Mechanical Ventilator Protocols

Positive patient outcomes related to mechanical ventilator weaning protocols are leading to shortened ventilator stays, safe extubations, and cost savings to the participating institute

During the course of the past decade, the use of respiratory care-driven protocols in the hospital setting has grown to a well-accepted standard of care. Promoted to help control accelerating medical expenses, respiratory protocols are largely of economic origin. By tailoring respiratory therapies to assessed patient needs, reductions in unnecessary care and corresponding costs were realized.¹ Less tangible, but no less valuable to the team concept of multidisciplined medicine, respiratory protocols have enhanced communications and fostered closer relationships between respiratory care staff and the accompanying nurse and physician services.² Brought together, the protocol experiment debuted a new asset to the field of respiratory care. Most important, these successes have been achieved without measurable changes in patient morbidity or mortality.³

To date, approximately 98% of RCPs are currently employing some form of protocol program within their daily care plan. Indeed, respiratory care-driven protocols represent the most far-reaching of allied health protocol systems.⁴

The majority of established protocol policies encompass noncritical patient assessments and therapy implementations. Nevertheless, respiratory protocols are now quickly evolving into the critical care arena. The goals remain the same, but the needs may be even greater. As the direct costs of health care increase at almost twice the rate of inflation in this country, the costs attributed to the intensive care unit (ICU) are rising even faster. While only 6.3% of hospital beds in the United States are committed to the ICU, 22% of an average hospital’s total cost is generated by these same ICUs.⁵

Managing Ventilated Patients
Of particular concern to critical care medicine is the extraordinary expense of managing patients on mechanical ventilation. Patients requiring ventilation are often the most debilitated and the burden of cost rapidly mounts when the need for life support is prolonged. Many such patients are eventually bound to intensive care not necessarily by their afflictions or disorders, but by use of the ventilator. This is particularly true of institutions that are lacking sufficient “step-down” units or facilities. Yet, regardless of the care environment occupied, mechanical ventilation remains a costly venture.

Clinically, the ability to stabilize the respiratory status of a mechanically ventilated patient is often easier than weaning, which is also know as “liberation” from the ventilator.⁶ Difficulty in weaning a patient from the ventilator has been reported in as many as 20% of all mechanically ventilated patients.⁷ Even when successful, the average weaning time consumes approximately 40% of the total ventilatory time.⁸ Any practice capable of reducing the weaning time without increasing complications will ultimately decrease ventilator days and the exceptional related costs. Using RCPs in a central role, mechanical ventilation protocols are proving worthy of the weaning challenge with positive results, though few objective works appear in medical literature.⁹

From complex algorithms to flexible guidelines so concise as to fit on a single page, the trend of developing ventilator weaning protocols to meet the individual requirements of a given hospital is hardly unusual. To date, there is no universal agreement among clinicians as to the best means of ventilator management, and no particular mode of ventilation has proved superior.¹⁰

To take the population of mechanically ventilated patients as a whole, no exacting procedure has proved feasible for all weaning situations. Many criteria, indexes, and charts of predictions have been designed for the purposes of weaning without any specific policy surpassing another. As a result, clinicians routinely construct ventilator and weaning protocols personally deemed to be the best. What is becoming clear is that a mechanical ventilator protocol based on a multidisciplinary approach consistently reduces ventilator days. It now appears that the decision to use a weaning protocol may be more decisive to success than the actual choice of any particular plan.¹¹

Advantages of Protocols
The advantage of mechanical ventilation weaning protocols over traditional weaning strategies seems related to a heightened consistency of care and the ability to exercise opportunities for early liberation from life support. Formal weaning standards promote consistency by coordinating the efforts of physicians, nurses, and RCPs into a common direction. With respiratory care services leading the protocol process, decreased weaning times and earlier extubations have been recognized against more traditional, physician-directed techniques.¹²

Such findings are explained by the observation that as individuals, physicians often pursue a more conservative approach to weaning. The duration of time spent on life support is thereby lengthened on the premise that the managing physician is not always aware of a patient’s immediate chance to wean.¹

Mechanical ventilation weaning protocols are most commonly found within the ICU, where respiratory failure patients are responsible for the highest direct costs among the critically ill.¹ Interestingly, the manner by which weaning protocols are employed in the ICU is in sharp contrast to the traditional respiratory care-driven protocol methods for noncritical, general floor assessments and therapies. While floor-centered protocols are usually initiated and implemented by RCPs under a given set of guidelines, ventilator management and weaning policies are much more likely to include a multidisciplinary team approach.² Indeed, many facilities have fostered a weaning team image to signify a concerted weaning system including the patient’s nurse, physician, and respiratory therapist.¹³

Though objective results of mechanical ventilator weaning protocols are infrequently published, the literature does reveal successful conclusions. Obviously, the success of any protocol program must first be based on whether patient care was improved by the action. Although cost containment is key to gaining widespread support for the protocol cause, no success can be declared short of benefiting the patient’s outcome.

The means of publishing the conclusions of reporting institutions can be as selective as the protocols that achieved them. Reduced ventilator time responses to standardized weaning criteria have been accounted for in days or hours, or by the direct and indirect costs associated with such care.

Cost Savings
Wholesale cost savings vary between institutes and are largely dependent on the size of the patient populations selected for measurement. Consistently, however, patient time spent on the ventilator using weaning protocols is notably less than the control average of the given facility.

