 during the post-protocol implementation period. The projected savings over a one year period was estimated at $192,084.

Tips for Others

A systematic, multidisciplinary approach to ventilator management is key to reducing mechanical ventilation times. Implementation of such a protocol may reduce lengths of hospital stay as well as reducing hospital costs, even by the most conservative estimates. Further, such a systematic approach to daily ventilator management can reduce the duration of mechanical ventilation and the risk of ventilator associated pneumonia without increasing the incidence of reintubation.

The crucial mechanism to sustaining success is consistency in protocol use. The SICU staff uses patient rounds and check lists to provide consistent care.  Common goals and communication between physicians, nurses and respiratory therapists is considered a priority and thoughtful consideration is given to all ideas concerning efforts at improving patient care and outcomes.

References

  1. Penuelas O, Frutos-Vivar F, Fernandez C, et al. Characteristics and outcomes of ventilated patients according to time to liberation from mechanical ventilation. Am J Respir Crit Care Med. 2011;184:430-437.
  2. O’Grady N, Murray P, Ames N. Preventing ventilator-associated pneumonia; does the evidence support the practice? JAMA. 2012; 307:2534-2539.
  3. MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120:375S-395S.
  4. Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest. 2006;130: 1664-1671.
  5. Rothaar RC, Epstein SK. Extubation failure: magnitude of the problem, impact on outcomes, and prevention. Curr Opin Crit Care. 2003;9: 59-66.
  6. Epstein SK. Extubation. Respir Care. 2002;47 :483-492.
  7. Epstein SK. Decision to extubate. Intensive Care Med. 2002;28:535-546.
  8. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997; 112:186-192.
  9. Critical Care Societies Collaborative (CCSC) website. www.ccsconline.org/ventilator-associated-pneumonia; accessed July 2012.
  10. CDC definitions for nosocomial infections, 1988. Am Rev Respir Dis 1989;139:1058-1059.
  11. ACS NSQIP – Chapter 4 Variables and Definitions. June 24, 2010. nsqip.healthsoftonline.com/lib/Documents/Ch_4_Variables_Definitions.