New standardized rounding tool reduces duration of mechanical ventilation for weaning patients

A Tennessee hospital reduced the amount of time patients required mechanical ventilation (MV) by nearly half, with a new standardized rounding tool that emphasizes weaning efforts.

"Using a Standardized Rounding Tool to Improve the Incidence of Spontaneous Awakening and Breathing Trials" details a process improvement project in a medical intensive care unit (MICU) at a midsized, privately owned hospital. The article is published in the April issue of Critical Care Nurse (CCN).

Weaning patients from MV is a complex process that requires multidisciplinary coordination of spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), multimodal pain management and pharmaceutical sedation. The project sought to develop a rounding tool that would standardize daily interdisciplinary rounds, increase the collaboration that follows and bring greater consistency to weaning patients from MV.

Lead author Billie Lancaster, DNP, AGACNP-BC, is an adult-gerontology acute care nurse practitioner. She developed the process improvement project as part of her doctoral studies at Vanderbilt University School of Nursing, where she is an instructor of nursing.

The rounding tool has improved daily discussion of ICU patient metrics and greatly reduced length of stay and duration of mechanical ventilation for our patients. This initiative was intentionally simple, with minimal costs. We spent only $110, yet it yielded results that are associated with better patient outcomes and significant savings to the organization."

Billie Lancaster, DNP, AGACNP-BC, Study Lead Author and Adult-Gerontology Acute Care Nurse Practitioner, American Association of Critical-Care Nurses

The project began with development of a one-page paper worksheet that included areas for nurse to document patient-specific events throughout 24 hours. The rounding tool specifically incorporated information about the patient's pharmaceutical sedation and pain management regimens and the outcomes of the patient's coordinated SAT and SBT for the day.

As part of the tool's introduction, the project team conducted informal education sessions with bedside nurses and other MICU staff about the initiative and reviewed the SAT and SBT algorithm.

Each day, nurses completed the rounding tool for each designated patient before multidisciplinary rounds. During rounds, the nurses presented the information, including the outcome of the attempted coordinated SAT and SBT.

If patients had a successful SAT and SBT, they were promptly weaned from MV and then extubated after the rounds. If patients met criteria for transfer out of the MICU, a member of the multidisciplinary team entered transfer orders.

The six-month study included preimplementation data from August and September 2019 and postimplementation data from October 2019 through January 2020. During the preimplementation period, 613 patients were managed in the MICU, including 47 who required MV. During the four months following implementation, the MICU had 1,271 patients admitted, of which 91 required MV.

The mean ICU length of stay and MV duration consistently declined following project implementation. The project was associated with a 24% (0.89-day) reduction in the mean length of stay, from 3.72 to 2.83 days. It also had a 46.3% (2.81 day) reduction in MV duration, from a mean of 6.06 days to 3.25 days.

In addition, the study found a decrease in ICU length of stay for all patients in the MICU, not just those requiring MV. It revealed that many patients remained in a critical care environment unnecessarily and could be moved to a lower acuity setting.

As the American Association of Critical-Care Nurses' bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.