Evaluation of a Sedation Vacation ProtocolGeorgianne Summer BSN RNAugusta UniversityDNP Project Final Defense

Introduction The eradication of healthcare associated infections

(HAIs) is a reimbursement directive set by the US Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS)

According to the Centers for Disease Control and Prevention (CDC) hospital-acquired pneumonia (HAP) accounts for approximately 15 of all HAIs HAP carries a crude mortality rate of 30-70 with the predicted attributable mortality rate of pneumonia between 27-50

(Mendel et al 2011 Tablan et al 2003)

Introduction Prolonged Length of Stay According to the CDC hospital

acquired pneumonia prolongs ICU stay 4-6 days and overall hospitalization 7-9 days

Expensive Care HAP adds $40000 to the cost of care per patient Mechanical ventilation (MV) is estimated to cost as much as

$1522 per day In 2003 US hospitals spent 16 billion dollars on PAMV patients In 2020 the cost will escalate to $60 billion

Increased Risk The National Nosocomial Infection Surveillance System (NNIS) found that patients receiving mechanical ventilation had 6-21 times the risk of developing hospital-associated pneumonia

(Bice et al 2013 Carson et al 2006 Zilberg et al 2008 Zilberg et al 2012)

Introduction In 2020 an estimated 625298 patients are projected to require prolonged

acute mechanical ventilation (PAMV) defined as patient being intubated and using mechanical ventilation ge 96 hours

Due to the significant risk of mechanical ventilation most of the research on hospital-associated pneumonia has been focused on ventilator-associated pneumonia (VAP) for the last 3 decades

In 2011 the Agency for Healthcare Research and Quality (AHRQ) developed guidelines to assist in preventing VAP which contains daily sedation vacation and spontaneous breathing trials

As healthcare institutions follow the recommended guidelines and initiate infection prevention and treatment programs it is essential to regularly reevaluate their effectiveness

(Agency for Healthcare Research and Quality 2011 Tablan et al 2003)

Background Mechanical ventilation (MV) is a method to assist or

replace spontaneous breathing and indicated when natural ventilation or respiration is insufficient

Goals of MV include maintain gas exchange reduce myocardial oxygen consumption attain lung expansion and stabilization of the thoracic wall

Patient dependency on MV may linger long after the gas exchange andor impaired ventilation has resolved

Comorbidities and severity of underlying disease processes increases the risk for hospital mortality This risk increases with age hospital acquired infections and multiple organ failure

(Hamed et al2006 Tabersrsquos Cyclopedic Medical Dictionary 2013)

Background Patients who survive experience

prolonged recovery and rehab overcoming hospital acquired deficits such as decreases in mobility and energy

substantial increase in sleep disorders and social isolation

Benefits of early weaning from MV include Decreased mortality Improved outcomes Reduced costs Decreases in the bodyrsquos stress response Increases in the patientrsquos comfort level

(Combes et al 2003 Hamed et al 2006)

Background Patients should be assessed daily

To determine if they can tolerate withdrawal of MV and sustain their own respiratory efforts

To determine if they can tolerate weaning or interruption of sedation medication

Critical care specialists remain challenged To deliver the ideal sedation Promote relaxation Decrease unwanted side effects

(Institute for Clinical Systems Improvement 2011 Jacobi et al 2002 Kress et al 2000)

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Introduction The eradication of healthcare associated infections

(HAIs) is a reimbursement directive set by the US Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS)

According to the Centers for Disease Control and Prevention (CDC) hospital-acquired pneumonia (HAP) accounts for approximately 15 of all HAIs HAP carries a crude mortality rate of 30-70 with the predicted attributable mortality rate of pneumonia between 27-50

(Mendel et al 2011 Tablan et al 2003)

Introduction Prolonged Length of Stay According to the CDC hospital

acquired pneumonia prolongs ICU stay 4-6 days and overall hospitalization 7-9 days

Expensive Care HAP adds $40000 to the cost of care per patient Mechanical ventilation (MV) is estimated to cost as much as

$1522 per day In 2003 US hospitals spent 16 billion dollars on PAMV patients In 2020 the cost will escalate to $60 billion

Increased Risk The National Nosocomial Infection Surveillance System (NNIS) found that patients receiving mechanical ventilation had 6-21 times the risk of developing hospital-associated pneumonia

