Long Term Mechanical Ventilation
Transitioning Patients from CrCU to an
Enhanced Care Unit to Improve Patient Flow
CACCN Evolutions in Critical Care 2014
Darlene Baldaro, BSc, RRT, PPL/Clinical Respiratory Educator, Respiratory
Therapy and Professional Practice
Tina Chopra BScN, RN, Clinical Nurse Educator, Neuro-Stroke Medicine Unit
Danielle Ferreira, RN, BScN, BHSc, Clinical and Special Projects
Coordinator/Critical Care Response Team Co-Lead, Critical Care Department
Background
2004/05: Ministry launched Critical Care Transformation Strategy
Purpose: improve quality of care and system performance in adult
critical care services1
Findings:
• Critical care bed capacity increasingly limited across province1
• Contributing factor to shortage - use of ICU beds for medically
stable chronically ventilated patients1
• No adequate alternative setting appropriate for these
patients1
1.
Chronic Ventilation Strategy Task Force Final Report, June 30, 2006
Long Term Mechanical
Ventilation Patients
Those patients suffering from a severe respiratory
impairment who require ventilatory support for
more than 6 hours per day for more than 21 days,
but who do not require additional services
provided by a CrCU.1
LTMV
Chronic Ventilation Strategy Task Force Final Report, June 30, 2006; page 11.
Patient
19 year old male with Duchenne muscular dystrophy
PMHx: wheelchair bound, cardiomyopathy
Suffered a left MCA stroke complicated by aspiration pneumonia
Admitted to KGH then transferred to NYGH
Intubation  Trach  Failed TM trials, PAV trials  considered
ventilator-dependent
Liaised with WPH:
Discussions – home or complex care centre
Patient and family resistance due to fear of transition out of ICU
Background
Demand for ICU beds for this patient population projected
to increase by 92 - 120% over the next 25 years1
Historically, these patients remain in ICU until an
alternative care setting is secured in either the
community or a chronic ventilator unit.1
The wait time for a LTMV bed can be several months to
years.2
Recognition that we needed to change and invest in how
we manage LTMV patients.1
1.
2.
Chronic Ventilation Strategy Task Force Final Report, June 30, 2006
Long-term Ventilation Service Inventory Program. Final Report. July 31, 2008.
Background
The Ontario Chronic Ventilation Strategy Task Group
was established to address Access to Services and Wait
Time Strategy.1
Mandate:
a. Identify strategies to facilitate the transfer of medically
stable, LTMV patients out of ICUs and into a more
appropriate care settings.1
b. Prepare a care strategy and related resource allocation
recommendations to address their needs.1
1.
Chronic Ventilation Strategy Task Force Final Report, June 30, 2006
Care Setting
2
2
CCC
Inpatient medical ward
2.
Long-term Ventilation Service Inventory Program. Final Report. July 31, 2008.
Interprofessional LTMV Transition
Planning Group
To improve patient flow and increase critical care
capacity, these patients, at times, are transferred to an
inpatient medical unit.
However, acute care hospitals were surveyed through
PPNO and the majority response indicated this was not
common.
Our Innovative Solution:
Transition care of LTMV patients from our CrCU to the
wards
Enhanced Care Unit (ECU)
3 bed intermediate care unit (not a step-down)
Located on a regular inpatient medical unit
(Neurology & Stroke)
Utilized for patients ready for transfer out of the ICU but
have ongoing complex care needs e.g. tracheostomy
patients with frequent suctioning
Staffed with ward nurses
Intermittent monitoring
1 nurse: 2 patients
2 nurses: 3 patients (today)
Transitioning Patients from CrCU to ECU
Purpose:
• To enhance patient quality of life
• Improve patient flow with improved bed turns
• Improve access to CrCU
• Increase critical care capacity
• Better utilization of resources
• Interprofessional collaboration
• Professional development
• Maximize scope of practice
Interprofessional LTMV Transition
Planning Group
Interprofession
al LTMV
Planning Group
• Transfer of Care
• Mentorship
Collaborative IP
• eDocumentation
Mentorship &
• Pt Concern Algorithm
Support
Contingency Plan
• Teaching package
• Interactive education
sessions
• Pre and post
confidence survey
IPE
Needs
Assessment
Patient
and
Family
Communication
Plan
• Chronic Ventilator
• Motorized
wheelchair
• Mobility devices for
ambulation
• Social media devices
•CrCU, RRT, Inpatient Unit
interprofessional HCP
•Coordinated coverage
between GIM and CrCU
MDs
•Patient & Family
•LTMV Patient Care Plan
Project Timeline
January 2013
• Monthly
Transition
Planning
Meetings
• Developed
Patient Concern
Algorithm
• Chronic
ventilator trial
•IS documentation
• Communication
Plan to CrCU and
RRT staff
February
2013
• Communication
re: physician
coverage
• Developed IP
Patient Care
Plan
• Developed
Education Plan
March 2013
• Communication
to ECU staff
April 2013
• Communication
to Patient/family
• IPE provided
• Allied Health
Team Meeting
Transition Go Live!
