PROJECT NAME: Extension of the Spontaneous
Breathing Trial (SBT) Protocols into other ICU’s at
Memorial Herman Hospital-TMC (MHH-TMC)
Institution: University of Texas-Houston
Primary Author: Brandy McKelvy, MD
Secondary Author:
Project Category: 8) Sustained CS & E Projects
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 nonphysicians), 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% reintubation 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), NeuroTrauma ICU (NTICU), the Heart and Vascular Institute (CCU and CVICU), ShockTrauma 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 <10%)
•
Track Compliance with wean protocols
•
Improved documentation in the EMR
Use of Quality Tools:
Check sheets tracked observations of compliance to key factors of protocol bundle
including all-or-none compliance.
A Measurement System Analysis (MSA) and a 2 x 2 table further detailed
discrepancies in compliance and documentation.
A fishbone identified causes of non-compliance and led us to focus on technology
modifications.
Brainstorming sessions gathered staff input into process breakdowns and
improvement areas.
Detailed process maps using Swim-lanes, clarified existing processes and
identified solutions.
Histogram of length of time on ventilator narrowed the subset of patients to focus
on for this project
Interventions:
•
Educated RNs and RT’s to highlight problems and clarify processes
•
Linked SBT protocol daily to the ventilator order set to ensure the task was
created and followed daily
•
Demonstrated at the critical care counsel the data entry sheets to the entire
intensive care faculty.
•
Over 2 academic years extend the pilot program from the MICU to each of
the other ICU’s at MHH-TMC
•
Educated the entire RT staff in all units to the importance of SBT’s and the
appropriate documentation of the process
•
Identified process difficulties and technology limitations
•
Removed residents from decision making/ordering sedation holiday
•
Standardized definition of “on” and “off” protocol
•
Required a daily sedation holiday for all patients that qualify (allow the
timing varies by ICU)
•
Created sedation holiday to be an automated computer task for the RN’s
•
Changed sedation holiday from one-time physician order to unit protocol
which is nurse driven
•
Updated sedation holiday form in CARE4 and clarified exceptions
•
Educated nursing staff how to document “not indicated” for sedation
holidays rather than “not done”. Efforts have continued for appropriate
documentation because now sedation holiday are electronically tracked
rather than on paper
•
Developed a new form in CARE4 to document SBT in a clear, consistent
format
•
Designed new process to ensure RN and RT collaboration
•
Updated SBT protocol documentation
•
In CARE4, directly connected SBT screen result to the form for the actual
SBT
•
Ensured that all intubated patients were screened for SBT on a daily basis
•
Added a field in Vent Data Base to track results
•
Eliminated paper documentation which allows repeated viewing of the
results of SBT’s
Results:
WITHOUT TRACH PATIENT EVENTS
FY 2008
FY 2009
FY 2010
FY 2011
FY 2012
Total Ventilator Events
17,052
18,723
16,238
14,969
14,476
Number of re-intubations
< 48 hours
104
84
113
111
143
Percent
0.66 or <1%
0.44 or < 1% 0.69 or < 1%
0.74 or < 1% 0.98 or < 1 %
Number of re-intubations
< 24 hours
28
21
18
Percent
0.16 or < 1%
0.11 or < 1% 0.25or < 1%
42
55
0.12 or < 1% 0.37 or < 1%
Revenue Enhancement /Cost Avoidance /Generalizability:
We recognized that even though protocols exist, frequently they are not used
appropriately or to their full extent. We must standardized documentation
and definitions to ensure full usage of protocols. Implementation of
electronic documentation not only eliminated the former paper process but
assured that results are available to any caregiver at anytime.
Utilizing a weaning protocol with daily spontaneous breathing trials and daily
sedation holidays did not increase the rate of re-intubations and so far is
less than the rate identified in the JP Kress, et al study from University of
Chicago in 2000.
Combing both daily SBT’s with daily awakening trials will significantly
decrease the number of days on the ventilator. A VAP adds an estimated
cost of $57,000 to a hospital admission. At our institution in the MICU, we
estimate a cost avoidance in fiscal year 2009 (between July 2009 and July
2010) of $901,000. In most of the ICU’s we have decreased the mean
ventilator time by about 1 day which equates to 1 day save in the ICU per
patient admission which saves about $1500 per patient ICU stay. Since this
is happening in multiple ICU’s simultaneously, the cost avoidance is
multiplied.
We also decreased the amount of drugs delivered and decreased the daily
cost of drugs in the ICU but we did not put a dollar amount on this since the
sedation holiday portion of the project is still evolving and will be reported
separately
Conclusions and Next Steps:
Since the initial pilot project in the MICU, we have standardized the protocols
and the documentation. We have extended the use of the SBT protocol into
the rest of the ICU’s. We are now seeing, slowly, the decrease in the
ventilator time we anticipate. We expect continued success and the protocol
is being considered to extend system wide to the 9 hospitals in the Memorial
Hermann system.
With investigation, we discovered multiple areas for improvement around
our use of daily sedation holidays and SBT’s. First, we eliminated resident
physician decision making, allowing daily sedation holidays in all patients
who met set criteria. By streamlining the system and allowing for electronic
documentation of events, we were able to improve compliance with the
protocol and decrease the total time on the ventilator and the length of stay
in the MICU. We continued to expand our project by education of all
respiratory therapists in all ICU’s in our hospital and now allow for
standardization of documentation of results. We intend to monitor full
implementation for follow-up and data collection. Eventually, we plan
implementation and utilization of forms and protocols throughout all ICU’s at
MHH and system wide. We are currently exploring delays in extubation. We
are no documenting patient passing his/her SBT but not immediately getting
extubated. If we can identify the causes, we can continue to decrease vent
days.
Appendixes
Measurement System Analysis
2X2
Documented on Protocol
No
Yes
Total
No 7 (9%)
23 (28%)
Correctly
Documented
45 (55%)
Yes 14 (19%)
38 (46%)
Incorrectly
Documented
37 (45%)
19 (23%)
61 (74%)
Observed
on Protocol
82 (100%)
References
Ely, EW, Baker, AM, Dunagan, DP, et al. Effect on the duration of mechanical
ventilation of identifying patients capable of breathing spontaneously. New
England Journal of Medicine 1996; 335:1864-1869
Kollef, MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocoldirected versus physician-directed weaning from mechanical ventilation. Critical
Care Medicine 1997;25:567-674
Kress, JP, Pohlman AS, O’Connor MF, Hall, LB. Daily interruption of sedative
infusions in critically ill patients undergoing mechanical ventilation. New England
Journal of Medicine 2000;342:1471-1477
Hooper MH and Girard TD. Sedation and Weaning from Mechanical Ventilation:
Linking Spontaneous Awakening Trials and Spontaneous Breathing Trials to
Improve Patient Outcomes. Critical Care Clinics 2009;25:515-525
Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning
protocol for mechanically ventilated patients in intensive care (Awakening and
Breathing controlled trial): a randomized controlled trial. Lancet 2008;371:126-132