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,