Quality project improves ventilator weaning
Rehab hospital takes multidisciplinary approach
Nurse practitioners, a multidisciplinary approach, and consistent standards of care were the keys to a quality improvement project that significantly improved the rate of ventilator weaning at a rehabilitation hospital in South Carolina.
Ventilator weaning was a priority for quality improvement leaders at Spartanburg Hospital for Restorative Care (SHRC). Unlike at most acute-care hospitals, a high percentage of patients at SHRC are ventilator-dependent, and many will never be weaned without a concerted effort, says Dianne Smith, RN, MSN, coordinator of performance improvement.
The SHRC system uses an interdisciplinary approach that helps promote the system’s benefits beyond the institution, she says. "Our average length of stay is 25 days. All patients are referred from acute facilities, so it’s very important to get buy-in from the medical department staff there, so they will refer patients to us."
The hospital wanted to reduce the length of time patients were on ventilators and also to increase the wean percentage. The one-year outcome for ventilator-dependent patients usually is not good, so the hospital wanted to work toward results that would set it apart from the typical facility. The multidisciplinary approach helped the hospital staff shed some territorial concerns, Smith says, and benchmarking with other respiratory care centers across the country helped establish standards of care.
In the recent Premier Awards for Quality, given by Charlotte, NC-based Premier Inc., SHRC won in the improvement achievement category for increasing survival rates and decreasing the length of time patients are kept on ventilators. The project was headed by SHRC medical directors Bert Knight, MD, and Wilson Smith, MD.
Ventilator weaning is ideal QI effort
Knight explains that ventilator patients represent a good opportunity for quality improvement efforts. "We’ve been doing a much better job of keeping them alive than we did a few years ago, but weaning them off the ventilator has taken a back seat to other efforts sometimes," he says. "We thought we could do better and improve their quality of care and their quality of life."
The interdisciplinary team also included rehabilitation staff, house staff, nursing staff, respiratory care staff, health management staff, medical nutrition therapy, pastoral care, and private physicians who supervise their patients’ treatment plans at SHRC. The team focused on the special concerns of its rehab patients, Wilson Smith says.
"Patients who have been on a ventilator for more than a couple weeks require a different approach for weaning the use of the ventilator than those on one for just a short time," he says. "This program has followed a team approach involving nurses, respiratory therapists, rehabilitation therapists, nutritionists, doctors, and even chaplain services to try and address the complex needs of these patients. It is in many ways like training an athlete, only the reward is not a gold medal but the ability to breathe again on one’s own."
Although technological advances in health care have improved patient management, patients requiring prolonged mechanical ventilation (longer than 21 days) have become more common, Wilson Smith says. The impact on clinical outcomes and health care resources of patients who fail to wean from mechanical ventilation is enormous. The objective of the project was to develop an organized, research-driven process to provide a standardized approach to weaning care at SHRC.
While the major goals of the project were to improve patient outcomes and safety through decreased ventilator days and decreased lengths of stay, Dianne Smith notes that achieving those goals also should reduce the cost of care in this resource-intensive patient population.
Prior to 1998, there were no protocols for the care and weaning of ventilator-dependent patients at SHRC. The weaning process depended upon physician presence at the bedside and the physician’s personal practice preferences. In March 1998, SHRC began using a method called T-Bar Trials as the primary weaning method, but the length of time to wean ventilator-dependent patients remained widely variable. The quality improvement team began reviewing the literature and benchmarking with other long-term acute-care hospitals caring for the ventilator-dependent population, and an interdisciplinary team made a site visit to Barlow Respiratory Hospital in Los Angeles.
After returning to SHRC, the team developed a research-based weaning protocol.
Knight says the SHRC team learned a lot from Barlow, and that helped them avoid a lot of trial-and-error attempts.
Wilson Smith agrees, saying that being able to use Barlow’s work on standards of care was a huge step forward.
"Up until recently, I think medicine was physician personal preference, but now with our best practices, I think patient care is improving," Dianne Smith says. "Having your physicians use the same general practice guidelines is crucial to success. Conversely, not using them can be the death knell of a program."
The ventilator-weaning program was managed by an interdisciplinary team including two board-certified pulmonologists, two nurse practitioners, respiratory care services, nursing care services, rehabilitation services, medical nutrition services, health management services, and chaplain services. Implementation of the weaning protocols was accomplished after appropriate staff were educated.
