Clinical Safety & Effectiveness
Decreasing Ventilator Days
in the Medical Intensive Care Unit
Department of Critical Care Medicine
Prolonged
Mechanical
Ventilation
A glimpse at the future…
Zilberberg et al. Crit Care Med 2008. 36(5):
1451-1455
Projected Annual Hospitalization Days in 10-year Increments
Spent by a Patient on Prolonged Acute Mechanical Ventilation
(PAMV) in Various Strata of Hospital Care. ICU is intensive care
unit. MV is mechanical ventilation. Y is year.
Zilberberg et al. BMC Health Services Research 2008, 8:242
Prolonged Mechanical Ventilation in the
United States
On any given day, 7000 to 11,000 PMV
patients…
300,000 patients per year
Annual costs exceed
20 billion dollars
$
Prolonged Mechanical Ventilation
Ventilator Associated Pneumonia
Deconditioning
Airway Trauma
Increased Mortality
Aim statement
“To decrease ventilator days in Medical
Intensive Care Unit patients by 10%,
by June 30th, 2011”
Our baseline = 6.62 days/patient
Brainstorming
Involve everyone involved:
Nurses, Nursing Leadership, Respiratory
Therapists, Physicians, Mid-level providers,
Pharmacists
Ask the question:
How can we work together to get
patients off the ventilator sooner?
Find the root cause:
What are the barriers to achieving this
goal?
Ishikawa(Fishbone)Diagram
Flow Chart of Weaning Process
Sedation Holidays & Spontaneous Breathing Trials
What is the evidence?
•Nurse and RT driven
•Significant decrease in:
•Ventilator free days
•Hospital length of stay
“daily interruption of
sedatives can reduce
the duration of
mechanical ventilation
without compromising
patient comfort or
safety”
•ICU length of stay (from 12.9 days to 9.1 days)
•1 year mortality (from 58% to 44%)
p=0.02
p=0.01
Our Current Sedation Protocol
Baseline Data
How were we doing in our
Intensive Care Unit?
Average Ventilator Days in the
Medical Intensive Care Unit at
the MD Anderson Cancer Center
before our intervention…
6.62 days per patient
Average Actual Performance for Sedation
& Analgesia Holiday Pre-Intervention
100
90
80
Percent
70
60
50
40
36
30
30
20
10
0
Sedation Holiday Performed
Analgesia Holiday Performed
Process Map
Baseline Average
Richmond Agitation Sedation Scale (RASS)
for intubated MICU patients between 7pm and 7 am
+4
+3
+2
+1
0
-1
-2
-3
-4
-5
Combative
Very Agitated
Agitated
Restless
Alert and Calm
Drowsy
Light Sedation
Moderate Sedation
Deep Sedation
Unarousable
Target
-3.5
(Our Average)
Our Interventions
starting February/March 2011
SBT & Sedation Holiday
Educational Meetings
“A Collaboration at Bedside”
Mandatory for
ICU RN’s & Therapists
(days and nights)
• When: 2/21 through 2/25
• Time: 7:00 AM (15mins)
• Location: ICU Classroom
Presented by: Dr. Rathi
Refreshments will be served
Improve Nursing Compliance with Automatic Sedation-Analgesia Holiday Protocols
Measure of success: Automated individualized compliance reports through PICIS
Pair Spontaneous Breathing Trials with Sedation-Analgesia
Holidays
RT-MD Rounds
8:30 am
Improvement
In RASS scores
at night
to an average
goal of 0 to -2
30 minute
goal to
decision to
extubate
after SBT
Communicate
Individual MD
rates of deferred
extubation
Improve
Nursing and RT
communication
of SBT readiness
Keeping the Momentum Going…
Bedside quizzes
with prizes
 Raffles
 Inservices
(RT and RN)
 Emails/staff
meetings