(Bice et al 2013 Carson et al 2006 Zilberg et al 2008 Zilberg et al 2012)

Introduction In 2020 an estimated 625298 patients are projected to require prolonged

acute mechanical ventilation (PAMV) defined as patient being intubated and using mechanical ventilation ge 96 hours

Due to the significant risk of mechanical ventilation most of the research on hospital-associated pneumonia has been focused on ventilator-associated pneumonia (VAP) for the last 3 decades

In 2011 the Agency for Healthcare Research and Quality (AHRQ) developed guidelines to assist in preventing VAP which contains daily sedation vacation and spontaneous breathing trials

As healthcare institutions follow the recommended guidelines and initiate infection prevention and treatment programs it is essential to regularly reevaluate their effectiveness

(Agency for Healthcare Research and Quality 2011 Tablan et al 2003)

Background Mechanical ventilation (MV) is a method to assist or

replace spontaneous breathing and indicated when natural ventilation or respiration is insufficient

Goals of MV include maintain gas exchange reduce myocardial oxygen consumption attain lung expansion and stabilization of the thoracic wall

Patient dependency on MV may linger long after the gas exchange andor impaired ventilation has resolved

Comorbidities and severity of underlying disease processes increases the risk for hospital mortality This risk increases with age hospital acquired infections and multiple organ failure

(Hamed et al2006 Tabersrsquos Cyclopedic Medical Dictionary 2013)

Background Patients who survive experience

prolonged recovery and rehab overcoming hospital acquired deficits such as decreases in mobility and energy

substantial increase in sleep disorders and social isolation

Benefits of early weaning from MV include Decreased mortality Improved outcomes Reduced costs Decreases in the bodyrsquos stress response Increases in the patientrsquos comfort level

(Combes et al 2003 Hamed et al 2006)

Background Patients should be assessed daily

To determine if they can tolerate withdrawal of MV and sustain their own respiratory efforts

To determine if they can tolerate weaning or interruption of sedation medication

Critical care specialists remain challenged To deliver the ideal sedation Promote relaxation Decrease unwanted side effects

(Institute for Clinical Systems Improvement 2011 Jacobi et al 2002 Kress et al 2000)

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Introduction Prolonged Length of Stay According to the CDC hospital

acquired pneumonia prolongs ICU stay 4-6 days and overall hospitalization 7-9 days

Expensive Care HAP adds $40000 to the cost of care per patient Mechanical ventilation (MV) is estimated to cost as much as

$1522 per day In 2003 US hospitals spent 16 billion dollars on PAMV patients In 2020 the cost will escalate to $60 billion

Increased Risk The National Nosocomial Infection Surveillance System (NNIS) found that patients receiving mechanical ventilation had 6-21 times the risk of developing hospital-associated pneumonia

(Bice et al 2013 Carson et al 2006 Zilberg et al 2008 Zilberg et al 2012)

Introduction In 2020 an estimated 625298 patients are projected to require prolonged

acute mechanical ventilation (PAMV) defined as patient being intubated and using mechanical ventilation ge 96 hours

Due to the significant risk of mechanical ventilation most of the research on hospital-associated pneumonia has been focused on ventilator-associated pneumonia (VAP) for the last 3 decades

In 2011 the Agency for Healthcare Research and Quality (AHRQ) developed guidelines to assist in preventing VAP which contains daily sedation vacation and spontaneous breathing trials

As healthcare institutions follow the recommended guidelines and initiate infection prevention and treatment programs it is essential to regularly reevaluate their effectiveness

(Agency for Healthcare Research and Quality 2011 Tablan et al 2003)

Background Mechanical ventilation (MV) is a method to assist or

replace spontaneous breathing and indicated when natural ventilation or respiration is insufficient

Goals of MV include maintain gas exchange reduce myocardial oxygen consumption attain lung expansion and stabilization of the thoracic wall

Patient dependency on MV may linger long after the gas exchange andor impaired ventilation has resolved

Comorbidities and severity of underlying disease processes increases the risk for hospital mortality This risk increases with age hospital acquired infections and multiple organ failure

(Hamed et al2006 Tabersrsquos Cyclopedic Medical Dictionary 2013)

