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Upgrading Respiratory Services

September 1, 2006
by root
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by the staff of The Silvercrest Center for Nursing and Rehabilitation, Briarwood, New York
Upgrading Respiratory Services
by the staff of The Silvercrest Center for Nursing and Rehabilitation, Briarwood, New York Mechanical ventilation incurs substantial morbidity, mortality, and costs. Because premature or delayed weaning can cause harm, weaning that is both expeditious and safe is highly desirable. We assessed 312 patients/residents over a three-year period, beginning in 2003, with the baseline and treatment populations well matched on population characteristics, age distribution, sex, and primary diagnosis. Implementation of our initiative increased the wean success rate by 40.9% from 2003 to 2004, and by 65.5% from 2003 to 2005. In 2005, the number of ventilator-associated complications decreased to zero.

Background and Planning
The target population included adults with various degrees of cardiopulmonary diseases and conditions requiring mechanical ventilation and other levels of respiratory support. Our goals were threefold:

  • To provide safe liberation or weaning from mechanical ventilation and other respiratory support for patients/residents admitted to a subacute/long-term care ventilator unit from an acute care setting where prior weaning efforts had failed.
  • To assist the patient/resident in achieving an optimal level of functioning.
  • To set standards of practice that enhance patient/resident safety, quality of life, and quality of care.

The ventilator unit was established in 1992 to complete a natural continuum of care for ventilator-dependent patients/residents from the affiliated acute care hospital to the community, and to ensure that adequate long-term beds were available for those unable to return home immediately. Ventilator beds outside the acute care setting had been limited in this area. Individuals who could not be liberated or weaned from the ventilator spent months in hospitals, typically with a compromised quality of life and at a tremendous expenditure of resources and finances.

Facility staff worked collaboratively with the New York State Department of Health to develop a program that would meet the needs of patients/residents outside the hospital setting. In the early years of the facility, the facility ventilator wean rate of approximately 40% matched or exceeded success rates at large regional weaning centers, demonstrating the benefits of ventilator programs in long-term care settings.

As respiratory services expanded, the number of subacute ventilator beds was increased from 8 to the current capacity of 48, making it the largest long-term ventilator program in the state. Noninvasive ventilation was introduced and initiated throughout the facility and, beginning in early 2003, upgrades to the facility's physical plant (an emergency electrical system) and ventilator alarm system were implemented. A larger supply of bulk oxygen was obtained, and the inventory of specialty beds and augmentative communication devices was increased. From 2003 through 2005, mechanical ventilators were replaced systematically with sophisticated models that more effectively accommodated weaning. Staff education was provided and competencies were established on revised policies and procedures resulting from the expansion of the program and allocation of the additional ventilator beds.

During 2003, as planning for the expansion of the unit continued, the facility's Performance Improvement Steering Committee (PISC) chartered the formation of a Respiratory Care Committee (RCC) consisting of both leadership and clinical staff. The PISC is an interdisciplinary group that includes facility leadership and is authorized by the Board of Trustees to provide oversight for the development, implementation, and evaluation of the Performance Improvement (PI) and Patient/Resident Safety Plan. Three representatives from the Board of Trustees are active members of this committee.

The RCC's mandate was to improve systems and processes that would facilitate optimal patient/resident outcomes, and respond to any care concerns or trends. The committee reported activities and outcomes to the Performance Improvement Committee (PIC) on a quarterly basis. A primary task of the group was to revise methods of data aggregation and analysis for identified respiratory measures, including patient/resident wean rates.

Current wean rates were difficult to compare with previous years' rates because the patients/residents admitted to our facility had increasingly complex medical and clinical presentations, requiring extensive nursing care, as well as equipment such as specialty tracheostomy tubes and augmentative communication devices. This increased clinical complexity was validated by the changing Case Mix Index (CMI), which increased from 1.7429 in 2003 to 1.7460 in 2005. A corresponding increase was noted in the CMI of the skilled nursing population. This overall increase in the CMI, coupled with the expansion plans for the respiratory programs, triggered recognition that existing systems should be revised to ensure continued quality and safety for our patients/residents.