successful ventilator weaning: a collaborative effort

4
Perspectives SUCCESSFUL VENTILATOR WEANING: A COLLABORATIVE EFFORT Suzanne Rogers, MA RN CRRN CNA-A Martha Ryan, AS RN Lawrence Slepoy, AS RCP RRT Teamwork can be successfully im- plemented. Rehabilitation nurses played a central role as our interdisciplinary staff worked together to improve our facili- ty's approach to weaning medically com- plex patients from the ventilator. Ventilator weaning is a difficult task that involves many variables. It cannot be accomplished alone-it takes en- couragement, endurance, and coaching, as well as the support and example of others. By working together, our facili- ty designed an educational format, a team structure, and a set of intermediate goals that helped patients and staff focus on the progressive steps needed for dis- charge. As a result of our collaborative effort, patient outcomes have improved and we have identified further areas for making improvements. A case study Consider the case of Mr. P., who was admitted to our hospital with a diagno- sis of "failure to wean." In fact, he was dependent on a ventilator for his every breath. But his eyes and his attitude re- vealed more than that. They seemed to say, "What's the use? I can't do this." When asked a question, Mr. P would shrug, look at the wall, or close his eyes. Of course, Mr. P.'s other problems also contributed to his difficulties with weaning. He had a poor nutritional state, underlying sleep apnea, a body weight of more than 350 lbs, diabetes, hyper- tension, poor bed mobility, and-not un- related to all of this-the beginning of a sacral pressure ulcer. Most of all, Mr. P.'s spirit was broken. He had failed several prior attempts to wean and was still un- able to breathe on his own. He was de- moralized, profoundly anxious, and more than a little skeptical that weaning was even possible for him. Two months later, however, Mr. P. walked out of our facility with the help of a cane. He was free of the ventilator and decannulated, his skin was intact, and he was 50 lbs lighter. He continued rehabilitation to increase his endurance, but his confident smile and the look in his eyes said, "I can do this." Mr. P. is an example of a patient who had real difficulty weaning from a ven- tilator in a short-term acute hospital set- ting due to his underlying chronic lung disease, weight, and a complicated med- ical history. At our long-term acute fa- cility, we specialize in the care and restoration to health of these challenging patients. Most of our patients come to us from ICUs in the Boston metropolitan region. Those admitted with a "failure to wean" diagnosis also have multiple underlying chronic medical conditions. Many are older people who lack proper nutrition and family and social support. They have had surgery or some critical medical event that placed them temporarily on a ventilator. However, once their acute medical or surgical event begins to re- solve, their progress slows. They often fail at initial attempts to wean from the ventilator, and they may begin to present more complex discharge issues. Examining the program Our ventilator weaning program had been in place for several years; howev- er, as we examined our program, we identified some new strategies that could improve patient outcomes. As a result of this improvement process, we have cre- ated a stronger interdisciplinary approach that has worked well, decreased the num- ber of days patients spend on the venti- lator, and increased the percentage of pa- tients who wean from the ventilator and go home. Three major strategies were central to this improvement project: the creation of a dedicated team of healthcare profes- sionals, the education and preparation of the team, and the deliberate structuring of the program to respond to each pa- tient's expected progress. Creating a dedicated team We determined that interdisciplinary, closely coordinated care is essential for a program dedicated to weaning patients from the ventilator. While we recognized and honored the specialized skills each healthcare professional brings to patient care, we also agreed that we must plan and work together as a team of skilled professionals, each of whom knows what the others are doing. We recognized that nurses, respirato- ry therapists, and rehabilitation therapists all needed to assign the same staff mem- bers to work with the same patients on a routine basis. This would enable each caregiver to know each of the other mem- bers of the patient's team. And when the same professionals worked with each other regularly, they would know who to call and whose assessments to rely on. Then, we wanted to avoid the follow- ing types of situations: the nurse calling the respiratory therapist when a patient needed to be suctioned, the respiratory therapist attempting a wean even though the patient had had a poor night's sleep, or the rehabilitation therapist scheduling a treatment time during the first few days of weaning. We resolved to all be on the same page-the patient's page. Each day, the plan of care would provide for the pa- tient's primary need for that particular day. Consistency and communication be- came our passwords. To accomplish these goals, several members of the interdisciplinary team met to brainstorm ideas. We included staff and managers from nursing, respi- ratory therapy, education, pulmonary medicine, social services, psychology, and discharge planning. We drew on our Rehabilitation Nursing> Volume 23. Number Sep/Oct 1998265

