Intensive care unit staff at a U.S. hospital reported average ventilation time fell by nearly 50%, or almost two days, when they used a specific protocol.
The protocol combined three tools proven to shorten ventilation time, according to a study in the Spring issue of AACN Advanced Critical Care.
Staff at CHRISTUS Good Shepherd Medical Center, Longview, Texas, helped develop and study the protocol combining use of the awakening and breathing coordination, delirium monitoring/management and early mobility (ABCDE) bundle, along with the Critical-Care Pain Observation Tool (CPOT) to assess a patient’s pain levels and the Richmond Agitation-Sedation Scale (RASS), which measures sedation quality and depth.
They implemented the protocol in the medical center’s 34-bed ICU and found a 76.5% compliance rate among nursing staff.
ABCDE bundle implementation resulted in a significant decrease in ventilation time in all patients. Sedation time was also less than without ABCDE bundle implementation, but that finding was not significant.
“Of the 34 patients included in the post-intervention phase of the study, one required reintubation within 24 hours,” the authors wrote. “None of the remaining 33 patients were readmitted within 30 days of hospital discharge or re-intubated within 30 days of extubation.”
A nurse-driven protocol
Nurses are the most likely providers to care for ventilated patients, according to the study’s senior author Wesley Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, assistant professor, University of South Alabama College of Nursing, Mobile, Ala. “At this particular facility and at most facilities, the nurse is with the vented patient 24-7,” he said.
Respiratory therapists also help to manage these patients’ breathing, but there might be one respiratory therapist assigned to several floors. “Therefore, it’s primarily the nurse’s responsibility to maintain the patient’s breathing and respiration by the vent and by being the stand-in person until the respiratory therapist is able to arrive,” Davis said.
Nurses not only manage patients’ breathing by the vent but also manage the sedation that helps patients to breath, tolerate the vent and manage anxiety.
Reducing ventilation time is key
Optimal ventilation is clearly associated with reduced ventilator-induced lung injury. And proper management of the vent allows nurses and respiratory therapists to work together to ween patients off the vents early, according to Davis.
“We know that the longer patients stay on the vent, the more likely they are to get things like nosocomial sepsis or ventilator-associated infections, such as ventilator-associated pneumonia,” he said. “There’s also lung injury that comes from the pressure that’s being applied to the lungs from the vent.”
The goal for the nurse and ICU team is to understand how to best manage the ventilator, have protocols in place to ween patients as early as possible and prevent further harm, according to Davis.
“The vents are like a drug,” he said. “They’re not without side effects if they’re used incorrectly.”
The three tools in the bundle have been proven to work individually on vented ICU patients, according to Davis.
“Our particular study looked at what would happen if we combined some of our most common tools and combined the results to try to get patients off the vent earlier,” he said.
Davis and colleagues looked at the predominate issues that cause increased ventilation time for patients, including pain, agitation and delirium. They then looked for tools that addressed those.
“It’s important to point out that the big lesson here is not just the three tools that we looked at, but there’s always a benefit in combining these proven calculators and predictors — combining them together for a synergist effect, so to speak,” Davis said.
Co-author Jennifer Bardwell, DNP, FNP-C, AGACNP-BC, a nurse practitioner at CHRISTUS Good Shepherd Medical Center and Taylor Medical Center Urgent Care in Longview, said performing the CPOT assessment after finding high scores on the Richmond Agitation-Sedation Scale assessment often helped nurses identify signs of pain rather than agitation, which would have required increasing the sedative dose.
“The components of the ABCDE bundle provided critical care providers with steps to discontinue sedation and mechanical ventilation for patients as early as possible,” Bardwell said, according to an American Association of Critical-Care Nurses press release on the study.
It’s one thing to implement a protocol, but if nurses don’t feel like they’re adequately trained in using a protocol compliance can be an issue. Staff training is even more important during a pandemic like COVID-19, Davis said.
“During COVID, the ICUs are packed and overrun with patients,” he said. “You have nurses that don’t typically work in an ICU and don’t typically use these tools. They may try to use them, but if they use them incorrectly, they’re not going to get the desired result. You have nurses that are not typically used to weaning patients from a vent who are now tasked with that responsibility.”
Although Davis and colleagues conducted their study before COVID-19, only about three-quarters of nurses complied with the protocol. That’s low, he said.
“It’s the standard of care for them to use; they should be using it,” Davis said. “We expect it to be applied to 100% of patients across the board who are on a vent.”
Since conducting the study in 2018, Davis said he and colleagues have examined why nearly 25% of nurses opted out of the protocol. Most nurses said they simply didn’t feel comfortable using the bundle.
“In other words, it was a lack of education,” Davis said. “We rolled out a new educational plan to get higher compliance. I have to say that right now on our vented patients in the ICU we’re close to 95% compliance with using this bundle.”
Take these courses to learn more about ventilation:
Mechanical Ventilation and Weaning
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Promoting patient safety is paramount in caring for mechanically ventilated patients. Patients who require mechanical ventilation for more than three days are at an increased risk to develop complications, prolonged length of stay in the ICU, ventilator dependence, and death. The nurse and other healthcare professionals must understand current modes and settings of ventilation, exercise-appropriate assessment, ventilation management skills, and safe and successful weaning techniques.
Noninvasive Positive Pressure Ventilation Requires Healthcare Team Spirit
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Noninvasive positive pressure ventilation (NPPV) provides an exciting alternative to invasive methods of managing ventilation. Used in appropriate patients, NPPV provides advantages for patients versus endotracheal intubation. NPPV can also be used as a mode to support the patient moving to a transitional care environment for continued care. This module will discuss NPPV and the educational needs of clinicians and patients using this therapy.
Providers Can Help Zap VAP
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Ventilator-associated pneumonia is an infection of the lungs that occurs after intubation and mechanical ventilation. Evolving definitions of VAP and data reporting create variability for statistical comparisons. VAP occurs in 9% to 27% of patients receiving mechanical ventilation and is the most common nosocomial infection among mechanically ventilated patients. This CE activity provides nurses, pharmacists, and respiratory therapists with information about VAP: its prevalence, pathogenesis, risk factors, diagnosis, management, and prevention.