Background Patients who survive experience

prolonged recovery and rehab overcoming hospital acquired deficits such as decreases in mobility and energy

substantial increase in sleep disorders and social isolation

Benefits of early weaning from MV include Decreased mortality Improved outcomes Reduced costs Decreases in the bodyrsquos stress response Increases in the patientrsquos comfort level

(Combes et al 2003 Hamed et al 2006)

Background Patients should be assessed daily

To determine if they can tolerate withdrawal of MV and sustain their own respiratory efforts

To determine if they can tolerate weaning or interruption of sedation medication

Critical care specialists remain challenged To deliver the ideal sedation Promote relaxation Decrease unwanted side effects

(Institute for Clinical Systems Improvement 2011 Jacobi et al 2002 Kress et al 2000)

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Introduction In 2020 an estimated 625298 patients are projected to require prolonged

acute mechanical ventilation (PAMV) defined as patient being intubated and using mechanical ventilation ge 96 hours

Due to the significant risk of mechanical ventilation most of the research on hospital-associated pneumonia has been focused on ventilator-associated pneumonia (VAP) for the last 3 decades

In 2011 the Agency for Healthcare Research and Quality (AHRQ) developed guidelines to assist in preventing VAP which contains daily sedation vacation and spontaneous breathing trials

As healthcare institutions follow the recommended guidelines and initiate infection prevention and treatment programs it is essential to regularly reevaluate their effectiveness

(Agency for Healthcare Research and Quality 2011 Tablan et al 2003)

Background Mechanical ventilation (MV) is a method to assist or

replace spontaneous breathing and indicated when natural ventilation or respiration is insufficient

Goals of MV include maintain gas exchange reduce myocardial oxygen consumption attain lung expansion and stabilization of the thoracic wall

Patient dependency on MV may linger long after the gas exchange andor impaired ventilation has resolved

Comorbidities and severity of underlying disease processes increases the risk for hospital mortality This risk increases with age hospital acquired infections and multiple organ failure

(Hamed et al2006 Tabersrsquos Cyclopedic Medical Dictionary 2013)

Background Patients who survive experience

prolonged recovery and rehab overcoming hospital acquired deficits such as decreases in mobility and energy

substantial increase in sleep disorders and social isolation

Benefits of early weaning from MV include Decreased mortality Improved outcomes Reduced costs Decreases in the bodyrsquos stress response Increases in the patientrsquos comfort level

(Combes et al 2003 Hamed et al 2006)

Background Patients should be assessed daily

To determine if they can tolerate withdrawal of MV and sustain their own respiratory efforts

To determine if they can tolerate weaning or interruption of sedation medication

Critical care specialists remain challenged To deliver the ideal sedation Promote relaxation Decrease unwanted side effects

(Institute for Clinical Systems Improvement 2011 Jacobi et al 2002 Kress et al 2000)

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Background Mechanical ventilation (MV) is a method to assist or

replace spontaneous breathing and indicated when natural ventilation or respiration is insufficient

Goals of MV include maintain gas exchange reduce myocardial oxygen consumption attain lung expansion and stabilization of the thoracic wall

Patient dependency on MV may linger long after the gas exchange andor impaired ventilation has resolved

Comorbidities and severity of underlying disease processes increases the risk for hospital mortality This risk increases with age hospital acquired infections and multiple organ failure

(Hamed et al2006 Tabersrsquos Cyclopedic Medical Dictionary 2013)

Background Patients who survive experience

prolonged recovery and rehab overcoming hospital acquired deficits such as decreases in mobility and energy

substantial increase in sleep disorders and social isolation

Benefits of early weaning from MV include Decreased mortality Improved outcomes Reduced costs Decreases in the bodyrsquos stress response Increases in the patientrsquos comfort level

(Combes et al 2003 Hamed et al 2006)

Background Patients should be assessed daily

To determine if they can tolerate withdrawal of MV and sustain their own respiratory efforts

To determine if they can tolerate weaning or interruption of sedation medication

Critical care specialists remain challenged To deliver the ideal sedation Promote relaxation Decrease unwanted side effects

(Institute for Clinical Systems Improvement 2011 Jacobi et al 2002 Kress et al 2000)

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Background Patients who survive experience

prolonged recovery and rehab overcoming hospital acquired deficits such as decreases in mobility and energy

substantial increase in sleep disorders and social isolation

Benefits of early weaning from MV include Decreased mortality Improved outcomes Reduced costs Decreases in the bodyrsquos stress response Increases in the patientrsquos comfort level

