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Outcomes in Post-ICU Mechanical Ventilation^*

A Therapist-Implemented Weaning Protocol

^* From the Barlow Respiratory Hospital and Research Center, Los Angeles, CA.

Correspondence reprint requests to: David J. Scheinhorn, MD, FCCP; 2000 Stadium Way, Los Angeles, CA 90026; e-mail: djs{at}barlow2000.org

Background: Therapist-implemented protocols have been used to extubate or wean patients in the ICU setting. Barlow Respiratory Hospital (BRH) functions as a center for weaning patients from prolonged mechanical ventilation (PMV) in the post-ICU setting of a long-term acute-care (LTAC) facility. A therapist-implemented patient-specific (TIPS) weaning protocol was developed at BRH to standardize weaning from PMV.

Study design: Prospective cohort study with historical control.

Methods: A weaning protocol incorporating the procedures and pace of LTAC weaning was developed using available scientific evidence and expert consensus. After training of staff, collection and analysis of pilot data, and revisions and refinement of the protocol, the TIPS protocol was implemented hospital-wide. It was monitored for outcome, variance, and respiratory care practitioner (RCP) and physician compliance.

Results: Forty-six RCPs worked with eight pulmonologists treating 271 consecutive patients admitted for weaning from PMV during an 18-month period. Nineteen patients were excluded from weaning attempts by any method after initial physician evaluation. The remaining 252 patients (9,135 total ventilator days) were compared with a group of 238 patients treated by the same physicians in the 2 years before instituting protocol weaning. Median time to wean declined significantly from 29 days in historical control subjects to 17 days for TIPS protocol patients (p < 0.001). Outcomes (scored at discharge) were comparable for the two groups (TIPS group vs control group): weaned, 54.7% vs 58.4%; ventilator-dependent, 17.9% vs 10.9%; died, 27.4% vs 30.7% (p = 0.10). Variances incurred by physicians and RCPs were 324 and 136, respectively, for the 9,135 ventilator days.

Conclusions: Patients weaned from PMV using a new therapist-implemented protocol at BRH, an LTAC facility specializing in weaning, had significantly shorter time to weaning than historical control subjects, with comparable outcomes. The weaning outcome data collected after the implementation of the TIPS protocol are in fact attributable to its use, as we found a high degree of compliance with the protocol.

Key Words: compliance • long-term acute care • outcome • prolonged mechanical ventilation • protocol • respiratory care practitioner • therapist-implemented • time to wean • variance • weaning

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