Weaning times remained somewhat variable throughout the next few months, but in June 2000, the hospital revised the weaning protocols with re-education of the staff. The revised protocol includes a daily evaluation of hemodynamic status and ventilator settings.
"One thing our program does that not everyone does is utilizing a nurse practitioner," Dianne Smith says. "We do multidisciplinary rounds on all our patients. Even the chaplain takes part in rounds. I’ve been a nurse for years, and this is one of the first truly multidisciplinary initiatives I’ve been involved in."
A pulmonologist also makes daily patient rounds with members of the interdisciplinary team. In addition to daily rounds, members of the interdisciplinary team, pulmonologists, and nurse practitioners meet the first and third Wednesday of each month. This schedule allows for prompt action regarding changes in the weaning process and plan of care on a daily basis with a global review done every other week. A pulmonologist and a nurse practitioner are available on site during daytime hours and by pager as needed. A house physician is available on site from 9 p.m. until 6 a.m. to assist attending physicians as needed during off-hours.
Dianne Smith says the key characteristics of the SHRC weaning program are administrative support, communication, a research-based approach, data-driven decision making, interdisciplinary collaboration, expert clinicians (the median experience level for the ventilator weaning team is 10 years), and uniformity of process. She says there have been very few negative outcomes, most notably two documented cases of ventilator-acquired pneumonia in the past four years. Certain factors ensure patient safety while trying to wean patients off ventilators, she says:
- Daily education/re-education of patient and family regarding the weaning process and expectations of care.
- Increased communication among members of the interdisciplinary team.
- Daily interdisciplinary patient rounds with the pulmonologist and nurse practitioner.
- Availability of physician and nurse practitioner on site.
- Shift-to-shift reporting by respiratory care services and nursing.
- Daily updates to the director of respiratory care services regarding progress in weaning each patient.
- Increased patient monitoring.
- Hemodynamic monitoring.
- Oxygen saturation monitoring.
- Direct visualization of each patient either in the intensive care unit or by in-room video monitors.
- Point-of-care testing: Arterial blood gas analysis at the bedside for immediate assessment and intervention.
- Hourly rounds by respiratory care services.
- Presence of respiratory care therapist at bedside for continuous monitoring with each change in ventilator settings.
- Alarm systems for ventilators and cardiac monitors are tied into the call system, which allows for immediate response to the bedside by clinical personnel.
- Increased staff-to-patient ratios: 1:4 for respiratory care services, 1:6 for nursing services, and 1:6 for rehabilitation services.
- Utilization of a highly educated and experienced staff.
- In-depth orientation process specifically tailored to the employee’s knowledge base and skill levels.
- Annual staff competencies to ensure continued proficiency.
- Median experience for the pulmonologists — 25 years.
- Median experience for respiratory care services — nine years.
- Median experience for nursing — 14 years.
To track patient outcomes, the team analyzed these data: length of time on the ventilator prior to transfer to SHRC; Apache III scores from the transferring facility (if available); Apache III scores upon admission to SHRC; length of time on ventilator at SHRC; method of weaning; status of weaning at time of discharge from SHRC; discharge disposition; SHRC mortality rate; survival at one, two, and three years post-discharge.
Patient outcomes have improved significantly since the project started. SHRC has narrowed vent-weaning indicators to median vent days, percentage of patients successfully weaned, survival rates, and cost savings. In 1998, with no established protocols, baseline data for these four indicators show the median number of vent days was 32, 47% of patients were successfully weaned, the survival rate was 24%, and cost savings were $8,100. In 1999, using established protocols, key changes in the indicators were noted. There was a decrease in median vent days to 23 days, an increase in the percentage of patients successfully weaned to 60%, an increase in the survival rate to 33%, and additional cost savings of $116,051.
Further refinement of the vent-weaning protocols in 2000 proved successful for SHRC based on the indicator values listed. The median vent days decreased to 20 days, the percentage of patients successfully weaned increased to 84%, and the survival rate increased to 45%.
[For more information:
• Bert Knight, MD; Dianne Smith, RN, MSN, Coordinator of Performance Improvement; Wilson Smith, MD; Spartanburg Hospital for Restorative Care, 389 Serpentine Dr., Spartanburg, SC 29303. Telephone (864) 560-3263.]
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