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Abstract

Introduction: We initiated a protocol for the escalation or de-escalation of ventilatory support for patients in our SICU in January, 2013. The respiratory therapists make all ventilator changes according to the protocol algorithms for oxygenation or ventilation. The protocol does not require individual orders to be entered into the electronic medical record provided the changes are compliant with the protocol. The therapists are required to document the changes in the ventilator settings in the respiratory flowsheet and the indication for the change in the progress note sections of the chart. A separate order is required for extubation or to escalate care from airway pressure release ventilation to volumetric (APRV) to volumetric diffusive respiration (VDR). Methods: During the first 3 months of the protocol, all ventilator changes were made with oversight by the faculty physician or the respiratory therapist team leader to identify any gaps or deficits not covered by the algorithms. We modified the protocol based on the feedback from the therapists and re-implemented its use. Over the next 3 months, we performed a prospective evaluation of 20% of all patients to determine whether the ventilator changes and documentation were made according to the protocol algorithms. Results: We identified a significant improvement in the rate of compliance with the protocol for ventilator changes from 82% in the first month to 88% in the second month to 90% in the third month (p < 0.05). Our rate of appropriate documentation in the progress note section remains unchanged 75, 72, and 72% over the last 3 months. We have identified 2 areas that resulted in most of the protocol violations for the past 3 months. These areas will be revised on the protocol to address the problems. Additionally, an educational program has been developed to improve documentation. Conclusions: We have successfully implemented a respiratory therapist-driven ventilator protocol in the SICU and created a compliance program that identified problems and developed solutions to address them.