Implementation of a Ventilator Weaning Pathway Reduces Duration of Mechanical Ventilation

Background: The CHOP pediatric intensive care unit (PICU) mechanically ventilates approximately 500 patients for > 24 h each year. Mechanical ventilation, while a life-saving therapy, introduces potential for infection, lung injury, and increased sedation. Prolonged intubation can also unnecessarily extend ICU and hospital length of stay. Ventilator weaning protocols and protocolized extubation readiness testing shorten the length of mechanical ventilation and ICU stay when applied to appropriate patients. Methods: In 2015, a multidisciplinary PICU team of respiratory therapists (RTs) and physicians developed and implemented a ventilator weaning protocol. The team reconvened in July of 2017 to increase pathway utilization with a SMART aim: to increase pathway utilization from 35% to above 50% by December 2017. With increased utilization, the team hoped to reduce duration of mechanical ventilation and ICU length of stay. Multidisciplinary educational interventions and clinical supports using the electronic health record (EHR) were utilized to increase pathway use. RTs, physicians, and nurses were educated through screensavers, and presentations at monthly division meetings. An EHR workbench report was developed to provide RTs with a list of eligible pathway patients to discuss on rounds. New flowsheet rows were added to RT documentation to identify reasons for delaying ventilation weaning and help initiate conversations about appropriate ventilation weaning decisions. Results: These interventions increased pathway utilization to above 50%, which has been sustained since December 2017. The mean time from criteria for pathway enrollment to extubation was shorter in those placed on the pathway (101 h vs 147 h). In addition, the total length of mechanical ventilation for patients on the pathway was lower (5. 2 days) compared to those who qualify but were not enrolled on the pathway (6.8 days). Despite this reduction, re-intubation rates have remained unchanged. Conclusions: We demonstrate increased utilization of the Ventilator Weaning Pathway through iterative improvements in pathway education and utilization of EHR tools. Increased utilization of the pathway also led to decreased length of mechanical ventilation without increasing re-intubation rates. Ongoing work is necessary to continue to further decrease length of mechanical extubation, time from extubation readiness to actual extubation, and ICU length of stay.