Liberating Patients from Mechanical Ventilation Sooner
HBR.org 2013-11-07
At the Mayo Clinic, we implemented sedation-weaning and ventilator-weaning protocols and a color-coded communications scheme in the ICU in an effort to more quickly identify mechanically ventilated patients who were able to be awakened and breathe on their own.
The Challenge
Timing is everything, but for critically ill patients on a mechanical ventilator (MV), or breathing machine, it’s the only thing. We know that the earlier we liberate patients from the MV, the better — it reduces the rate of mortality — but premature extubation can lead to a host of other problems. The key is to correctly and quickly identify mechanically ventilated patients who are able to breathe on their own.
The Solution
A spontaneous breathing trial (SBT), during which a patient is temporarily weaned from the MV on a daily basis, has become standard practice; however, a spontaneous awakening trial (SAT), which involves daily interruption of a patient’s sedation, has been shown to reduce the amount of time a patient remains on the MV. Although the use of the SAT or SBT alone can decrease the length of time a patient is on the MV, the pairing of the two protocols could reduce the mortality rate more than the use of SBT alone. We explored the combined use of the SAT sedation-weaning protocol and the SBT ventilator-weaning protocol in our ICU.
Because our providers acknowledged an association between the SAT and SBT, we also conducted a survey to determine the reason the combined protocols were not yet integrated in our ICU. We surveyed 196 of our providers, including ICU registered nurses (RNs), respiratory technicians, and physicians, and recorded 87 responses. Communication problems (27%) were the most cited barrier — medical team daily work schedule (24%), unit staffing (21%), and physician availability (21%) encompassed 93% of the total reported barriers.
The Implementation
The protocol was implemented between November 2011 and May 2012. To improve communication among ICU staff, my colleagues and I added a communication scheme with color-coded signal cards that are posted at the patient’s bedside.
Card 1: A for “Awake”
Card 2: AB for “Awake and Breathing”
When a patient passed the SAT, an RN posted the A card. If the same patient also passed the SBT, a respiratory technician replaced the A card with the AB card, which indicated to the ICU team that the patient was ready for extubation.
The Evidence
Before we instituted the SAT and SBT protocols and color scheme program, 46% of our providers acknowledged an association between SAT and SBT. After adopting the program, the providers’ perception of an association between the SAT and SBT increased by 14%.
We should note that we did not collect patient outcomes data — this project was designed only to improve our compliance with the SAT and SBT protocols, which have been proven to be beneficial. Future investigations need to be performed to observe patient outcomes.
The Next Steps
We believe this intervention improved communication among our ICU staff and further linked the SAT and SBT in the minds of our providers. As a result, this protocol has become the standard of care in our ICU. Further stakeholder deployment of social marketing, which combines marketing concepts with research and best practices to influence behavior for greater social good, is a good path to improving communication among providers. In an era of increasing costs, similar inexpensive interventions can be effective for multidisciplinary team building, patient safety, and improved outcomes.
Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us at healtheditors@hbr.org, and sign up to receive updates here.
