Up, Up, And Away…With Mechanical Ventilation

Project Topic:

Standardizing Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) in the Medical and Surgical Intensive Care Units

Hospital, City and State:

Seattle Veterans Affairs Medical Center, VA Puget Sound Healthcare System, Seattle, Washington

Unit:

Medical Intensive Care Unit (MICU) and Surgical Intensive Care Unit (SICU)

CSI Participants:

• Diana Chudak, BSN, RN
• Maliah Haroldson, BSN, RN, CCRN
• Tammy Sol, BSN, RN, CCRN

Project Goals/Objectives:

1. Increase AACN Healthy Work Environment Assessment Tool (HWEAT) True Collaboration score above 4.2
2. Achieve daily SAT/SBT charting compliance of at least 90%
3. Decrease total ventilator days 0.5 days
4. Decrease ventilator-associated events (VAEs) and infection-related ventilator-associated complications and possible ventilator-associated pneumonia (IVAC Plus) rate 10%
5. Decrease ICU length of stay (LOS) 0.5 days
6. Improve perceived consistency of the SAT/SBT process by an average score of 2

Project Outcomes:

1. No change in HWEAT True Collaboration score
2. Decreased HWEAT aggregate score 0.03 (3.76 --> 3.73)
3. Increased SAT daily charting compliance between 33 and 87%; SBT daily charting compliance between 67 and 94%; SBT charting reached goal three of the months
4. Decreased MICU average ventilator days 1.1
5. Decreased SICU average ventilator days 0.27
6. Decreased MICU VAE from 3 to 1
7. SICU VAE rate remained at 1 pre and post
8. Increased MICU ICU LOS 0.13 days
9. Decreased SICU ICU LOS 1.18 days
10. Improved staff satisfaction with the SAT/SBT process by an average score of 2
11. These outcomes resulted in a positive estimated annual fiscal impact of $182,961

Project Overview:

While the Medical Intensive Care Unit (MICU) and Surgical Intensive Care Unit (SICU) cater to different patient populations, both units observed issues with disorganization and inconsistency of spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT). A lack of standardization of SAT/SBT leads to delays in extubation, patient dissatisfaction, and staff distress. Furthermore, the CSI team theorized that delayed extubation also results in increased ventilator days, ventilator-associated complications, and ICU length of stay.

Before choosing SAT/SBT standardization, our team met with MICU and SICU attending physicians and the Respiratory Therapist (RT)/MICU/SICU managers to elicit feedback and buy-in as stakeholders. The CSI team designed our project intervention to include staff education, an update in current electronic health records for SAT/SBT features, and improved charting compliance. RN and RT education included facility SAT and SBT protocols with clarification of RN and RT scope of practice and order sets. Education was provided at staff meetings and separate kickoff events. To encourage survey participation, we offered staff a selection of treats, coffee, and snacks.

Throughout the project, our team sent updates via email and continued to engage with nurses both during staff meetings and through one-on-one interactions. Furthermore, at the 9-month mark, we provided an update and outlined our project to the Critical Care Committee. We encouraged staff and stakeholders to ask questions and share feedback throughout the project.

At the conclusion of our project, we achieved several of our goals. The MICU reduced average ventilator days by 1.1 days and decreased VAE from 3 to 1 total cases. The SICU saw a reduction in average ventilator days by 0.27 and a decrease in average ICU length of stay by 1.18 days. While these changes are modest, the overall projected fiscal impact is $182,961. Although we didn't meet all of our initial goals, we experienced other successes throughout the project. Notably, we strengthened our relationship with the Respiratory Therapy Department and will continue to focus on enhancing that collaboration moving forward.

Additionally, presenting at the Critical Care Committee sparked further discussions about the SAT/SBT protocol. As a result, the Committee has updated the SBT criteria, now allowing Respiratory Therapy (RT) to perform SBT on patients receiving low-dose vasopressors without requiring additional orders. This change will enable more patients to receive earlier SBTs. We plan to incorporate this update, along with other changes, into our protocol to ensure continued standardization beyond the project's timeline.

Our team faced several challenges throughout the project. Because of the differences in culture and practices between the ICUs, it quickly became clear that a single protocol would not work for both units, and that flexibility was needed to accommodate the varying workflows of SICU providers. We also encountered limitations in hospital resources during night hours, particularly with RT staffing and the availability of the airway team, as there was only one airway resident on call at night. Chart auditing posed another challenge, as we struggled to obtain all necessary data and keep up with the auditing process. In hindsight, we regret we didn’t utilize our unit champions or early adopters on the unit to a higher capacity, which may have helped our Team focus on other aspects of the project. Additionally, we lost valued team member who transitioned to a different hospital, and the MICU underwent management changes, which impacted the morale of nurses completing the post-project surveys. Despite these challenges, the project has significantly improved our understanding of how to implement change at the unit level and has contributed to our professional development. Most importantly, it has led to improvements in patient outcomes. Moving forward, we plan to continue encouraging staff to utilize the SAT/SBT protocol daily.