• CrCU Nursing
mentorship
• RRT mentorship
• Mobility training
(PT, CrCU Team
Attendant with
Unit RN/PT/PTA
Future
Build
capacity
Training and Support
Interactive workshop
•
•
•
•
22 participants
Performance skills stations and simulation scenarios
Performance evaluation competency assessment
Post evaluation survey
CrCU Interprofessional
PFCC Team
Patient Family Centred Care (PFCC)
Mentorship
Interprofessional:
• CrCU Team → ECU Team (e.g. RRT→ RN)
Intraprofessional:
• CrCU nurses → ECU nurses
• CrCU Allied Health → ECU Allied Health
Inpatient Unit Nursing Response
to Mentorship
87.5% responded to the survey; 100% of respondents were positive
“It increased my self-confidence and understanding how to look after
patient on ventilator.”
“They were able to encourage and mentor really well.”
“Increased confidence.”
“It gives me confidence that somebody is available in case I needed
help.”
“ICU nurses very helpful.”
“Parameters and when to ask for help with the CCRT and RT was
helpful.”
Enhanced Care Unit
PFCC Team
Results
Patient Update
Transferred to chronic ventilator
Family participation in care
Daily outings on hospital grounds; occasional external
outings
Visited complex continuing care chronic ventilator unit
Improved quality of life with patient directing their care
Increased Capacity/Bed Turn in the CrCU
Chronic Vent Business Case
Analysis
• Increase capacity is based on average LOS for our CrCU
patients of 5.1 days applied to the extra bed days made
available by relieving chronic vent pressures
• Based on the initiative to move chronic vents out of the CrCU
there could be an increase in annual fiscal capacity/bed turns of:
Extra Daily Capacity
Increased Fiscal
Average Monthly
by relieving chronic Capacity/Bed Turns @
Increase
vent bed pressure CrCu ALOS *(5.1 days) Capacity/Turns
3
2
Average
Source: Critical Care Information System (CCIS)
215
143
179
18
12
15
Conclusion
The IP project group identified barriers, implemented
resources and effective strategies to facilitate the
transfer of care of a LTMV patient from the CrCU to
an inpatient medical unit.
A vast amount of coordination and collaboration of
education, mentorship and care was completed.
The IP, collaborative PFCC effort between the CrCU,
RRT and ECU Teams enabled a successful
transition.
Where We Are Today
ECU policy and standard of care
Continued family involvement and training
Increased census of patients in the ECU
Model of care is continually evolving; Increase skill mix to include RPNs
Continue to liaise with Alternative Care Settings for disposition and
best practices in LTMV management
Need to monitor efficiencies and effectiveness, i.e. bed turns, surge in
CrCU
Need to monitor calculated days for ECU blocked beds
Questions
Special Thanks To: Interprofessional LTMV Planning Group
Susan Woollard, RN, Project Manager
Dr. Donna McRitchie, MD
Dr. Phil Shin, MD
Millie Paupst, MD
Wendy Cheung, RN
Marina Bitton, RN
Elizabeth Villar-Guerrero, RN
Sandra Ramdeyall, RN
Tanya Chinner, RRT
Jo-Ann Fernando, RN
Kathy Tossis, PT
Tova Milnes, Taheera Habib, SW
Debbie Conway-Chung, RN
References
1.
2.
3.
4.
5.
The Chronic Vent Strategy Task Group. Chronic ventilation strategy task force: final report [Internet]. Toronto: The
Ministry of Health and Long-Term Care; 2006 Jun 30. [cited 2013 Jan]. Available from:
http://www.health.gov.on.ca/english/providers/program/critical_care/docs/report_cvtg.pdf
National Long Term Mechanical Ventilation Steering Committee. Long-term ventilation service inventory program:
final summary report [Internet]. The Ministry of Health and Long-Term Care: Toronto; 2008 Jul 31. [cited 2013 Jan].
Available from: http://www.rtso.ca/themes/acquia_marina/pdfs/LTV%20SIP%20Summary%20Report-FINAL.pdf
College of Respiratory Therapists of Ontario. Optimizing respiratory therapy services: a continuum of care from
hospital to home [Internet]. Toronto: The College; 2010 Jun. [cited 2013 Jan]. Available from:
http://www.crto.on.ca/pdf/ProfPractice/HFO_Final_Report.pdf
Improving the experience of patients requiring or at risk of long-term mechanical ventilation final report. July 2010.
McKim DA, Road J, Avendano M, Abdool S, Côté F, Duguid N, et al. Home mechanical ventilation: A Canadian
Thoracic Society clinical practice guideline. Can Respir J [Internet]. 2011 [cited 2013 Jan];18(4):197-215. Available
from: http://www.respiratoryguidelines.ca/sites/all/files/2011_CTS_HMV_Executive_Summary.pdf