Clinical Safety & Effectiveness
Decreasing Ventilator Days in the Medical Intensive Care Unit
Department of Critical Care Medicine
ProlongedMechanicalVentilation
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
300,000 patients per year
$
Annual costs exceed 20 billion dollars
On any given day, 7000 to 11,000 PMV patients…
Prolonged Mechanical Ventilation
Increased Mortality
Ventilator Associated Pneumonia
Deconditioning
Airway Trauma
Aim statement
“To decrease ventilator days in Medical Intensive Care Unit patients by 10%,
by June 30th, 2011”
Our baseline = 6.62 days/patient
BrainstormingInvolve 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 TrialsWhat is the evidence?
•Nurse and RT driven
•Significant decrease in:
•Ventilator free days
•Hospital length of stay •ICU length of stay (from 12.9 days to 9.1 days) p=0.01
•1 year mortality (from 58% to 44%) p=0.02
“daily interruption of sedatives can reduce
the duration of mechanical ventilation without compromising
patient comfort or safety”
Our Current Sedation Protocol
Baseline Data
How were we doing in our
Intensive Care Unit?
6.62 days per patient
Average Ventilator Days in the Medical Intensive Care Unit at
the MD Anderson Cancer Center before our intervention…
Process Map
Baseline Average Richmond Agitation Sedation Scale (RASS)
for intubated MICU patients between 7pm and 7 am
+4 Combative
+3 Very Agitated
+2 Agitated
+1 Restless
0 Alert and Calm
-1 Drowsy
-2 Light Sedation
-3 Moderate Sedation
-4 Deep Sedation
-5 Unarousable
-3.5
Target
(Our Average)
Our Interventions
starting February/March
2011
SBT & Sedation Holiday Educational Meetings
“A Collaboration at Bedside”
Mandatory forICU 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 ProtocolsMeasure of success: Automated individualized compliance reports through PICIS
Pair Spontaneous Breathing Trials with Sedation-Analgesia Holidays
RT-MD Rounds8:30 am
30 minute goal to
decision to extubate after SBT
Improve Nursing and RT communication of SBT readiness
CommunicateIndividual MD
rates of deferred extubation
Improvement In RASS scores
at nightto an average goal of 0 to -2
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
Intervention
p = 0.116
Intervention
p = 0 .117
Improvement in RASS (sedation score) at night post-intervention
+4 Combative
+3 Very Agitated
+2 Agitated
+1 Restless
0 Alert and Calm
-1 Drowsy
-2 Light Sedation
-3 Moderate Sedation
-4 Deep Sedation
-5 Unarousable
Target
-3.5Baseline Average
-1.2 post intervention
Respiratory Data
Post-intervention
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 = $3872.00Respiratory 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 $782,608.64 +Savings in Vent Days $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
Intervention
Intervention
43
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– 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,