Mechanical ventilation study: A comparison between physician initiated and standardized non-physician initiate weaning from mechanical ventilation

Background: Of the various weaning methods, Esteban et al (Spanish Hospital Study) showed that using once daily spontaneous breathing trials to wean patients from mechanical ventilation resulted in shorter intubation courses and ICU length of stay; there were also fewer complications. (10) Evidenced based clinical guidelines recommend that to reduce unnecessary or harmful variations In approach, ICU clinicians should use weaning protocols. (6) Cohen et al found a multi-disciplinary team including physicians, respiratory therapists, and nurses reduced duration and costs of mechanical ventilation when compared with weaning done by critical care fellows. (5) This study examines the difference in total intubation time and ICU stay before and after the implementation of a weaning protocol at Salem Hospital. Hypothesis: Results from post protocol implementation will show shorter total intubation times and ICU length of stay. Methods: A retrospective chart review was conducted on patients 18 years or greater who, were intubated for greater than 48 hours, and treated by members of Salem Pulmonary Associates in the Salem Hospital ICU, during the time periods January 1 2002 to December 31, 2002 and January 1,2006 to December 31, 2006. Charts were chosen for review based on ICD codes for extended ventilation, birth date April 1983 or earlier, facility doctor number and admit dates. Data meeting study criteria collected by ICU Clinical Nurse Specialist (for an unrelated institutional IRB approved study), also were eligible for review. Results: Primary outcomes are defined as total length of intubation, mechanical ventilation (MV) and ICU stay. All outcomes decreased after the implementation of standardized non-physician initiated weaning. The results from all of the primary outcomes were statistically significant (p\u3c.05). The mean intubation time decreased from 9.03+/-10.58 days (95% CI, 5.68-8.06) in 2002 to 6.87+/-10.59 days (95% CI, 3.15-10.59) in 2006, a difference of 2.16 days per patient (p=O.OO). MV time decreased from 9.03 +/- 10.03 days (95% CI, 4.93-12.29) in 2002 to 6.29 +/-3.51 days (95% CI, 5.34-7.25) in 2006, a difference of 2.41 days per patient (p=O.OO). Total ICU length of stay decreased from 10.42 +/-12.18 days (95% CI, 5.95-14.89) in 2002 to 8.42 +/- 4.96 days (95% CI, 7.08-9.76), a difference of 2.0 days per patient (p=O.OO). Secondary endpoints included: the number of days from admission to pulmonary involvement (an average of 1.03 days more in 2006, p=.OO); average number of patients using, and average number of days on T -piece ( 1 % more patients and 0.95 days per patient less in 2006, p=O.Ol); percentage of patients with a tracheostomy (2% more patients with a tracheostomy tube in place and 5% more tracheostomy tubes placed in 2006, p=0.41) and finally mortality rate (7 % decrease in 2006, p=0.48). Re-intubation rates in 2006 were 20%; only one patient was re-intubated (however, was re-intubated twice) in 2002 (3%), (p=O.OO). Conclusion: All of the primary endpoints are statistically significant and consistent with the preponderance of literature stating that implementation of a standardized protocol using non-physician health care providers to initiate weaning results in shorter intubation times and ICU stays