Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning

• Published in: American journal of respiratory and critical care medicine Vol. 159; no. 2; pp. 439 - 446
• Main Authors: ELY, E. W, BENNETT, P. A, BOWTON, D. L, MURPHY, S. M, FLORANCE, A. M, HAPONIK, E. F
• Format: Journal Article
• Language: English
• Published: New York, NY American Lung Association 01.02.1999
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Clinical Protocols; Emergency and intensive respiratory care; Female; Follow-Up Studies; Humans; Intensive care medicine; Interprofessional Relations; Male; Medical sciences; Middle Aged; Organizational Innovation; Patient Care Planning; Practice Patterns, Physicians; Prospective Studies; Respiratory Insufficiency - therapy; Respiratory Therapy - methods; Surveys and Questionnaires; Treatment Outcome; Ventilator Weaning; Human; Program; Weaning; Physician; Respiratory intensive care; Implantation; Application method; Artificial ventilation; Mechanical ventilation; Result
• ISSN: 1073-449X; 1535-4970
• DOI: 10.1164/ajrccm.159.2.9805120

We prospectively investigated the large-scale implementation of a respiratory-therapist-driven protocol (TDP) that included 117 respiratory care practitioners (RCPs) managing 1,067 patients with respiratory failure over 9,048 patient days of mechanical ventilation. During a 12-mo period, we reintroduced a previously validated protocol that included a daily screen (DS) coupled with spontaneous breathing trials (SBTs) and physician prompt, as a TDP without daily input from a physician or "weaning team." With graded, staged educational interventions at 2-mo intervals, RCPs had a 97% completion rate and a 95% correct interpretation rate for the DS. The frequency with which patients who passed the DS underwent SBTs increased throughout the implementation process (p < 0.001). As the year progressed, RCPs more often considered SBTs once patients had passed a DS (p < 0.001), and physicians ordered more SBTs (46 versus 65%, p = 0.004). Overall, SBTs were ordered more often on the medicine than on the surgical services (81 versus 63%, p = 0.001), likely reflecting medical intensivists' prior use of this protocol. Important barriers to protocol compliance were identified through a questionnaire (89 respondents, 76%), and included: Physician unfamiliarity with the protocol, RCP inconsistency in seeking an order for an SBT from the physician, specific reasons cited by the physician for not advancing the patient to a SBT, and lack of stationary unit assignments by RCPs performing the protocol. We conclude that implementation of a validated weaning strategy is feasible as a TDP without daily supervision from a weaning physician or team. RCPs can appropriately perform and interpret DS data more than 95% of the time, but significant barriers to SBTs exist. Through a staged implementation process, using periodic reinforcement of all participants in ventilator management, improved compliance with this large-scale weaning protocol can be achieved.