In the United States, approximately 800,000 hospital patients are placed on mechanical ventilation each year. Approximately 300,000 of these individuals require prolonged mechanical ventilation lasting 3 days or longer. Prior to 2006 at Kingsbrook Jewish Medical Center, patients who required mechanical ventilators remained on these devices for an average of 11 days, and only 14 percent of patients were successfully weaned from mechanical ventilation.
In 2006, Kingsbrook Jewish Medical Center implemented a hospital-wide approach to weaning patients from ventilators based on national guidelines. A multidisciplinary mechanical ventilation weaning team (MVWT), consisting of a pulmonologist, clinical pharmacist, respiratory therapist and clinical nurse manager, met weekly to plan and implement interventions to improve the care of these patients.
Changes to the weaning process included implementation of evidence-based guidelines recommended by the Institute for Healthcare Improvement, including:
• changing the types of ventilator settings used in this patient population
• prophylaxis for deep vein thrombosis and stress ulcers
• electrolyte monitoring
• elevating the head of the bed to 30 degrees
• sedation holidays.
The clinical pharmacist assumed responsibility for the medication-related components of the ventilator weaning bundle. These included:
• making recommendations for deep vein thrombosis and stress ulcer prophylaxis
• monitoring electrolytes and provision of recommendations for replacement therapy
• addressing the use of medications, such as opioids, that contribute to weaning failures
• ensuring use of the most appropriate antibiotics
• monitoring for adverse drug events
• identifying and reporting medication discrepancies.
As a result, the number of patients whose treatment adhered to national guidelines increased from 63.7 percent to 91.7 percent. The number of cases of ventilator-associated pneumonia decreased by 70 percent. Successful weaning rates increased from 14 percent in 2005 to 21 percent in 2009. The length of time that patients spent on a ventilator decreased from 11.1 days in 2005 to 9.4 days in 2009.
Kingsbrook Jewish Medical Center has demonstrated that a multidisciplinary approach to implementation of ventilator management bundles, with pharmacist leadership of the medication-related components of care, can result in improved outcomes.
Multidisciplinary Team:
Henry Cohen, M.S., Pharm.D., FCCM, BCPP, CGP, Team Chair
Maria Arias, R.N.C., B.S.N., M.S.N.
Albert Belaro, R.N., M.A., CCRN
Steven Brooks, Ph.D.
Dumouriez Fievre, AAS, RRT
Wilfred Herard, M.D., FCCP
Steven B. Levy, Pharm.D., BCPS, CGP
Bishoy Luka, Pharm.D., BCNSP
Christine Ottley, R.N., B.S.N.
Carren Samuel, M.P.A., RRT