Suzanne M. Burns

Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned.

ObjectiveTo determine the effect of an institutional approach to the care of patients requiring mechanical ventilation for longer than three consecutive days in five adult intensive care units (ICU) on clinical and financial outcomes. DesignA multidisciplinary team was selected from five adult ICUs to design the approach. Planning occurred from August 1999 to September 2000. The process was called outcomes management (OM) and included an evidence-based clinical pathway, protocols for weaning and sedation use, and the selection of four advanced practice nurses (called outcomes managers) to manage and monitor the program. SettingThe project was completed in a 550-bed mid-Atlantic academic medical center. The ICUs included the following: coronary care, medical ICU, neuroscience ICU, surgical trauma ICU, and thoracic cardiovascular ICU. PatientsThe sample included 595 pre-OM patients and 510 post-OM patients mechanically ventilated for greater than three consecutive days. InterventionsFull implementation of the OM approach occurred in March 2001. Retrospective baseline (18 months pre-OM) and prospective (12 months OM) clinical and financial data were compared. Measurements and Main ResultsStatistically significant differences in clinical outcomes were demonstrated in the managed patients compared with those managed before the institutional approach. Outcomes include ventilator duration (median days declined from ten to nine; p = .0001), ICU length of stay (median days declined from 15 to 12; p = .0008), hospital length of stay (median days declined from 22 to 20; p = .0001), and mortality rate (declined from 38% to 31%, p = .02). More than

Developing a new, national approach to surveillance for ventilator-associated events*.

3,000,000 cost savings were realized in the OM group. ConclusionsThis institutional approach to the care of patients ventilated >3 days improved all clinical and financial outcomes of interest. To date, few similar initiatives have demonstrated similar results. The approach and lessons learned in this process improvement project may be helpful to other institutions attempting to improve outcomes in this vulnerable population.

Report on the development of a procedure to prevent placement of feeding tubes into the lungs using end-tidal CO2 measurements.

Objective:To develop and implement an objective, reliable approach to surveillance for ventilator-associated events in adult patients. Design:The Centers for Disease Control and Prevention (CDC) convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group in September 2011. Working Group members included representatives of stakeholder societies and organizations and federal partners. Main results:The Working Group finalized a three-tier, adult surveillance definition algorithm for ventilator-associated events. The algorithm uses objective, readily available data elements and can identify a broad range of conditions and complications occurring in mechanically ventilated adult patients, including but not limited to VAP. The first tier definition, ventilator-associated condition (VAC), identifies patients with a period of sustained respiratory deterioration following a sustained period of stability or improvement on the ventilator, defined by changes in the daily minimum fraction of inspired oxygen or positive end-expiratory pressure. The second tier definition, infection-related ventilator-associated complication (IVAC), requires that patients with VAC also have an abnormal temperature or white blood cell count, and be started on a new antimicrobial agent. The third tier definitions, possible and probable VAP, require that patients with IVAC also have laboratory and/or microbiological evidence of respiratory infection. Conclusions:Ventilator-associated events surveillance was implemented in January 2013 in the CDC’s National Healthcare Safety Network. Modifications to improve surveillance may be made as additional data become available and users gain experience with the new definitions.

Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation.

ObjectiveTo determine the accuracy of a technique using capnography to prevent inadvertent placement of small-bore feeding tubes and Salem sump tubes into the lungs. SettingTwelve-bed medical intensive care unit (MICU) in a 557-bed teaching hospital. PatientsA total of 25 ventilated adult MICU patients were studied—5 in phase 1 and 20 in phase 2. DesignPhase 1 tested the ability of the end-tidal CO2 (ETCO2) monitor to detect flow (and thus accurately detect CO2) through small-bore feeding tubes. A small-bore feeding tube, with stylet in place, was placed 5 cm through the top of the tracheostomy tube ventilator adapter in five consecutive patients. The distal end of the feeding tube was attached to the ETCO2 monitor. The ETCO2 level and waveform were assessed and recorded. Because CO2 waveforms were successfully detected, a convenience sample of 20 adult MICU patients who were having feeding tubes placed (13 Salem sump tubes, 7 small-bore feeding tubes) was then studied. The technique consisted of attaching the ETCO2 monitor to the tubes and observing the ETCO2 waveform throughout placement. ResultsThe study hypothesis was supported. Of the seven small-bore feeding tubes tested, all were successfully placed on initial insertion. Placement was confirmed by absence of an ETCO2 waveform and by radiograph. Of the 13 Salem sump tubes, 9 were placed successfully on first attempt and confirmed by absence of CO2 and by air bolus and aspiration of stomach contents. ETCO2 waveforms were detected with insertion of four of the Salem sump tubes; the tubes were immediately withdrawn, and placement was reattempted until successful. ConclusionsThe technique described is a simple, cost-effective method of assuring accurate gastric tube placement in critically ill patients.