Some hospitals also define protocol success by recognizing reductions in patient complications related to being supported by mechanical ventilation. Such complications include stress ulcers, impaired mobility leading to deep venous thrombosis, and, most prominent, ventilator-associated pneumonia.¹⁴

The need to reintubate patients removed from the ventilator and extubated under weaning protocols commonly compares to experiences using more traditional weaning strategies. In only one review did protocol-directed weaning increase the possibility of reintubation and a return to mechanical ventilation, yet these differences were not considered statistically significant.¹⁵

Positive patient outcomes related to mechanical ventilator weaning protocols are leading to shortened ventilator stays when compared to physician-directed strategies, and are being concluded with safe extubations¹⁶ combined with real cost savings to the participating institute. The future of the weaning protocol concept may next evolve into the intermediate or postanesthesia areas.¹⁷

John Edward Scaggs, RRT, is clinical supervisor at Memorial Medical Center, Springfield, Ill.

References
1. Stoller JK. Why therapist-driven protocols? A balanced view. Respiratory Care. 1994;39:706-708.
2. Shrake KL, Scaggs JE, England KR, Henkle JQ, Eagleton LE. Benefits associated with a respiratory care assessment-treatment program: results of a pilot study. Respiratory Care. 1994;39:715-724.
3. Shrake KL, Scaggs JE, England KR, Henkle JQ, Eagleton LE. A respiratory assessment-treatment program: results of a retrospective study. Respiratory Care. 1996;41:703-713.
4. Op’t Holt TB. Donald F. Egan lecture: Are RTs effective? Examining the evidence. AARC Times. 2001;25:42-75.
5. Silver MR. Cost of care in the intensive care unit. Clinical Pulmonary Medicine. 1999;6:41-51.
6. Manthous CA, Schmidt GA, Hall JB. Liberation from mechanical ventilation. Critical Care. 1998;114:886-901.
7. Saura P, Blanch L, Mestre J, Valles J, Artigas A, Fernandez R. Clinical consequences of the implementation of a weaning protocol. Intensive Care Medicine. 1996;22:1052-1056.
8. Kupfer Y, Tessler S. Weaning the difficult patient: the evolution from art to science. Chest. 2001;119:7-9.
9. Durbin CG Jr. Therapist-driven protocols in adult intensive care unit patients. Respiratory Care Clinics of North America. 1996;2:105-116.
10. Cohen IL. Weaning from mechanical ventilation—the team approach and beyond. Intensive Care Medicine. 1994;20:317-318.
11. Koller MH, Horst HM, Brock WA. Reducing the duration of mechanical ventilation: three examples of change in the intensive care unit [abstract]. New Horizons. 1998;6:52-60.
12. Horst HM, Mouro D, Hall-Jenssens RA. Decrease in ventilation time with a standardized weaning process. Arch Surg. 1998;133:483-438, 488-489.
13. Kupfer YY, Wietschner T, Newman B. The wean team: a successful approach to weaning [abstract]. Chest. 1993;104:S49.
14. Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. 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. 2000;118:459-467.
15. Koller MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25:567-574.
16. Wood G, MacLeod B, Moffatt S. Weaning from mechanical ventilation: physician-directed vs a respiratory-therapist-directed protocol. Respiratory Care. 1995;40:219-224.
17. Stoller JK, Kester L. Respiratory care protocols in postanesthesia care [review]. Journal of Perianesthesia Nursing. 1998;13:349-358.

Additional Reading
Blackwood B. The art and science of predicting patient readiness for weaning from mechanical ventilation [abstract]. International Journal of Nursing Studies. 2000;37:145-151.

Burns SM. Making weaning easier. Pathways and protocols that work. Critical Care Nursing Clinics of North America. 1999;11:465-479.

Burns SM, Ryan B, Burns JE. The weaning continuum use of acute physiology and chronic health evaluation III, Burns wean assessment program, therapeutic intervention scoring system, and wean index scores to establish stages of weaning. Crit Care Med. 2000;28:2259-2267.

Butler R, Keenan SP, Inman KJ, Sibbald WJ, Block G. Is there a preferred technique for weaning the difficult-to-wean patient? A systematic review of the literature. Crit Care Med. 1999;27:2331-2336.

Koh Y, Hong SB, Lim CM, et al. Effect of an additional 1-hour T-piece trial on weaning outcome at minimal pressure support [abstract]. J Crit Care. 2000;15:41-45.

Leitch EA, Moran JL, Grealy B. Weaning and extubation in the intensive care unit—clinical or index-driven approach? Intensive Care Medicine. 1996;22:752-759.

Monroe SW, Zibrak JD, Benotti MD, Silvestri RC, MacDonald GF. Impact of a multidisciplinary weaning service on morbidity, mortality, and critical care resource utilization in ventilator dependent patients. Chest. 1991;100:S79.

Rady MY, Ryan T. Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery. Crit Care Med. 1996;27:340-347.

Scheinhorn DJ, Chao DC, Stearn-Hassenpflug M, Wallace WA. Outcomes in post-ICU mechanical ventilation. A therapist-implemented weaning protocol. Chest. 2001;119:236-242.

Wesley EE, Bennett PA, Bowton DL, Murphy SM, Allison FM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Amer J Respir Crit Care Med. 1999;159:439-446.