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Page 1: Successful Ventilator Weaning: A Collaborative Effort

Perspectives

SUCCESSFUL VENTILATOR WEANING:

A COLLABORATIVE EFFORT

Suzanne Rogers, MA RN CRRN CNA-AMartha Ryan, AS RNLawrence Slepoy, AS RCP RRT

Teamwork can be successfully im­plemented. Rehabilitation nurses playeda central role as our interdisciplinary staffworked together to improve our facili­ty's approach to weaning medically com­plex patients from the ventilator.

Ventilator weaning is a difficult taskthat involves many variables. It cannotbe accomplished alone-it takes en­couragement, endurance, and coaching,as well as the support and example ofothers. By working together, our facili­ty designed an educational format, ateam structure, and a set of intermediategoals that helped patients and staff focuson the progressive steps needed for dis­charge. As a result of our collaborativeeffort, patient outcomes have improvedand we have identified further areas formaking improvements.

A case studyConsider the case of Mr.P., who was

admitted to our hospital with a diagno­sis of "failure to wean." In fact, he wasdependent on a ventilator for his everybreath. But his eyes and his attitude re­vealed more than that. They seemed tosay, "What's the use? I can't do this."When asked a question, Mr. P wouldshrug, look at the wall, or close his eyes.

Of course, Mr. P.'s other problemsalso contributed to his difficulties withweaning. He had a poor nutritional state,underlying sleep apnea, a body weightof more than 350 lbs, diabetes, hyper­tension, poor bed mobility, and-not un­related to all of this-the beginning of asacral pressure ulcer. Most of all, Mr.P.'sspirit was broken. He had failed severalprior attempts to wean and was still un­able to breathe on his own. He was de­moralized, profoundly anxious, and morethan a little skeptical that weaning waseven possible for him.

Two months later, however, Mr. P.walked out of our facility with the help

of a cane. He was free of the ventilatorand decannulated, his skin was intact,and he was 50 lbs lighter. He continuedrehabilitation to increase his endurance,but his confident smile and the look inhis eyes said, "I can do this."

Mr.P. is an example of a patient whohad real difficulty weaning from a ven­tilator in a short-term acute hospital set­ting due to his underlying chronic lungdisease, weight, and a complicated med­ical history. At our long-term acute fa­cility, we specialize in the care andrestoration to health of these challengingpatients.

Most of our patients come to us fromICUs in the Boston metropolitan region.Those admitted with a "failure to wean"diagnosis also have multiple underlyingchronic medical conditions. Many areolder people who lack proper nutritionand family and social support. They havehad surgery or some critical medicalevent that placed them temporarily on aventilator. However, once their acutemedical or surgical event begins to re­solve, their progress slows. They oftenfail at initial attempts to wean from theventilator, and they may begin to presentmore complex discharge issues.

Examining the programOur ventilator weaning program had

been in place for several years; howev­er, as we examined our program, weidentified some new strategies that couldimprove patient outcomes. As a result ofthis improvement process, we have cre­ated a stronger interdisciplinary approachthat has worked well, decreased the num­ber of days patients spend on the venti­lator, and increased the percentage ofpa­tients who wean from the ventilator andgo home.

Three major strategies were central tothis improvement project: the creation ofa dedicated team of healthcare profes-

sionals, the education and preparation ofthe team, and the deliberate structuringof the program to respond to each pa­tient's expected progress.

Creating a dedicated teamWe determined that interdisciplinary,

closely coordinated care is essential fora program dedicated to weaning patientsfrom the ventilator. While we recognizedand honored the specialized skills eachhealthcare professional brings to patientcare, we also agreed that we must planand work together as a team of skilledprofessionals, each ofwhom knows whatthe others are doing.