WAKE UP and
BREATHE
Have you done your
sedation/analgesia holiday today?
How are we doing?
Post Intervention Data
Actual Performance for Sedation Holidays
Sedation Holiday Performed
Linear (Sedation Holiday Performed)
100
90
80
70
Intervention
Percent
60
58
55
50
46
45
40
42
39
31
30
31
30
30
40
44
42
45
44
29
26
23
20
10
0
Jan
Feb
Mar
Apr
May
Jun
Jul
2010
Aug Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
2011
May June
p = 0.116
Actual Performance for Analgesia Holidays
Analgesic Holiday Performed
Linear (Analgesic Holiday Performed)
100
90
80
Intervention
70
65
Percent
60
50
50
40
40
30
46
42
40
30
29
52
52
48
38
32
28
28
28
21
20
16
10
0
Jan
Feb
Mar
Apr
May
Jun
Jul
2010
Aug Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
2011
May June
p = 0 .117
Improvement in RASS (sedation
score) at night post-intervention
+4
+3
+2
+1
0
-1
-2
-3
-4
-5
Combative
Very Agitated
Agitated
Target
Restless
Alert and Calm
Drowsy
Light Sedation
-1.2
Moderate Sedation
Deep Sedation
Unarousable
-3.5
Baseline
Average
post intervention
Respiratory Data
Post-intervention
DB
I
DC
HC
EG
EH
EM
EN
J
ER
K
Provider Average Round Time
March - June 2011
I, 9:38
ER 9:00
HC 8.4
EG 8:44
J 8:44
EM 8:37
DC 8.26
EH 8:25
DB 8:18
EN, 8:22
K 8:48
To Sleepy
Thick
Secretion
Heme
No Extubation
Dialysis
Today
Apnea
Unable to
follow
Commands
tachycardia
Getting Trach
Anxiety/Precid
ex
Language
Barrier
Low MV
Problem
Waiting for PT
Need
Scan Tachycardia
Poor
Mechanics
Too weak
Questional
Mental Status
Intervention
Baseline = 6.62 days/pt; Post intervention Average = 5.84 days/pt
Ventilator Days Decreased by 0.78 or 12%
Intervention
Baseline = 9.46 days/pt; Post intervention Average = 8.22/pt
MICU LOS Decreased by 1.24 days or 13%
ACTUAL Return on Investment
Costs of Project:
Payroll + materials = $18,062.50
$$
ICU Costs:
Cost of ICU/Day
= $3872.00
Respiratory Costs/Day= $3133.00
Decrease in Average ICU LOS for ventilated patients since
March 1st, 2011 = 1.24 days (13 % decrease)
Decrease in Average ventilator days since March 1st, 2011 =
0.78 days (12 % decrease)
March 1st to June 30th 2011:
Savings in ICU LOS
+Savings in Vent Days
$782,608.64
$398,329.62
= $1,180,938.26
Costs of Project
- 18,062.50
TOTAL NET COST SAVINGS = $1,162, 875.76
Potential Cost Savings…
$3,488,627.28
per year
Upcoming Challenges

Maintain gains and continue
improvements

Ongoing education (new staff)

Continue to improve practitioners’
variability

Implement initiatives in the Surgical ICU
Upcoming Challenges

Maintain gains and continue
improvements

Ongoing education (new staff)

Continue to improve practitioners’
variability

Implement initiatives in the Surgical ICU
p value 0.012
Actual Performance for Sedation Holidays
80
Intervention
70
60
58
55
53
Percent
50
46
45
40
30
42
39
31
31
30
26
30
40
42
44
45
55
51
44
29
23
20
10
0
Jan Feb Mar Apr May Jun
Jul
2010
Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun
2011
Jul
Aug Sept
Actual Performance Analgesia Holidays
80
Intervention
70
65
60
57
Percent
50
50
40
30
40
29
56
48
42
40
30
52
52
48
55
38
32
28
28
28
21
20
16
10
0
Jan Feb Mar Apr May Jun
Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun
2010
2011
Jul Aug Sept
The Wean Team
• CS & E Class Participants
– Nisha Rathi, MD.
– Clarence Finch, MBA,
MHA, RRT, FCCM
– Estella Estrada, BS
– Nathan Wright, MD
– Wendi Jones, MSN,
ACNP-BC
• Facilitator and Sponsor
– Joseph Nates, MD,
MBA-HCA, FCCM
•
Additional Team Members
–
–
–
–
–
–
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–
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–
–
–
–
–
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Laura Withers, MBA, RRT, CPFT
Quan Ngyuen, BS, RRT
Mick Owen, BSN, RN
James Darden, RN, BSN
Enedra McBride, RN, BSN
Mary Lou Warren, RN, CNS, CCRN, CCNS
Rhea Herrington, RN, BSN, CCRN
Natalie Clanton, RN
Jennifer Harper, RN
Fallon Benavides, RN, MSN
Jeffrey Bruno, PharmD, BCNSP, BCPS
Gregory Botz, MD, FCCM
Sajid Haque, MD
Hetal Brahmbhatt, MHA, CPhT
Lora Washington, MHA, JD
Andrew Dinh, BS
Hollie Lampton, B.S.
Rose Erfe, B.S.
Dee Cano
Edward Scott, B.S,
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