International Perspectives on the Influence of Structure and Process of Weaning From Mechanical Ventilation

Background An update of evidence‐based guidelines concerning liberation from mechanical ventilation is needed as new evidence has become available. The American College of Chest Physicians (CHEST) and the American Thoracic Society (ATS) have collaborated to provide recommendations to clinicians concerning liberation from the ventilator. Methods Comprehensive evidence syntheses, including meta‐analyses, were performed to summarize all available evidence relevant to the guideline panel’s questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, and the results were summarized in evidence profiles. The evidence syntheses were discussed and recommendations developed and approved by a multidisciplinary committee of experts in mechanical ventilation. Results Recommendations for three population, intervention, comparator, outcome (PICO) questions concerning ventilator liberation are presented in this document. The guideline panel considered the balance of desirable (benefits) and undesirable (burdens, adverse effects, costs) consequences, quality of evidence, feasibility, and acceptability of various interventions with respect to the selected questions. Conditional (weak) recommendations were made to use inspiratory pressure augmentation in the initial spontaneous breathing trial (SBT) and to use protocols to minimize sedation for patients ventilated for more than 24 h. A strong recommendation was made to use preventive noninvasive ventilation (NIV) for high‐risk patients ventilated for more than 24 h immediately after extubation to improve selected outcomes. The recommendations were limited by the quality of the available evidence. Conclusions The guideline panel provided recommendations for inspiratory pressure augmentation during an initial SBT, protocols minimizing sedation, and preventative NIV, in relation to ventilator liberation.

The weaning continuum use of Acute Physiology and Chronic Health Evaluation III, Burns Wean Assessment Program, Therapeutic Intervention Scoring System, and Wean Index scores to establish stages of weaning.

BACKGROUND Recently, clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation. One such process, use of a weaning protocol, has yielded conflicting results, arguably because of the influence of existing context and processes. OBJECTIVE To compare international data to assess differences in context and processes in intensive care units that could influence weaning. METHODS Review of existing national data on provision of care for critically ill patients, including structure, staffing, skill mix, education, roles, and responsibilities for weaning in intensive care units of selected countries. RESULTS Australia, New Zealand, Denmark, Norway, Sweden, and the United Kingdom showed similarities in critical care provision, structure, skill mix, and staffing ratios in intensive care units. Weaning in these countries is generally a collaborative process between nurses and physicians. Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care units health care team. Nurses may be excluded from direct management of ventilator weaning in some institutions, as this role is primarily assumed by respiratory therapists guided by medical directives. Availability of critical care beds was highest in the United States and lowest in the United Kingdom. CONCLUSION Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries. Further quantification of these contextual influences should be considered when translating research findings into local clinical practice and when designing randomized controlled trials.

Weaning from Mechanical Ventilation: A Method for Assessment and Planning

Objective To determine whether four stages of weaning (acute, prewean, wean, and outcome) could be identified by using clinical instruments designed to quantify severity of illness, patient stability, or weaning readiness. The instruments used were the Acute Physiology and Chronic Health Evaluation (APACHE III), the Therapeutic Intervention Scoring System (TISS), the Burns Wean Assessment Program (BWAP), and the Wean Index (WI). The stages were adapted from those proposed by the American Association of Critical Care Nurses Third National Study Group’s Weaning Continuum Model. Design Prospective, convenience cohort. This study was part of a larger study designed to test an outcomes managed approach to weaning by using an outcomes manager and a clinical pathway. Setting University medical intensive care unit. Patients Adult patients requiring mechanical ventilation >3 days admitted to the medical intensive care unit between November 1994 and May 1995. Interventions None. Measurements and Main Results Scores for the APACHE III, TISS, BWAP, and WI were collected on 97 patients every other day until they weaned, were transferred, or died. Outcomes described for each stage of weaning were dated on the clinical pathway when achieved. Comments about patient stability and ventilator progress also were recorded along with a subjective determination of the stage of weaning. We used decision rules to identify time intervals for each stage of weaning and outcomes attained by stage. Finally, APACHE III, TISS, BWAP, and WI scores were placed in each stage by date for analysis. The APACHE III, TISS, and BWAP scores were able to differentiate the acute, prewean, and wean stages but not the outcome stage. Conclusions By identifying distinct scores for each stage, we may be able to better explore appropriate interventions for the stages as well as predict weaning outcomes. Indices that include physiologic and respiratory factors can differentiate weaning stages, but respiratory factors alone cannot.