We recognized that nurses, respirato­ry therapists, and rehabilitation therapistsall needed to assign the same staff mem­bers to work with the same patients on aroutine basis. This would enable eachcaregiver to know each of the other mem­bers of the patient's team. And when thesame professionals worked with eachother regularly, they would know who tocall and whose assessments to rely on.

Then, we wanted to avoid the follow­ing types of situations: the nurse callingthe respiratory therapist when a patientneeded to be suctioned, the respiratorytherapist attempting a wean even thoughthe patient had had a poor night's sleep,or the rehabilitation therapist schedulinga treatment time during the first few daysof weaning. We resolved to all be on thesame page-the patient's page. Each day,the plan of care would provide for the pa­tient's primary need for that particularday. Consistency and communication be­came our passwords.

To accomplish these goals, severalmembers of the interdisciplinary teammet to brainstorm ideas. We includedstaff and managers from nursing, respi­ratory therapy, education, pulmonarymedicine, social services, psychology,and discharge planning. We drew on our

Rehabilitation Nursing> Volume 23. Number 5· Sep/Oct 1998265

Page 2: Successful Ventilator Weaning: A Collaborative Effort

Figure 1. CRICUEducational ProgramTopics

Note. These classes are taught by staff members in collaboration with the CRICU EducationPlanning Committee. Each program offers continuing education credit. Selected self-studyprograms are available by contacting the education coordinator.

Trachs: Different kinds, different care needsUnderstanding blood gasesThe patient with COPD and blood gas disturbancesPhysical assessment for nurses and respiratory therapistsKnowing what you are seeing: Important observations for CNAsPneumonia: The benefits of nutritional interventions for outcomesUnderstanding EKGs: A two-part series (1 hour for each part)Weaning the ventilated patient who is receiving dialysisCardiopulmonary lecture: A case study

wide range of experiences to identify theneeds of these patients. We determinedthat our patients typically need dailymedical attention; management of nutri­tional status; attention to skin integrity;bowel and bladder management; man­agement of secretions and ventilator set­tings; assistance with communication,swallowing, mobility, activities of dailyliving (ADLs); and help in dealing withfeelings of frustration, anger, and lone­liness. Patients and their families alsoneed support and education.

During this brainstorming session, wetalked about the patient's needs, notabout each discipline's scope of service.We drafted a vision statement-a brief,nontechnical description of the ideal pro­gram within the continuum of care. Thenwe began planning for the best way toshare and implement this vision.

Getting startedOnce we agreed on a basic descrip­

tion of our program, we reviewed thedata we already had to determine bench­marks for later improvements. Our car­diopulmonary department had main­tained a database of patient outcomes inrelation to respiratory status, successfulweans, and eventual discharge. During1996, we provided care for 57 ventilat­ed patients. In the course of that year, wehelped 19 of those patients wean fromthe ventilator and discharged 14 of themto their homes. The other 5 patients wereweaned from the ventilator and dis­charged to nursing homes. While thesestatistics are by no means impressive,they were a starting point.

To better allocate resources, we de­cided to cluster patients according to spe­cific categories. We began by placing allnon-ICU patients who Were ventilator­dependent on the same cardiorespirato­ry intermediate care unit (CRICU). Weunderstood that not all staff memberswould want to work on this unit everyday, so we selected staff who had a par­ticular interest in this area.

Perspectives

We recognized that all caregivers hadto be aware of the new vision of care andthat they also had to be trained in the ad­ditional skills required to care for thesepatients. Then we created a staffing andcare delivery system that clustered thesame set of interdisciplinary caregiverswith the same patients. We called this ourprimary team model.

Educating the teamNext, we worked together to design

training modules for all staff, includingRNs, LPNs, CNAs, physicians, respira­tory therapists, physical therapists, oc­cupational therapists, speech-languagepathologists, swallowing specialists,pharmacists, dietitians, social workers,psychologists, and case managers.Everyone was involved in identifyingcontent, attending or presenting classes,and evaluating the usefulness of theclasses. One-hour educational sessionswere given on the unit and were pre­sented by staff members who volun­teered to teach specific topic areas. Thecurriculum continues to evolve as we de­velop greater expertise and as new staffjoin the program (see Figure1).

