Primary Author: Alexandris Aman Secondary Author: Bela Patel MDOther Team Members: Adam Mullaly, Respiratory Therapist Lead, Memorial Hermann

UT Health Texas Center of Healthcare Quality Innovation at Memorial Hermann-TMC: Kristy Gomez, Kavitha Gopal, Denise Jackson, Todd Johnson PhD, Michelle Narat, Shekhar Patil MD MPH

Get to Green: Improving Team Communication to Reduce Ventilator Hours

Overview Critically ill patients on mechanical ventilators are at high risk to develop worsening lung injury, delirium, and hospital acquired infections, which can lead to worsening multi-system organ failure and death. All efforts should be made to decrease ventilator hours to reduce the likelihood of mechanical ventilation complications. In an inter-disciplinary environment, team communication is critical for optimal outcomes. The Medical Intensive Care Unit (MICU) at Memorial Herman – Texas Medical Center hospital has 16 beds and admits 125 patients a month of which 40% receive mechanical ventilation. The average time on mechanical ventilation was 4.4 days in 2014 which was in the top 25% for similar MICUs in high volume academic hospitals (UHC data). The average cost of stay for a typical ICU intubated patient is approximately 2,500 dollars per day. A multi-disciplinary team of physicians, respiratory therapists, nurses, process improvement engineer, and applications analyst were formed to address the length of ventilator hours in MICU by focusing on team communication.

Aim Statement

InterventionsThe Get to Green Visual Display was placed in each patient’s door. Multidisciplinary team reviewed goals of management of each area not yet “green” for extubation. Respiratory therapists and nursing updated the board every 2 hours. When the parameters reached their respective targets, a green checkmark was placed in front of that parameter. When all the parameters reached their targets, the spontaneous breathing trial process (SBT) took place and the team was activated for extubation evaluation. Multiple times during each 24 hour period, physicians, nurses, and respiratory therapists discussed the barriers to extubation and plan of care to mitigate those factors. The daily and weekly dashboards have also served as effective tools to discuss ways to address the timely extubation process. Physicians, residents, nurses and respiratory therapists were among the stakeholders receiving the dashboard reports.

Figure 4. Workplace Visual Communication Board (Get to Green)

Figure 5. Patient-Level Get to Green to Extubation Daily Dashboard

Figure 6. Patient-Level Get to Green to Extubation Weekly Dashboard

ResultsAverage mechanical ventilator days were decreased by 37% (4.1 days to 2.6 days) within 10 months (Figure 7). The average time from “Getting to Green” to Extubation Time improved from 82 hours to 35.4 hours in 2016 (Figure 8). Additionally, Figure 9 shows that the average number of reintubations has not increased since the start of the ”get to green” initiative (1.11 in 2014, and 1.08 in 2015). A paired T Test demonstrated a statistical significance in the pre and post populations (Figure 10).

Conclusions, Next StepsThe Get to Green project of a visual interdisciplinary communication board has been an effective strategy to decrease mechanical ventilator hours. The daily and weekly dashboards have also served as effective tools to discuss different ways to address the process of timely extubation process. Expansion into multiple other ICUs has been initiated. Real time electronic dashboards are in development.

Quality ToolsOne of the first steps in this project was to understand the extubation process and all the steps necessary for a successful extubation. The process map was developed showing all the test requirements and stages in the extubation process cycle. The PDCA cycle was utilized as a problem solving tool to identify issues relating to delayed extubation. The 5 Whys methodology was applied as a root cause analysis tool to identify the real issues causing delayed extubation for patients on mechanical ventilator. A workplace communication board (labeled “Get to Green”) was developed as a visual tool to exhibit the current patient’s extubation status.

Figure 1. Process Map of Patients on Mechanical Ventilator

Figure 2. PDCA Cycle Methodology

Figure 3. Root Cause Analysis (5 Whys Methodology)

Measures of SuccessPrimary measure: Reduction of ventilator days by 20% in the MICU.Secondary measure: Reduction of time from meeting extubation readiness criteria (Getting to Green) to extubation.

Results (Continued)

Revenue Enhancement, Generalizability

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The primary aim of this project was to decrease ventilator days by 20% in 10 months in the Medical Intensive Care Unit at Memorial Hermann – Texas Medical Center.

Start of Weaning Process

Current PROTOCOL-DIRECTED WEANING PROCESS FLOW(INTENSIVE CARE UNIT)

Patient’s RASS Score is -3 or Less?

No

STOP!

Patient can Pass Readiness Testing?

Yes

No

All of the following should be met for passing score:

Pa/FIO2 >180PEEP<5-8 cm H2O

pH>7.32RR 8-35 br/minHR<130 BPM

MAP>65 mmHgNorepinephrine or equivalent<5 µg/min

HGB=>7g/DlAbility to CoughICP<15 mmHg

Patient Chemically Paralyzed?

Yes

Patient Able to Breath Spontaneously?

STOP!

