Physician Kaiser Permanente Sacramento, California, United States
Introduction: Respiratory insufficiency or failure requiring mechanical ventilation is a common admitting diagnosis among intensive care unit (ICU) patients. Mechanical ventilation, often requiring continuous sedation for patient comfort and compliance, is associated with poor outcomes including prolonged ICU and hospital length of stay (LOS), therefore timely ventilator weaning is imperative. Seminal research has demonstrated that paired spontaneous awakening trials (SATs), daily interruption of sedative agents, and spontaneous breathing trials (SBTs), resulted in decreased ventilator and ICU LOS. Ventilator liberation protocols, inclusive of SATs and SBTs, are recommended by critical care experts. In a 30-bed medical, surgical, and trauma ICU in Northern California, internal data demonstrated that SATs and SBTs were poorly timed and coordinated, and the ventilator liberation protocol lacked objective criteria. The purpose of this project was to develop and implement an objective and coordinated SAT/SBT protocol.
Methods: A literature review was completed to determine SAT and SBT best practices. Permission was obtained to revise an existing ventilator liberation protocol. An interprofessional team of physicians, registered nurses, and respiratory therapists revised the protocol, making each SAT and SBT safety screen and failure criteria objective. All disciplines were educated on the revised protocol, the importance of coordinating both interventions, and re-timing from early morning to mid-morning hours to align with interprofessional rounds and minimize sleep disruption. SAT/SBT protocol compliance and ventilator LOS data were collected.
Results: The mean ventilator LOS was 4.51 days in the pre-implementation period from June 2020 through May 2021. At 15-months post-implementation, the mean ventilator LOS was 4.14 days, an overall decrease of 0.37 days. At 19-months post-implementation, the mean ventilator LOS was 3.87 days, an overall decrease of 0.64 days.
Conclusions: Development and implementation of a revised and coordinated SAT/SBT protocol, timed for daytime hours, demonstrated a clinically significant improvement in ventilator LOS. As compliance with the protocol increased, ventilator LOS decreased.