(Combes et al 2003 Hamed et al 2006)

Background Patients should be assessed daily

To determine if they can tolerate withdrawal of MV and sustain their own respiratory efforts

To determine if they can tolerate weaning or interruption of sedation medication

Critical care specialists remain challenged To deliver the ideal sedation Promote relaxation Decrease unwanted side effects

(Institute for Clinical Systems Improvement 2011 Jacobi et al 2002 Kress et al 2000)

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Background Patients should be assessed daily

To determine if they can tolerate withdrawal of MV and sustain their own respiratory efforts

To determine if they can tolerate weaning or interruption of sedation medication

Critical care specialists remain challenged To deliver the ideal sedation Promote relaxation Decrease unwanted side effects

(Institute for Clinical Systems Improvement 2011 Jacobi et al 2002 Kress et al 2000)

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Background The Society of Critical Care Medicine (SCCM) guidelines for

ventilator management includes goals to decrease pain anxiety ventilator days and ICU length of stay

One guideline of SCCM identifies the desired level of sedation for mechanical ventilation to be a calm and easily arousable patient However less than 30 of critical care physicians report using these sedation guidelines or achieving this level of acceptable sedation

No matter who institutes the sedation protocol it remains a nursing responsibility and their attitudes judgments and behavior impact sedation practices

(Belfort et al 2009 Guttormson et al 2010 Lonardo et al 2014)

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Problem Statements While mechanical ventilation is a life-saving intervention

it is also associated with several potential complications such as decreased cardiac output acute lung injury diaphragmatic atrophy oxygen toxicity and barotrauma

The cost to patients is more than financial they have referred to mechanical ventilation as ldquothe most inhumane treatment ever experiencedrdquo

Although a clinical practice guideline for sedation vacation was established 11 years ago it remains a significant practice issue due to noncompliance by nurses to use this practice guideline

(Belfort et al 2009 Chlan et al 2000 Hamed et al 2006 Miller et al 2012 Roberts et al 2010)

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

PurposeThe purpose of this clinical protocol evaluation project was to determine if the implementation of a sedation vacation protocol in a medical intensive care unit (MICU) reduced the incidence of pneumonia duration of intubation and MICU length of stay for mechanically-ventilated adult patients

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Literature Review

Databases Utilized

CINAHLPubMedOvid MEDLINECochrane Library

Key Search Terms

IntubationMechanical VentilationSedationSedation Vacation

Limits

Research in English languageResearch from 2000-2015Research of human adult subjects

Results

190 articles identified30 relevant articles includedRanked according to the Stetler Evidence Hierarchy System

Picot Question Does the implementation of a SV protocol in a medical ICU reduce the incidence of pneumonia duration of intubation and ICU length of stay (LOS) for mechanically-ventilated adult patients

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Literature ReviewThemes

Daily Sedation Vacation

Ventilator Bundle Care

Spontaneous Breathing

Trials

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Ventilator Bundle Care Adherence to bundle care

leads to a significant VAP reduction

Supported by CDC AACN AHRQ NIH and IHI

(Blackwood 2011 Griffin amp Nolan 2012IHI 2012 Lawrence et al 2011 Munroe et al 2014 Stetler et al 1998)

Literature Review

Ventilator Bundle

HOB elevated

Daily SV

Assess readiness to

wean

Oral care with chlorhexidine

Peptic ulcer prophylaxis

DVT prophylaxis

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Literature ReviewDaily Sedation Vacation Daily sedation vacations allow for proper

assessment of the patientrsquos readiness to be extubated

Evidence indicates that patients who receive daily interruption of sedation have decreased number of MV days as well as decreased LOS in the ICU

Associated with decreased use of sedation and lower incidence of sedation related side effects

(American Thoracic Society 2005 Girard et al 2008 Jackson et al 2010 Kress et al 2000 Mendez et al 2013)

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Literature ReviewSpontaneous Breathing Trials Allows for proper assessment of the patientrsquos readiness

to be extubated Evidence indicates that its use decreases the length of

weaning time number of MV days as well as decreased LOS in the ICU

Used in conjunction with daily sedation vacation Recommended American College of Chest Physicians amp

