Hospital cuts time on ventilators, ICU LOS
May 1, 1999
Hospital cuts time on ventilators, ICU LOS
Protocol lets staff aggressively wean patients
Most hospitals have the same problem that Nash General Hospital in Rocky Mount, NC, was facing a couple of years ago: too many wasted patient days in the ICU, accompanied by long weaning times for patients on ventilators and nosocomial infections.
Staff at most hospitals would be surprised at how quickly Nash fixed the problem.
In a matter of nine months, a grass-roots staff effort headed by a nurse led the hospital to cut the overall length of stay (LOS) in the ICU by 25%. The LOS for patients on ventilators dropped 34%. The ICU reported no cases of ventilator-associated pneumonia in that period, down from an average of 12.9 infections per 1,000 ventilator days.
The average duration of mechanical ventilation dropped 38% (4.7 days vs. 2.9 days), and the mean hospital LOS dropped by 23% (20.2 days vs. 15.6 days). Ventilator patients averaged savings of $35,000 in hospital charges compared to the baseline group.
How did the hospital do it? Lorna Prang, RN, BSN, CCRN, former manager of the intensive care and cardiac care units at Nash (which were recently merged into one critical care unit) and leader of the effort, says the key was a genuine desire by the bedside staff to improve outcomes for patients in the ICU.
Registered nurses participating in a quality improvement team headed by Prang felt that the large population of ventilator patients was staying in the ICU longer than necessary.
It’s a problem across the country, according to the Boston-based Institute for Healthcare Improve ment (IHI). The institute says that two out of every five ICU days are wasted in American hospitals.
"Part of it has to do with physician practice," Prang says. "They genuinely respect the care we give in the ICU. The floors get overloaded — and it’s not that patients get bad care there — but if a patient is quite sick, the physician might feel more comfortable having him in the ICU. There’s not a good intermediate place between critical care and the floors."
To jump-start their improvement effort, Prang and two colleagues attended IHI’s conference on improving critical care, and the hospital became part of a yearlong IHI collaborative on the topic. Nash set goals to decrease the average number of ventilator days by 25%, decrease the costs associated with providing mechanical ventilation by 25%, and decrease the incidence of ventilator-associated pneumonia in the ICU.
They passed with flying colors, mainly due to a ventilator-weaning protocol introduced in 1996 that lets nurses and respiratory therapists begin the weaning process under standard physician orders. Mary Wells, RN, chairwoman of the vent collaborative team that meets monthly to monitor progress, says that before the protocol was developed, physicians had to be called at every turn. That often resulted in delays that weren’t medically necessary.
Six actions form basis of ventilator program
Key elements of the ventilator protocol are:
• Cut down on the number of times blood is drawn from a patient to check breathing status after ventilator changes are made. When possible, nurses use pulse oximetry instead, which costs less and is less invasive for patients.
• Start tube feeding immediately after the patient is placed on the ventilator, provided the physician agrees. Before, patients may have gone a day or two before they were fed. "If you don’t have that nutritional reserve, you won’t get anywhere because the patient has nothing to pull from," Wells says.
• Give drugs for sedation if the patient becomes restless.
• Get a chest X-ray right after a patient is placed on a ventilator to make sure the tubing is in place.
• Take sputum cultures to determine a baseline for organism growth and the need for antibiotics.
• Wean the patient at certain oxygen levels.
"The protocol gives our respiratory therapists the ability to aggressively wean people without having to go through the physician for every change," Wells says. "In the past, they would draw a blood gas, then call the physician to OK the change. After that change, they would draw another blood gas and call the physician again. Now, they can wean patients almost to the point of being extubated. At that point, they call the physician."
Another helpful change was the implementation of a daily rating system for ICU patients that helps determine when patients need to be moved out of ICU, Wells says. An "A" rating means the patient is on a ventilator or drips and needs to stay in the ICU. A "C" rating means the patient is off the ventilator and drips, is stable, and is ready to move to a regular floor. A "B" rating means the patient is at a point in between and should stay in the ICU until becoming stable.
"The bottom line is the comfort level of the patients," Wells says. "If we can decrease their chances of pneumonia, we can increase their comfort and they’ll be back home sooner."
A standard set of ventilator orders is included in every patient’s chart, and the ventilator protocol is posted in the unit. Pam Johnson, BSN, RN, CCRN, clinical educator for critical care services, says the standardization improves patient care and makes staff education much easier. "Before, the nurses and therapists had to work with 30 different physicians with 30 different ways to wean," she says. "Now there’s less stress for the staff, and it’s easier for them to learn."
Johnson goes over the protocol during new staff orientation, touches on the topic in monthly inservices for existing staff, and discusses treatment options during daily rounds. She also participates in interdisciplinary rounds twice a week. Physicians receive a manual with the protocols, and the nurses constantly remind them to think about weaning patients.
"We’re not minimizing the role of the physician," she says. "We’re letting good care be driven by the caregivers who are at the bedside 24 hours a day, seven days a week."
The key to success, Prang says, is that the project has had support on all levels. The medical director of the ICU started using the protocol first, and data from his patients were shared with other physicians at medical staff meetings. Prang put graphs up every two or three weeks showing the results of patients who were on the protocol vs. those who weren’t. As they started to see progress, physicians started using the protocol with their patients as well.
"We didn’t have 40 dozen committees approve it," Prang says. "We started with one doctor’s patients and showed solid data to the other doctors. It gathered steam, and then the hospital took the position that the protocol was the way to go.
"It was a team project, not a top-down initiative. As nurses, we often don’t feel like we can impact care, but we can. We felt so empowered."
[For more information, contact Mary Wells, RN, Critical Care Unit, Nash General Hospital, 2460 Curtis Ellis Drive, Rocky Mount, NC 27804. Telephone: (252) 443-8723.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content