The Long-Term Mechanically Ventilated Patient: An Outcomes Management Approach

Weaning patients from mechanical ventilator assistance is difficult and often requires the input of experts. Though researchers have identified numerous factors that impede weaning and continue to develop criteria to determine ability to wean, no single factor or set of criteria have yet emerged to guide clinicians. In an effort to design a tool that assists critical care nurses in forwarding the wean process, the authors developed a comprehensive, integrated, computerized ventilator weaning program that stimulates the thinking and care planning strategies of experts. The Burns Wean Assessment Program also teaches complex concepts and tracks the progress of the weaning patient.

Multifactor Clinical Score and Outcome of Mechanical Ventilation Weaning Trials: Burns Wean Assessment Program

As noted previously, prior to permanently instituting an outcomes approach, we compared the effects of such a model to a nonoutcomes-managed approach. The positive trend noted during the study interval has been sustained 2 years later, and the variables of cost, LOS, and ventilator duration (median = 9 days for DRG 475, 483 combined) for these patients continue to be favorably affected (see Figure 2). In addition, the outcomes-management model has been well accepted by all members of the health care team. The outcomes manager is a respected and valued member of the team and is central to the ongoing success of the approach. Although the clinical pathway is an essential tool for focusing and delineating multidisciplinary best-practice, the pathway (and processes of care contained within) must be continually evaluated and changed as needed. The pathway cannot be static if care is to be progressive. Essential to the process is a method of collecting and processing data in a timely way. Further, it is important that data collection, while important, not be the focus of the role of outcomes manager. Instead, the focus is the delivery of timely and effective care. Our current outcomes model applies to management of patients beyond the boundaries of the MICU or pulmonary suite. In other words, once weaned and transferred to a regular floor the outcomes manager no longer manages the patients (although she does track selected outcomes). Management of patients throughout hospitalization is a future goal, but we are convinced that this cannot be accomplished by a single outcomes manager. Although we are aware that other outcomes models do follow patients throughout the continuum of hospitalization and beyond, our highly clinically interactive model precludes that possibility. We are currently considering other similar unit-based positions to provide the desired continuity following discharge from the MICU or pulmonary suite. Despite our enthusiasm for the outcomes-management model, we recognize that other models may also result in comparable, favorable outcomes. It is important that those who adopt similar models of care delivery for managing patients requiring prolonged ventilation be scientific in their approach. Long-term studies of the efficacy of these models are essential if we are to truly provide quality care for our patients in the future. Unfortunately, as noted earlier, bias will be hard to overcome. Hospitals vested in rapidly establishing a stable financial bottom-line are likely to embrace quick applications. Projects with a true experimental design to evaluate efficacy, such as this one, will be rare in these organizations. Finally, it is critical that variables of interest be inclusive of specific quality indicators such as ventilator duration and complications rather than global institutional markers such as LOS. Standardization of variables of interest is imperative if outcomes are to be compared. For example, patients requiring long-term mechanical ventilation are identified by the AACNs Third National Study Group on weaning as those who require mechanical ventilation for more than 3 days. If we are to compare other variables of interest such as total ventilator duration, such as definition is essential or we will be comparing apples and oranges in the future. Provision of quality, cost-effective care for patients requiring prolonged ventilation is a true clinical challenge. Outcomes management is a multidisciplinary method of care delivery that is systematic and comprehensive in approach. Although little science exists related to the application of the model for patients requiring prolonged ventilation, preliminary reports are promising and warrant future applications and evaluation of the same.

Increasing the Safety of Blind Gastric Tube Placement in Pediatric Patients: The Design and Testing of a Procedure Using a Carbon Dioxide Detection Device

BACKGROUND The Burns Wean Assessment Program is a 26-factor weaning assessment worksheet and scoring instrument used to reduce practice variability in the clinical management of patients receiving mechanical ventilation. The instrument has been tested in patients in a medical-surgical intensive care unit, but further testing in different populations of adult patients is needed. OBJECTIVES To determine the relationship between Burns Wean Assessment Program scores and outcomes of weaning trials in patients treated with mechanical ventilation for 3 or more days. METHODS For 5 years in 5 adult critical care units (surgical, medical, neurological, thoracic-cardiovascular, and coronary care), advanced practice nurses collected scores within 24 hours of a weaning attempt. All patients were managed similarly by using a multidisciplinary pathway, the Burns Wean Assessment Program checklist, protocols for weaning trials, and sedation guidelines. RESULTS Of 1889 weaning attempts, 1669 (88%) were successful, and 220 (12%) were unsuccessful. Weaning outcomes did not differ according to sex, but significantly more trials were successful in younger patients than in older patients (P = .002) and in patients in different units (P = .01). Regardless of unit, patients with Burns Wean Assessment Program scores greater than 50 were significantly more likely to be weaned successfully (P = .001) than were patients with lower scores. CONCLUSIONS Systematic tracking of the factors and scores on the Burns Wean Assessment Program may be helpful in care planning and management and in determining weaning potential.