American College of Critical Care Medicine

(AHRQ 2011 Girard et al 2008 Kahn et al 2014 MacIntyre 2001 Marelich 2000)

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Literature Review Summary Introduction of guidelines and protocols was

associated with improvements in outcomes including ICU and hospital length of stay duration of mechanical ventilation costs mortality and reduction of nosocomial infections incidences

Adherence to IHI recommended bundle led to a significant reduction of VAP

Nurse driven protocols were more successful with both implementation and compliance

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Conceptual Framework Quality and safety are ultimately measured by the

degree to which health care improves significant patient outcomes

According to the Institute of Medicine quality in health care is a direct correlation between the level of enhanced health services and the individualrsquos andor populationrsquos anticipated health outcome

Donabedianrsquos Systems model has proven to be an essential framework for measuring both quality of care and patient safety in healthcare

The model has been utilized in quality improvement research by national and international agencies like WHO NIH AHRQ

(AHRQ 2005 AHRQ 2011)

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Conceptual Frameworkbull Application of Donabedianrsquos Systems Model

Application of Systems Model for process evaluation Adapted from ldquoAgency for Healthcare Research and Quality US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement

strategies Volume 7mdashCare Coordination Technical Review]rdquo AHRQ Publication No 04(07)-0051-7

StructuresIntensive Care Unit patients physicians nurses respiratory therapists policies

and protocols

Processes Delivery of sedation vacation guided by

evidence based protocol

OutcomesICU Length of stay

Incidence of PneumoniaDuration of mechanical ventilation

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Aims Determine if the utilization of the

sedation vacation protocol in MICU was sustained in 2014Physicians ordering protocol Nurses documentation indicated use

Determine if the implementation of the sedation vacation protocol decreased the incidence of pneumonia duration of intubation and ICU LOS

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Methodology Design

Retrospective chart review 12-month period January 1 2014 - December 31

2014 Setting

550 bed Academic Medical Center in Augusta Georgia

Adult in-patient 24 bed Medical intensive Care Unit Sample Patients selected by ICD-9 and V codes from the

Enterprise approved EMR data mining tool I2B2

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

MethodologyInclusion Criteria Exclusion Criteria

Patients at least 18 years of age Diagnosis of pneumonia upon admission to hospital

Patients admitted to the Medical Intensive Care Unit

Diagnosis of pneumonia upon admission to Medical Intensive Care Unit

Patients endotracheally intubated for ge 24 hours

Diagnosis of acute severe laryngeal edema or any upper airway obstruction

Patients requiring mechanical ventilation

Diagnosis of severe acute respiratory distress syndrome or status asthmaticus

Patient receiving a continuous infusion sedative medication

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Results of Data Mining Search Strategy

348 429

123 47 33

EMRs during 2014 searched using ICD-9 Codes for Respiratoryndashrelated and Mechanical Ventilation diagnoses

81 additional EMRs added with V code for using a respirator during 2014

EMRs matched to MICU admissions

EMRs after excluding no ventilator (7) tracheostomies (7) outside time frame (22) pre-existing pneumonia (14) DNRno intubation order (2) MICU patient in other unit (4) incomplete (7)

Final EMRs after excluding no ventilator (1) chronic ventilator (1) multiple intubations DNR (2) pre-existing pneumonia (9)

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Statistical Analysis Descriptive statistics

Nonparametric Chi-square test

Nonparametric Cochranrsquos Q test

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Results (n = 33)

Caucasian 55African American 33Hispanic 3OtherUnknown 9

Race

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Gender

Measures of Central Tendency

Female 51Male 49

Results (n = 33)

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

ResultsPrimary Hospital Admission Diagnosis

Primary (hospital admission) diagnoses grouped by similarity

Diagnosis Frequency PercentRespiratory Decompensation 3 9

Known Infectious Process 4 12Altered Mental Status 15 46

Cancer 3 9GI Bleed 1 3

Liver Failure 2 6Cardiovascular Decompensation 3 9

Miscellaneous 2 6Total 33 100

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

ResultsMedical Intensive Care Unit Admitting Diagnosis

Diagnosis Frequency Percent

Respiratory Decompensation 14 43

Known Infectious Process 8 24

Acid-Base Imbalance 2 6

GI Bleed 3 9

Liver Failure 2 6

Cardiovascular Decompensation 3 9

Miscellaneous 1 3

Total 33 100

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

ResultsSedation Vacation Protocol Documentation

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Sample Size n=33 Frequency Percent p value