Structuring the programAs we developed this program, we

found that we wanted to move patientsalong a continuum even within our fa-

cility. Thus we deliberately structuredthe program to respond to the patient'sexpected progress. Patients are admittedfirst to our ICU, where we establish theirmedical stability and familiarize themwith the program. Some patients also be­gin weaning from the ventilator at thispoint; however, the standard plan is toprepare them to move to the CRICU,where most of the weaning is carried out.

As patients successfully maintain in­dependent ventilatory efforts off the ven­tilator, they are transferred to the Central2 Unit, a less intense unit where staff pre­pare patients for discharge. This unit'sstaff focus on teaching ADLs, increasingpersonal responsibility for learning, andgetting the family involved. Prior to thisphase of care, there is too much work re­lated to ventilator weaning to be done andpatient anxiety is too high to add dis­charge teaching to the mix of tasks.

Our original plan called for movingpatients to this less intense unit in orderto reduce the possibility of infections;however, we found that patients re­sponded positively to this move-it gavethem a sense of graduating. Once on thisunit, they are expected to be more mo­bile and can focus their energy on plan­ning to go home, surrounded by otherswho are doing the same. We now use thisgraduation terminology when preparingpatients for this move.

266 Rehabilitation Nursing > Volume 23, Number 5· Sep/Oct 1998

Page 3: Successful Ventilator Weaning: A Collaborative Effort

Getting patients through this contin­uum is truly a matter of highly individ­ualized care. There is no magic formulaor protocol other than assessing the pa-

Perspectives

tient's responses to interventions, com­paring assessments across disciplines,and helping the patient see that we are aunified team focused on our goals. We

pay attention to all team members' as­sessments on an ongoing basis. And welisten to the patient's own assessment ofhis or her progress.

Figure 2. VencorHospitaI-Boston's North Shore VentilatorWeaningClinical Staircase

Anticipated Outcome forPatient with Underlying COPD:Discharge home, off ventilator (from admission at ICU Level to CRICU discharge)

Intermediate Outcome DischargeExpectationAspect of Care Specific Interventions Done (Ready for CRICU) Met (Readyfor Central2 Unit)

Functional health • Prehospital status • Expected level of assistance at • Able to begin retraining ofstatus • All assessments within discharge identified basic ADL functions at pre-

48 hours • Initial discharge plan agreed to hospital levelby patient and family • Medically stable

Nursing needs • Assessment of skin • Skin intact • Skin intact, bowel regimencare needs and resting • Special resting surface effective, able to performsurfaces, medication • Bowel regimen identified and transfers to and from bedregime, bowel protocol effective or commode with minimal

• Baseline medical problems stable assistance, oriented,participates in self-care

Respiratory status • Baseline ABGs, EKG, • Patient beginning trach collar • Trach collar: Tolerating offsputum culture, ventila- wean up to 2 hours a day, on ventilator for 48-72 hourstor settings, number of night ventilation • Normal pulse and whiteprevious weans • Secretions managed with suction- blood cell count, chest clear

ing 3 times a day• Pulse oximetry at 90%-95%

white blood cell count withinnormal limits

Patient and family • Expectations • Home evaluation • Education begun concerningteaching • Contact person • Informal daily contact with home preparation: Medica-

caregivers: Information about tions, respiratory needs atprogress, medical needs home, pacing, lifestyle

Rehabilitation • Assessment of patient • Patient able to transfer out of bed • Able to participate in low-therapies (e.g., phys- goals with minimal assistance, tolerate intensity daily therapy,ical, occupational, • Swallowing evaluation sitting up to 4 hours a day beginning ambulation withspeech) • Direct supervision of meals respiratory equipment

Nutrition • Recent albumin or • Adequate caloric and nutritional • Eating modified diet withprealbumin intake distant supervision

• Caloric needs • Adequate oral intake

Discharge planning • Psychosocial assessment • Focus on necessary intermediate • Daily teaching and focus• Community support goals, ventilator weaning, transi- on community reentry

services tion to Central 2 Unit preparation

Variance/change inplan

Rehabilitation Nursing> Volume 23, Number 5· Sep/Oct 1998 267

Page 4: Successful Ventilator Weaning: A Collaborative Effort

Perspectives

We drafted a description ofthe idealprogramwithin the continuum ofcafe and made plans

to share and implement this vision.

