ABSTRACT & COMMENTARY
Synopsis: In patients who required more than three days of mechanical ventilation, outcomes management did not affect the duration of mechanical ventilation or length of hospital stay, although the cost-per-case was slightly lower with this approach.
Source: Burns SM, et al. Am J Crit Care 1998;7:45-57.
Burns and colleagues tested the efficacy of an outcomes-managed approach to weaning patients from mechanical ventilation (MV). Developed by a multidisciplinary team, the approach included an outcomes manager, a care pathway, and weaning protocols. The study subjects were 181 patients admitted to a medical ICU. The study had two parts: 1) a six-month interval that used alternate-month assignment of patients who required more than three days MV (n = 91) to outcomes-managed vs. usual care; and 2) a six-month interval that used outcomes-managed care for all patients who required more than three days MV (n = 90). Subjects were monitored by the outcomes manager three days/week (Monday, Wednesday, Friday). Weaned was defined as spontaneous breathing for more than 24 hours. All subjects were followed for 90 days or until they were discharged, transferred, or died.Outcomes management had no significant effect on total duration of MV, length of hospital stay, days of MV with/without tracheostomy, or outcome (weaned, withdrawal of MV, death, or transfer). However, duration of MV was 1.3 days shorter and length of hospital stay was 2.1 days less in the outcomes-managed group. Also, direct costs-per-case (calculated by the institution's financial department) were $3,341 less when compared to patients managed in the same unit during the 12 months prior to the study. These savings resulted from fewer days of MV, earlier transfer from the ICU, and fewer diagnostic and laboratory tests.
COMMENT BY LESLIE A. HOFFMAN, RN, PhD
The outcomes-managed approach used in this study was systematically developed and implemented. The outcomes manager actively participated in rounds, tested weaning potential at regular intervals, wrote specific weaning plans, determined pathway deviations, intervened to rectify these deviations, and documented outcomes. The approach was implemented by five nurse clinicians with expertise in pulmonary nursing, including cross-training in ventilator management and weaning assessment. Although results suggested a trend toward a shorter duration of MV, significant differences were not seen for duration of MV or any other outcome.There are several potential explanations for these findings. Prior to the study, the ICU had incorporated a number of steps to make weaning from MV more systematic, including the use of weaning teams and ventilator mode-specific weaning protocols. Nevertheless, their use was described as "sporadic." Implementation of outcomes management on alternative months may have diminished the impact of the intervention, since many approaches introduced in the "intervention" month would also likely be used in the subsequent "usual care" month. The sample size was small, and a subsequent power analysis indicated a much larger sample would have been needed to demonstrate significance. It is also possible that outcomes management may not change care sufficiently to cause a significant change in outcomes in this complex group of patients.
Outcomes management has been suggested as a model of care delivery that
can decrease costs while improving outcomes for patients who require long-term
MV. This study is one of the few to systematically test use of this approach.
While significant changes were not seen, trends did suggest a benefit from
this approach. Given the positive trends, further testing is indicated
to clarify if this approach can significantly change outcomes in this complex
group of patients.
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