Statistical Significanc

eRichmond Agitation Sedation Scale Documented

33 100

Spontaneous Breathing Trial Documented

23 70 024 Statistically Significant

Sedation Titration Documented 23 70 024 Statistically

Significant

3 indirect EMR indicators investigated to determine if the SV protocol was used but not documented

Results

Cochranrsquos Q test revealed no statistical significant association was found among these three SV protocol indicators (p = 92)

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

ResultsIndicators of VAP Diagnosis Documentation

IndicatorsFrequenc

yPercen

tPneumonia Diagnosis documented

Yes 5 15 No 28 85

Total 33 100

Positive Chest X-ray documented

Yes 9 27 No 24 73

Total 33 100

Positive Sputum Culture documented

Yes 12 36 No 21 64

Total 33 100

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Discussion Respiratory decompensation accounted for 43 of

the MICU admission diagnoses many of the patients were discovered to have positive chest x-rays during the endotracheal tube verification and therefore VAP could not be determined

The duration of ventilation and MICU LOS results are inconclusive due to the severity of illness within this patient population many in this sample were terminally extubated and therefore have the same number of days for both endotracheal intubation and MICU length of stay

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Discussion Ventilator Days and MICU LOS in this project were 15 and

3 days respectively more than that found by Kress et al (2000)

Therefore the 67 compliance shown by the MICU nurses demonstrated the need for 100 compliance of formal SV documentation (If itrsquos not documented itrsquos not done)

Protocol Compliance Physicians ordering protocol 100 Nurses formal documentation of protocol 67 Nurses performing SV indicators but not documenting protocol 70

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

DiscussionSurvey by Roberts et al (2010) and other

researchers showed that barriers to protocol compliance included Patient agitation or painNursing acceptance of practiceFear of patient self-extubation or harm

(Mendez et al 2013 Miller et al 2012 Roberts et al 2010 Belfort et al 2009)

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Limitations

Variability in

physician

charting

ICD-9 Coding

variability

I2B2 inability

to search

by location

or procedural code

Small single center study n=33

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Implications for Practice Educational Opportunities

Critical Care education on sedation with sedation vacation protocol

Significance of the sedation weaning and daily interruption

Importance of documenting rationale for patients excluded from sedation vacation

Importance of spontaneous breathing trials Importance of ventilator bundle care

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Conclusions While the reviewed evidence supports the use of

protocols for MV and SV with improved outcomes the findings suggest that no clear conclusion could be made concerning the effectiveness of the sedation vacation protocol in this particular MICU

Research is needed to accurately determine the efficacy of the sedation vacation protocol at this facility as well as compare patient populations based on severity of illness with other hospital locations across the United States

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Plan for dissemination of Information

Project will be presented to MICU Leadership Project will be presented AUHealth Evidence Based

PracticePerformance Committee and Education Committee

Project will be submitted for publication based on committeersquos recommendation

Future Conferences TBD

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Acknowledgements Committee Chair

Dr A Schumacher PhD RN Committee Member

Dr P Hartley DNP RN Advisors

William Todd MSN RN FNP-C (DNP site preceptor)Michelle Sweat MSN RN (MICU Nurse Educator) Joy Hayman (PowerTrials and i2b2 Administrator)

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Referencesbull Agency for Healthcare Research and Quality (2011) Prevention of

ventilator-associated pneumonia Health care protocol Retrieved from httpwwwguidelinegovcontentaspxid=36063

bull Agency for Healthcare Research and Quality (2005) The Donabedian model of patient safety Medical teamwork and patient safety The evidence-based relation Retrieved from httparchiveahrqgovresearchfindingsfinal-reportsmedteammedteamworkpdf

bull Agency for Healthcare Research and Quality-US Department of Health and Human Services (2007) Closing the quality gap A critical analysis of quality improvement strategies Volume 7mdashCare Coordination [Technical Review] Retrieved from wwwahrqgov httpwwwahrqgovresearchfindingsevidence-based-reportscaregappdf

