Abstract and Introduction
Abstract
Background: Despite multiple reminders, education sessions, and multidisciplinary team involvement, adherence to an evidence-based mechanical ventilation weaning protocol had been less than 1% in a general systems intensive care unit since implementation.
Objective: To assess the effectiveness of using an implementation program, the Model for Accelerating Improvement, to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit.
Methods: A prospective comparative design, before and after implementation of the Model for Accelerating Improvement, was used with a consecutive sample of 129 patients and 112 multidisciplinary team members. Clinical outcomes were rate of unsuccessful extubations, rate of ventilator-associated pneumonia, and duration of mechanical ventilation; practice outcomes were staff's understanding of the mechanical ventilation weaning protocol, perceptions of the practice safety climate, and adherence to the weaning protocol.
Results: After the intervention, the rate of unsuccessful extubations decreased, and staff's understanding of and adherence to the weaning protocol increased significantly. The rate of ventilator-associated pneumonia, duration of mechanical ventilation, and staff's perceptions of the practice safety climate did not change significantly.
Conclusion: Implementing the Model for Accelerating Improvement improved understanding of and adherence to protocol-directed weaning and reduced the rate of unsuccessful extubations.
Introduction
Mechanical ventilation is required in more than 90% of critically ill adults in intensive care units (ICUs). Prolonged mechanical ventilation, defined as mechanical ventilation for more than 3 days, can increase healthcare costs as a result of longer stays in the ICU, costs associated with mechanical ventilation, and exposure of patients to unnecessary risks. These risks include increased mortality, ventilator-associated pneumonia (VAP), airway trauma, increased need for sedation, and decreased satisfaction among staff, patients, and patients' families. On the other hand, premature discontinuation of mechanical ventilation can contribute to unsuccessful extubation, requiring reintubation. Rates of reintubation range from 4% to 33%. Reintubation potentially induces harm with associated airway trauma, gastric aspiration, acute lung injury, cardiovascular compromise, and hypoxia. Compared with the first intubation, with reintubation, the estimated risk for nosocomial pneumonia is 8 times higher and the increase for mortality increases 6- to 12-fold. Thus, discontinuation of mechanical ventilation must be balanced against the possibility of premature extubation and unnecessary prolonged ventilation.
The process of weaning critically ill adults from mechanical ventilation refers to the gradual discontinuation of mechanical ventilation. Although a variety of approaches are available to wean patients from mechanical ventilation, evidence from clinical trials suggests that protocol-directed weaning consistently reduces duration of mechanical ventilation, reduces ventilator-associated complications, and reduces the rate of reintubation. A total of 4 randomized controlled trials and 14 nonrandomized trials in which protocol-directed weaning was compared with standard weaning in critically ill adults have been reported. In all 4 randomized controlled trials, compared with weaning directed by a physician, protocol-directed weaning resulted in a reduction in duration of mechanical ventilation. In 2 randomized controlled trials, the rate of reintubation decreased when weaning was protocol directed, and in 1 trial, the rate of VAP decreased when weaning was protocol directed. In 7 nonrandomized trials, the duration of mechanical ventilation was significantly shorter for protocol-directed weaning than for physician-directed weaning. In 1 trial, compared with physician-directed weaning, protocol-directed weaning resulted in significant reductions in the rates of both reintubation and VAP.
Thus, protocol-directed weaning seems to be an effective strategy for managing mechanical ventilation, yet few reports about how to transfer this knowledge to practice have been published. Protocols potentially can create resentment and frustration among healthcare professionals because procedural care may be perceived as removing clinical judgment without considering all facets of the patients involved. However, an improvement in staff's perceptions related to a proposed procedural protocol has been associated with decreases in the number of errors, lengths of stay, and employee attrition. The Model for Accelerating Improvement, initially developed as a framework for accelerating improvement in clinical outcomes, is a process that guides healthcare teams in making procedural changes (Figure 1).
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Figure 1.
Steps of the Model for Accelerating Improvement.