Tracheostomy protocol: experience with development and potential utility.

OBJECTIVES: To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning. DESIGN: Prospective, observational data collection. SETTING: Academic medical center. PATIENTS: Surgical intensive care unit patients requiring mechanical ventilatory support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p < .001). For patients requiring ventilatory support for > or = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy. CONCLUSIONS: A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

Multicenter implementation of a consensus-developed, evidence-based, spontaneous breathing trial protocol.

OBJECTIVE: Evidence-based practice recommendations abound, but implementation is often unstructured and poorly audited. We assessed the ability of a peer network to implement an evidence-based best practice protocol and to measure patient outcomes. DESIGN: Consensus definition of spontaneous breathing trial followed by implementation in eight academic medical centers. SETTING: Six medical, two surgical, and two combined medical/surgical adult intensive care units among eight academic medical centers. STUDY POPULATION: Patients initiating mechanical ventilation through an endotracheal tube during a 12-wk interval formed the study population. INTERVENTIONS: Adoption and implementation of a common spontaneous breathing trial protocol across multiple intensive care units. MEASUREMENTS AND MAIN RESULTS: Seven hundred five patients had 3,486 safety screens for conducting a spontaneous breathing trial; 2072 (59%) patients failed the safety screen. Another 379 (11%) patients failed a 2-min tolerance screen and 1,122 (34%) patients had a full 30-120 min spontaneous breathing trial performed. Seventy percent of eligible patients were enrolled. Only 55% of passing spontaneous breathing trials resulted in liberation from mechanical ventilatory support before another spontaneous breathing trial was performed. CONCLUSIONS: Peer networks can be effective in promoting and implementing evidence-based best practices. Implementation of a best practice (spontaneous breathing trial) may be necessary for, but by itself insufficient to achieve, consistent and timely liberation from ventilator support.

Improved extubation rates and earlier liberation from mechanical ventilation with implementation of a daily spontaneous-breathing trial protocol.

BACKGROUND: Daily spontaneous-breathing trials (SBTs) are promulgated as the best method for assessing readiness for discontinuation of mechanical ventilation. SBT protocols have also been shown to improve outcomes as opposed to wild-type implementation of daily SBT recommendations. Here we determine whether implementation of a mandatory, protocol-driven daily SBT on all ventilated patients in the ICU improves extubation rates and accelerates liberation from mechanical ventilation. STUDY DESIGN: A daily 30-minute SBT protocol was introduced into an academic surgical ICU in July 2005 and followed through September 2006. Decisions about next steps (continued mechanical support versus liberation) after each trial were recorded. Owing to the low liberation rate, physicians began (in January 2006) recording the reasons for continuing mechanical ventilation after a passing SBT. Differences in patient outcomes were compared for the first and last 8 weeks of the study period, corresponding to similar times in the academic and calendar years. RESULTS: Four hundred eighty-eight patients experienced 547 mechanical ventilation episodes from July 2005 to September 2006. A total of 2,835 safety evaluations for SBTs were completed. Rate of extubations of passing patients after the first 8 weeks of implementation (n = 73 patients) was 27% (35 extubations of 131 passed trials). This rate improved in the last 8 weeks to 42% (42 of 101) (p < 0.02) (n = 57 patients). Reintubation rate was similar at 6% for the first 8 weeks and 8% for the final 8 weeks (p = 0.65), including self-extubations. CONCLUSIONS: Implementation of a daily SBT protocol resulted in improvement of extubation rates during the year of implementation without a change in the reintubation rate. Requesting that physicians enumerate reasons for continuing mechanical ventilation in the face of a passing breathing trial was associated with a sustained improvement in extubation rate.