Measuring outcomes:Does it work?

A comparisonof thefirst6 monthsof1996with the first6 monthsof 1997un­derscores the success of this approach.From January to June 1996, we dis­charged 4 patients home who had beenweanedfrom the ventilator. In the same

time period in 1997, we discharged 13patients.The percentageof patientswhowere weaned off the ventilator and dis­charged home increased from 12% in1996 to 50% in 1997.Another measureof successcan be foundin thedecreasedaverage numberof daysrequiredto weana patient from the ventilator-this num­ber dropped from 38 days in 1996 to 27days in 1997.

We are now designing a clinical"staircase" for these patients, as a wayto predict patient needs, progress, andgoals (seeFigure 2). Wedefinedthe fol­lowing seven major aspects of patients'care needs from admissionto dischargeandalsoallowedspaceto documentvari­ances in and changes to the plan:

• functional health status• nursing needs• respiratory status• patient and family teaching• rehabilitationtherapies• nutrition• dischargeplanning

Each of these categorieshas its own dis­charge goals and corresponding inter­mediate goals. The intermediate goalsindicate patients' readiness to progressto less complex settings and then to re­turn home. The intermediate goals also

provide each discipline with an oppor­tunityto plan,coordinate, andfocuscare.

This typeof designis differentfrom aclinicalpath, in whichmany of the care­giving activities are identified to reachpredetermined outcomesin a predictableperiod of time. In our plan, intermediateand even dischargegoals may be modi-

fiedbasedon thepatient'sprogressand ex­pectations. Tomakechangestogoals, the pa-tient,family, and

entire teammust be involved. Weevalu­ate each patient'sprogresson a dailyba­sis, adjustingventilatorsettings,extend­ing weaning times, monitoring pulseoximetry, assessing levelsof anxietyandstress, and sharingour assessmentswiththe team and the patient.

We use understandable, concreteterms to explain to patients and familiestheprogressthathasbeenmadeandwhatwe expect, so that the patient may be­come free of the ventilator and returnhome. Our clinicalstaircaseis goal-spe­cificbutnot time-specific. It helpsus de­scribe to patients, families, physicians,caregivers, and case managers what toexpect in this program.So far, however,we havenotbeenableto predicton a dai­ly or evena weeklybasishowlongit willtake each patientto progress,what com­plicationsmayarise,or whatadaptationswill be necessary.

Making a differenceManaged care has prompted all

healthcare professionals to ask and an­swer the question, "How do you knowwhen the patient is ready?" By showingexternal case managersour plan, we areable to share our general expectationsand to show the specific intermediate

goals we are planning.While we cannotpredict the total time it will take any pa­tient to completethe weaningprocess oreven which patients will succeed, ourplanhasprovideda kindof roadmap.Aspatients achieve specific intermediateoutcomes, we are better able to predicthowmuch longer it will takefor them toreach their dischargegoal.

Havewe madea difference? We thinkso. Ask Mr. P.,who is now at home andfree from the ventilator. Ask our staff,who now must be selected from a wait­ing list to workon our unit. Ask the areavisiting nurses and external case man­agers who follow these patients and tellus how well theydo. Weare a team, andgoal-oriented teamworkdoesmakea dif­ference.

All ofthe authors are affiliated with Ven­cor Hospital-Boston's North Shore inPeabody, MA. Suzanne Rogers is the di­rector ofnursing, Martha Ryan isa nursemanager ofcritical care, and LawrenceSlepoy is the manager of cardiopul­monary care. Address correspondence toSuzanne Rogers, MA RN CRRN CNA-A,Vencor Hospital-Boston 's North Shore,15 King Street, Peabody, MA 01960.

AcknowledgmentThe authorsacknowledge the support

of Della Underwood, RN, Administra­tor, Vencor Hospital-Boston's NorthShore.

Editor's noteThis article is based on a paper pre­

sentation thatwasgivenat the 1997ARNAnnualEducationalConferencein Bal­timore.

268 Rehabilitation Nursing' Volume 23, Number 5· Sep/Oct 1998