Yes

No

STOP! – Notify Attending Physician

for Further Instructions

Whether to Proceed with SBT or Follow

New Orders for Patient Readiness

Re-Testing

No

STOP! – Notify Attending Physician

for Further Instructions

Whether to Proceed with SBT or Follow

New Orders for Patient Readiness

Re-Testing

Initiate SBT By Adjusting Ventilator

Settings

Patient Passed SBT Performance

Yes

No

STOP! – Notify Attending Physician

for Further Instructions

PSV 5-10 cmH20 or PSV=0 with

Automatic Airway CompensationPEEP<5 cmH20

FIO2<50%

RN/RT Assesses Appropriateness of Sedation Holiday Using RASS

RT Must be Present for the 1st 5-10

Mins. Of The SBT Trial

SBT Trial Passing Criteria:RR<35 br/min (RSBI<105)

SaO2/Sp02>88% and <5% fall HR <130 bpm and <20%

increase in RateSBP<180, >90 mmHg

ABG shows <20% Rise in PaCO2Minimal Sign of Anxiety or Agitation

SBT Trial Passing Criteria:RR<35 br/min (RSBI<105)

SaO2/Sp02>88% and <5% fall HR <130 bpm and <20%

increase in RateSBP<180, >90 mmHg

ABG shows <20% Rise in PaCO2Minimal Sign of Anxiety or Agitation

Extubation Successful?

No

Physician's Final Assessment of Patient (good cough, secretion clearance , passing of leak test and overall

SBT Test results)

Patient Will be off

Ventilator

Patient is Ready to be Extubated?

Yes

No

Go Back to The Start of Weaning Process

Yes

Reintubate Patient and Go Back to The Start of

Weaning Process

Yes

PASSFAIL 18:35

Bed. No. 11Gender Male

DOB 01/18/1975Vent Start Date/Time 12/29/15 11:55 AM

MICU Arrival Date/Time 12/29/15 6:35 PMPatient On Paralytics No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100

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Vent Parameters

Last Test/Reading Before MICU Arrival

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PEEP 10 10 10 10 8 5

FIO2 60 60 60 100 60 60 50 40 40

pH 7.46 7.46 7.32 7.13 7.4 7.4

RR 28 25 29 25 20 20

HR 111 118 109 111 93 96 97 101 106 100 88 83 85 94 90 91 100 106 104

HGB 11.7 10.1

MAP 127 136 107 108 101 56 70 74 78 107 79 63 68 80 81 68 87 101 114 136

Norepinephrine

RASS -1 -2 -4 1 1 1

Fourth Attempt at SBT Trial Hours From MICU ArrivalResult

First Attempt at SBT Trial Hours From MICU Arrival 17 ResultPassed

MIC

U A

rriv

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ime

Number of Hours From MICU Arrival

Status Indicator

Second Attempt at SBT Trial Hours From MICU ArrivalResult

Third Attempt at SBT Trial Hours From MICU ArrivalResult

Fourth Attempt at SBT Trial Hours From MICU ArrivalResult

SBT AssessmentSBT Trial Extubation

ICU Arrival/Vent Time

All Parameters Turned Green (1st time)

Extubation

2:15 PMPatient Information ICU Location 12/28/2015Male-Apr,03,1960-

Bed No.01 MICU 45

12:21 PMPatient Information ICU Location 12/30/2015

Female-Nov,03,1965-Bed

No.16MICU 66

12:05 PMPatient Information ICU Location 12/30/2015Male-Jan,18,1975-

Bed No.11 MICU 24

5:27 AMPatient Information ICU Location 12/31/2015Male-Oct,08,1990-

Bed No.09 MICU 74 2

Time 10:46 PM Duration (Hours) 3:00 AM Duration (Hours)12/30/2015

10 57

18 6

Time 11:55 AM Duration (Hours) 6:05 AM Duration (Hours)12/29/2015 12/30/2015

Total Extubation Time (Hours)12/31/2015

17Duration (Hours)

10:13 AMDuration (Hours)12/27/2015

28

Total Extubation Time (Hours)

12/28/2015

Total Extubation Time (Hours)

Weekly Patient Extubation Profile

Time 6:00 PM Duration (Hours) 3:37 AM Duration (Hours)Total Extubation

Time (Hours)

Time 5:26 PM12/26/2015

12/27/2015

Figure 7. Average Days of Patients on Mechanical Ventilator

Figure 8. Average Days When All Ventilator Parameters Met Targets to Extubation Time

Figure 9. Average Number of Reintubation Per Patient

Paired Differences

Sample size 10Mean 10.74 90% CI (2.3657, 19.114)Standard deviation 14.446

Statistics Differences*Paired

Individual Samples

Mean 63.83 53.09Standard deviation 12.073 16.426

Statistics GTG- 2014 GTG- 2015

GTG- 2015 (p < 0.05).The mean of GTG- 2014 is significantly greater than the mean of

Yes No

0 0.05 0.1 > 0.5

P = 0.022

403020100

0

interpreting the results of the test.differences to zero. Look for unusual differences before• Distribution of Differences: Compare the location of theand 95% confident that it is greater than 2.3657.that the true mean difference is between 2.3657 and 19.114,mean difference from sample data. You can be 90% confident• CI: Quantifies the uncertainty associated with estimating themean of the paired differences is greater than zero.greater than GTG- 2015 at the 0.05 level of significance. The• Test: You can conclude that the mean of GTG- 2014 is

Mean TestIs GTG- 2014 greater than GTG- 2015?

*Difference = GTG- 2014 - GTG- 2015

Distribution of the DifferencesWhere are the differences relative to zero?

Comments

Paired t Test for the Mean of GTG- 2014 and GTG- 2015Summary Report

Figure 10. Paired T- Test Showing Effectiveness of Implemented Quality Initiatives

By reducing the average days on mechanical ventilator to 2.6 days per patient in 2016, we have an annual cost saving potential of $810,000 based on 1.5 days reduction in ventilator days with an average mechanically ventilated patient population of 50, and an average cost of $900 for utilization of lower level of care in MICU.