Decreasing Duration of Mechanical
Ventilation by Implementing Evidence
Based Protocols in the Medicine ICU
TEAM
• Team Members
 Edward Best, RRT, RCP, MBA, MSHA,
 Director Respiratory Care, Parkland Health & Hospital System
 Dean Holland , RRT, RCP
 Respiratory Care Educator Parkland Health & Hospital System
 Harold Wey, RRT, RCP
 MICU & CPICU Clinical Team Leader, Parkland Health & Hospital System
 Pheba Abraham, RN, MSN, CPHQ
 PI Project Manager, Parkland Health & Hospital System
 Alayne Royster, RRT,RCP
 Respiratory staff
 Martin Flores RN, CCRN MICU
 Peter Hoffmann, MD, M Phil
 SVP Chief Quality Officer, Parkland Health & Hospital System
• Physician Champion
 Craig S. Glazer, MD, MSPH
 Associate Professor, Division of Pulmonary & Critical Care Medicine,
University of Texas Southwestern Medical Center
Problem Statement
Patients receiving mechanical ventilation
are at increased risk for pneumonia, airway
trauma, and iatrogenic lung injury. To
minimize risk, patients should be liberated
from mechanical ventilation as quickly as
possible.
AIM Statement
Decrease the duration of mechanical
ventilation in MICU by one day by
instituting a standardized approach
to awakening and spontaneous
breathing trials
MICU
Unit Description
 14 bed ICU
 4720 total patient days FY 2011
 4736 total patient days FY 2010
MICU Physician Staffing
 Two attending pulmonologists and one pulmonary fellow
together oversee and round with 4 MICU teams
 MICU teams are composed of a resident, an intern and a
rotating PM call intern
Physician Staffing Rotations
 Attending faculty rotate off service every two weeks
 The fellow and the residents rotate off every four weeks
 Interns rotate off service every calendar month on the first
MICU
Nursing and Respiratory Care Staffing
 There are no travelers or agency staff used for nursing
or respiratory care
Nursing Staff
 Consistently staff with the number of nurses needed
based upon census and acuity of the patient population
 Staffing ratio of 1:1 or 2:1
Respiratory Care Staffing
 2 MICU therapists assigned per shift
Measure of Success
Goal
Decrease the
duration of
ventilation for
each ventilated
patient
Measure
Baseline
Target
Duration of
ventilation
Jan- April 2010
MICU vent days =
6.1
(147.51 hours)
Decrease by 1 day
MICU vent days =
5.1
(122.4 hours)
Jan- April 2010
Re-intubation rate
MICU= 6.9 %
*5-10% ( best
practice /
literature)
Oct 2010 – Jan
2011
MD Orders - 57%
RN SAT - 18%
RT Screen - 75%
100%
Re-intubation rate =
Maintain or
# of re-intubations
decrease current
within 48 hrs of
re-intubation rate
extubation / # of
patients intubated
Protocol
100% protocol
compliance = #
compliance for
compliant with
all disciplines
protocol / # of
patient audits
Fishbone Diagram
Physician Directed Flow Map
Cause and Effect Analysis
100%
50%
100%
94%
45%
90%
87%
40%
80%
70%
Category
35%
70%
30%
60%
25%
50%
20%
40%
35%
15%
30%
10%
20%
5%
10%
35%
35%
17%
7%
6%
People
Method/Process
Measurement
Machine/Equipment
Environment
0%
0%
Protocol Directed Flow Map
Project Timeline
EMR Charting for SBT
Physician Order
Results
Jan – Apr 2010
Jan – Apr 2011
Results
SAT/SBT Ordering and Screening Compliance -MICU
Audit: 10/30/10 - 5/31/11
Oct -Jan (N=109)
Feb - May (N= 40)
100%
90%
P<.01
P<.01
100%
P<.01
100%
80%
85%
70%
75%
60%
50%
57%
40%
30%
20%
10%
18%
0%
MD ORDER
RN SAT SCREEN
RT SCREEN
Results
Ventilation days decreased by 2.1 days (34.6% ) in the MICU
(P = .04)
Rates of Reintubation
Rate (Number of reintubations per 100 intubations)
Comparison of Rates of Reintubation
10
9
8
7
6.9
P = .44
6
5
4.4
4
3
2
1
0
January - April 2010 (n=116)
January - April 2011 (n=90)
Results
17% decrease in Vent
Days as compared to
2010
Results
32% decrease in
32% decrease
VAP rate
Discussion
 Protocol driven process decreased the duration
of MV in our MICU by 2.1 days in the first six
months of protocol implementation
 Difference in rate of reintubation was not significant
 House-wide ventilator days were reduced by
17% when comparing FY 10 to FY 11
 House-wide rate of VAP was reduced by 32%
(7.8 vs. 5.3) when comparing FY 10 to FY 11
 30 fewer patients developed VAP in FY 2010 vs 2011
Lessons Learned
 Multidisciplinary team is key for success
 Automated protocol in EMR streamlines
the process
 Implementation in phases leads to
difficulty in protocol compliance
Next Steps
 Data collection automated in EMR
 Year to year comparison for further
analysis to determine sustainability
 Investigate the impact of protocols on
VAP
Special Thanks
 Carlos Girod MD

Professor Internal Medicine UT Southwestern Medical Center , Medical director MICU Parkland Health & Hospital
System
 Sanjuana Wilhoite RN

PI & PS Specialist, Surgical Services
 Mary Lynn Fancher RRT

Manager Respiratory Care
 Alissa Lockwood PharmD.

Clinical Pharmacy Specialist
 Carol HirschKorn RN, MSN, ACNP, CCRN

Nurse Practitioner in the trauma ICU
 Paul A Carlson PHD

Application System Analyst/Program-SR
 Jennifer De La Garza RRT, RCP

Respiratory Therapist
 Sarah Clemente RN,CCRN

Unit Manager MICU & CPICU; Manager PICC Service
 Billy J Moore PHD


Chief Biostatistician, Centers for Clinical Innovations
Vicki Crane MBA, FASHP, RPh

Senior Vice President Clinical Support Services
QUESTIONS?