Abstract
Introduction: The presence of mechanical ventilation (MV) is one of the most common indicators for utilization of Intensive Care Unit (ICU) beds. We sought to evaluate the use of protocol-guided ventilator management by nurses and respiratory therapists to accomplish rapid and safe extubation of critically ill patients and to see the effects upon ICU and hospital length of stay. Methods: After baseline ventilator information (Phase 1) was prospectively gathered in the NeuroTrauma ICU of a 600-bed tertiary referral center with level I trauma center (October 1997 through February 1998), an algorithm for ventilator management was developed by a multidisciplinary team. The algorithm allows respiratory therapists to increase or to decrease ventilator settings based upon objective data and guided by nursing. Data was prospectively obtained for comparative analysis from July 1998 through May 1999 (Phase 2). The primary outcome measure was the duration of MV from tracheal intubation until discontinuation of ventilation. Results: There were 93 patients with MV in Phase 1 and 220 patients in Phase 2. The average APACHE II scores were 17.1 and 15.6, respectively. The average time of MV prior to first extubation was reduced from 106 hours (Phase 1) to 96 hours (Phase 2). Reintubation rates were 9% in Phase 1 and 7% in Phase 2. Total time of MV was 227 hours in Phase 1 and 119 hours in Phase 2 (p<0.05). ICU length of stay and hospital length of stay were reduced from 12.0 days and 20.3 days to 7.4 days and 15.9 days. Hospital mortality remained the same (27% versus 28%). Conclusions: Protocol-guided ventilator management, as performed by nurses and respiratory therapists, is safe and leads to extubation more rapidly than physician-directed, non-algorithmic weaning. With more rapid extubation, both ICU and hospital length of stay are reduced.