Referencesbull Belfort J A (2009 March-April) A brief report of student research Protocol

versus nursing practice sedation vacation in a surgical intensive care unit Dimensions of Critical Care Nursing 28(2) 81-82 httpdxdoiorg101097DCC0b013e318195d5d6

bull Blamoun J Alfakir M Rella M Wojcik J Solis R Khan A amp DeBari V (2009) Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit American Journal of Infection Control 37(2) 172-175 httpdxdoiorg101016jajic200805010

bull Blackwood B Alderdice F Burns K Cardwell C Lavery G amp OHallaran P (2011) Use of weaning protocols for reducing duration of mechancal ventilatoin in critically ill adult patients Cochran systematic review and meta-analysis British Medical Journal Jan 13 httpdxdoiorg101136bmjc7237

bull Brook A Ahrens T Schaiff R Prentice D Sherman G Shannon W amp Kollef M (1999) Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation Critical Care Medicine 27(12) 2609-2615 httpdxdoiorg10109700003246-199912000-00001

Referencesbull Combes A Costa M Trouillet J Baudot J Mokhtari M Gilbert C amp Chastre

J (2003) Morbidity mortality and quality-of-life outcomes of patients requiring ge 14 days of mechanical ventilation Critical Care Medicine 31(5) 1373-1380 httpdxdoiorg10109701ccm000006518887029c3

bull Carson S S (2006) Outcomes of prolonged mechanical ventilation Current Opinion in Critical Care 12(5) 405-411 httpdxdoiorg10109701ccx000024411808753dc

bull Donabedian A (1966) Evaluating the quality of medical care The Milbank Quarterly 83(4) 691ndash729 Retrieved from httpwwwncbinlmnihgovpmcarticlesPMC2690293

bull Donabedian A Wheeler JR amp Wyszewainski L (1982) Quality cost and health An integrative model Medical Care 20(10) 975-992

bull Donabedian A (1988) The quality of care How can it be assessed The Journal of the American Medical Association 260(12) 1743-1748 Retrieved from httpwwwncbinlmnihgovpubmed3045356

bull Frazier S (1999) Neurohormonal responses during positive pressure mechanical ventilation Heart and Lung 28(3) 149-165 httpwwwncbinlmnihgovpubmed10330211

Referencesbull Girard T Kress J Fuchs B Thomason J Schweickert W Pun B Ely

E (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care A randomized controlled trial Lancet 371 126-134 httpdxdoiorg101016S0140-6736(08)60105-1

bull Griffin R amp Nolan H (2012) Using care bundles to improve health care quality Institute for Healthcare Improvement Retrieved from wwwIHIorg

bull Guttormson J Chlan L Weinert C amp Savik K (2010) Factors influencing nurse sedation practices with mechanically ventilated patients A US nationalsurvey Intensive and Critical Care Nursing 26 44-50 httpdxdoiorg101016jiccn200910004

bull Hamed H Ibrahim H Khater Y amp Aziz E (2006) Ventilation and ventilators in the ICU What every intensivist must know Current Anaesthesia amp Critical Care 17 77-83 httpdxdoiorg101016jcacc200607008

Referencesbull Institute for Clinical Systems Improvement (2011) Health care protocol

Prevention of ventilator-associated pneumonia Fifth Edition Retrieved from httpswwwicsiorg_assety24ruhVAPpdf

bull Jacobi J Fraser G Coursin D Riker R Fontaine D Wittbrodt E Lumb P (2002) Clinical practice guidelines for the sustained use of sedative and analgesics in the critically ill adult Critical Care Medicine 30(1) 119-141 httpdxdoiorg101097CCM0b013e3182783b72

bull Kress J Pohlmon A OrsquoConner M amp Hall J (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation New England Journal of Medicine 342(20) 141-147 httpdxdoiorg101056NEJM200005183422002

bull Lawrence P amp Fulbrook P (2011) The ventilator care bundle and its impact on ventilator-associated pneumonia A review of the evidence Nursing in Critical Care 16(5) 222-234 httpdxdoiorg101111j1478-153201000430x

