The implementation of ventilator management protocols expedites ventilatory liberation.

Mechanical ventilation in the ICU requires a large amount of clinical resources. It is critically important that patients are assessed for ventilatory liberation as soon as they are deemed clinically stable. The implementation of ventilator management protocols has expedited this process and allows the clinician to provide optimal patient assessment. The acutely ill patient requires rapid clinical assessment and timely interventions, but often the direct patient caregiver is too overwhelmed with bedside interventions to examine every option available for optimal ventilatory management. To address this issue and provide a mechanism to assess patients for possible ventilatory liberation, our respiratory care department developed the role of a ventilator assessor.

The role of a ventilator assessor was developed in conjunction with our institution’s goal to reduce ventilator duration of patients diagnosed with respiratory failure. Over the last 5 years, the role has expanded to providing bedside education to the clinical staff regarding new ventilatory technology and changing ideology. The expanded role also has provided an opportunity to collect data for research and performance improvement. The development and refinement of ventilatory protocols were also accomplished through daily ventilatory assessment rounds.

Process
Ventilator rounds are performed by either the educational coordinator or his designee. The primary purpose of the rounds is to monitor the ventilatory process to ensure that it reaches the clinical end points generated by the clinical team. During the rounds, the ventilatory settings are recorded and the patient-ventilator interface is observed. Gas exchange end points are reviewed and discussed by the nurse and therapists. After a review of all elements of the current ventilatory status, a recommendation is made and documented in the patient’s chart. This bedside assessment of the ventilatory management of the patient is a valuable learning opportunity for the team. Also, this is a chance for the clinical team to discuss issues associated with the new technology and the ventilatory strategy being utilized. This interaction aids in the development of good clinical assessment skills, facilitates educational growth, and allows for a true understanding of the interface between technology and the patient. In difficult ventilatory scenarios, the individual performing ventilator assessments remains at the patient’s bedside and facilitates the implementation of the new ventilator strategy. Also, this practitioner will interact with the clinical team to address any pertinent patient interventions. Often a follow-up round is performed to observe the effect of the newly implemented intervention.

The rounds ensure that quality performance is being evaluated and maintained, and the role of the individual performing ventilator rounds is to ensure that staff understands the benefit for improving patient outcomes. Rounds can often serve as an educational tool—valuable, because often the practitioner cannot create a similar classroom scenario. Informal unit in-services are often conducted during the rounds for the whole patient care team. Quality assurance indicators are developed in response to clinical issues.

The development of ventilatory protocols was a by-product of interactions between all clinical team disciplines. Information gleaned from the ventilator rounds was presented to the team for input and design. Once the protocols were approved by the critical care directors, they were utilized by the bedside clinicians, and during ventilator rounds feedback on the effectiveness of the protocols was reported. The importance of collecting this data and implementing protocols is well understood, but being able to correlate it with current ventilatory function is instrumental to gaining improved staff compliance.

Data collection
The ventilator data was collected and sent to the assistant chair of the department of medicine. The chair then set up a meeting with the clinical team to discuss any ventilated patients who had required ventilation for longer than 48 hours. During this meeting, the clinical team would discuss and develop a ventilatory strategy to optimize care of the patients and to recognize which patients would be on the ventilator for a prolonged duration. Over 3 years, ventilator duration was reduced from an average of 32 days to 28 days for patients who were classified as respiratory failure (DRG-483). Also during that time our institution saved $900,000 yearly in reimbursement costs. Over the next several years, the information was collected on paper and transferred into an Excel database for educational and research options. Currently, we are utilizing a portable LifeBook computer for entering the ventilatory information into Access and Excel databases. This information is being utilized for research and to gauge current infection control practices.

Conclusion
Daily ventilatory assessment has improved ventilatory management using protocols that have been developed with the data from daily ventilator rounds. These protocols include a stepwise approach to the ventilator management of patients with specific disease entities. The weaning process has been revised and refined. Because of the data obtained during monitoring rounds, such as patient position and adherence to the humidification protocol, ventilator-associated pneumonia has decreased. Also, monitoring adherence to the departmental and institutional quality improvements has led to an increase in compliance and improved patient care.

Daily ventilator assessments have improved patient outcomes in both patient care and ventilator management. Their impact is not only at the patient’s bedside but also at the heart of improving the ventilatory management process. The interaction between the clinical team is focused not only on parameter settings but also on the clinical assessment of the interface between technology and patient. Daily ventilator assessments can improve patient outcomes, act as an educational venture, decrease ventilatory duration, and promote strong team interaction.

Kenneth Miller, MEd, RRT-NPS, is clinical educator for respiratory care, Lehigh Valley Hospital, Allentown, Pa.