Referencesbull Lonardo N Mone M Nirula M Kimball E Ludwig K Zhou X Sauer B

Nechodom K Teng C amp Barton R (2014) Propofol is Associated with Favorable Outcomes Compared to Benzodiazepines in Ventilated ICU Patients American Journal of Critical Care Medicine 10-April httpdxdoiorg101164rccm201312-2291OC

bull MacIntyre N (2001) Evidence-based guidelines for weaning and discontinuing ventilatory support A collective task force facilitated by American college of chest physicians the American association for respiratory care American college of critical care medicine Chest 120375-396 httpdxdoiorg101378chest1206_suppl375S

bull Marelich G Murin S Battistella F Inciardi J Vierra T Roby M (2000) Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses Effect on weaning time and incidence of ventilator-associated pneumonia Chest 118(2) 459-467 httpdxdoiorg101378chest1182459

bull Mehta S Burry L Martinez-Motta J Stewart T Hallett D McDonald E Cook D (2008) A randomized trial of daily awakening in critically ill patients managed with a sedation protocol A pilot trial Critical Care Medicine 36(7) 2092-2099 httpdxdoiorg101097CCM0b013e31817bff85

Referencesbull Mehta S Burry L Cook D Fergusson D Steinberg M Granton J Meade

M (2012) Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol Journal of the American Medical Association 308(19) E1-E8 httpdxdoiorg101001jama201213872

bull Mendel P Weissbein D Weinberg D Farley D Baker D amp Kahn K (2011) Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety Longitudinal Program Evaluation of the HHS Action Plan to Prevent Healthcare‐Associated Infections Year 1 Report September 1 Retrieved from httphealthgovhcqpdfshhs-action-plan-eval-reportpdf

bull Mendez M Lazar M DiGiovine B Schuldt S Behrendt R Peters M amp Jennings J (2013) Dedicated multidisciplinary ventilator bundle team with compliance and sedation vacation American Journal of Critical Care 22(1) 54-59 httpdxdoiorg104037ajcc2013873

bull Miller A Bosk E Iwashyna T amp Krein S (2012) Implementation challenges in the intensive care unit The why who and how of daily interruption of sedation Journal of Critical Care 27 218e1-218e7 doi101016jjcrc201111007

bull Munro N Ruggiero M (2014) Ventilator-associated pneumonia bundle Reconstruction for best care Advanced Critical Care 25 (1) 163-175 httpdxdoiorg101097NCI0000000000000019

Referencesbull Quenot J Ladoire S Devoucoux F Doise J-M Cailliod R Cunin N

Aube H Blettery B Cahrles E (2007) Effect of a nurse-implemented sedation protocol on the incidence of ventilator associated pneumonia Critical Care Medicine 35(9)2031-9 httpdxdoiorg10109701ccm0000282733830894d

bull Roberts R deWitt M Epstein S Didomenico D amp Delvin J (2010) Predictors for daily interruption of sedation therapy A nursing prospective multicenter study Journal of Critical Care 25 660e1-660e7 doi101016jjcrc201003007

bull Sessler C Gosnell M Grap M Brophy G OrsquoNeal P amp Keane K (2002) The Richmond agitationndashsedation scale validity and reliability in adult intensive care unit patients American Journal of Respiratory and Critical Care Medicine 166 1338ndash1344 httpdxdoiorg101164rccm2107138

bull Stetler C Brunell M Giuliano K Morsi D Prince L amp Newell-Stokes V (1998) Evidence based practice and the role of nursing leadership Journal of Nursing Administration 28(78) 45-53

Referencesbull Tablan O Anderson L J Besser R Bridges C amp Hajjeh R (2003)

Guidelines for preventing health-care associated pneumonia 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee Retrieved from httpwwwcdcgovmmwrpreviewmmwrhtmlrr5303a1htm

bull U S Department of Health and Human Services Health Resources and Services Administration (HRSA) (2011) Quality Improvement Retrieved from httpwwwhrsagovqualitytoolbox508pdfsqualityimprovementpdf

bull Ventilation (2013) In A D Venes (Ed) Tabersrsquos cyclopedic medical dictionary (22nd ed pp 2319-2321) Philadelphia PA FA Davis

bull Zilbergerg M De Wit M amp Shorr A (2012) Accuracy of previous estimates for adult prolonged acute mechanical ventilation volume in 2020 Update using 2000-2008 data Critical Care Medicine 40(1) 18-20 httpdxdoiorg101097CCM0b013e31822e9ffd

bull Zilberberg M Luippold R Sulsky S amp Shorr A (2008) Prolonged acute mechanical ventilation hospital resource utilization and mortality in the United States Critical Care Medicine 36(3) 724-730 httpdxdoiorg101097CCM0B013E31816536F7