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Rose Lewis, RN, MSN, CCNS, APN
University of Virginia Health System
Charlottesville, Virginia, USA
Sidenia Earven, RN, MSN, CCRN, APN
University of Virginia Health System
Charlottesville, Virginia, USA
Charles Fisher, RN, MSN, CCRN, APN
University of Virginia Health System
Charlottesville, Virginia, USA
Paul Merrel, RN, MSN, APN
University of Virginia Health System
Charlottesville, Virginia, USA
Improving Care With An Outcomes-Managed Approach
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Outcomes managers can bring unique insights and skills to the team. By carefully managing outcomes and procedures, these team members can identify specific evidence-based approaches to improve care. Outcomes managers at the University of Virginia Health System found success developing guidelines for mechanically ventilated patients, and this outcomes-managed approach can be utilized to improve patient safety across many patient populations.
Recent studies focusing on interventions to reduce time on the ventilator and to shorten both intensive care unit (ICU) and hospital lengths of stay (LOS) for patients requiring long-term mechanical ventilation (LTMV) suggest the importance of decreasing practice variation to reach these goals.1-12 These studies demonstrate the importance of guidelines, protocols and algorithms to ensure the timely, yet safe, application of weaning trials 6,7 and the withdrawal of sedation.8,9 However, few reports include details of the protocol implemented, the barriers to its implementation and whether the effect is sustained following the study period.
A multiprofessional team from the University of Virginia Health System in Charlottesville, Virginia, USA, successfully designed and implemented an evidence-based, comprehensive care initiative for patients receiving ventilation longer than three consecutive days. The team, covering five ICUs in a 550-bed academic medical center, designed a clinical pathway based on the philosophy that successful weaning is dependent on many aspects of care (e.g., nutrition, early mobilization, tight glucose control and prevention of complications such as deep vein thrombosis and ventilator-associated pneumonia) and is not solely confined to ventilator management. Other essential elements of the pathway included guidelines for daily weaning trials and withdrawal of sedative infusions. The initiative involved four advance practice nurses acting as outcomes managers (OMs) who were responsible for clinical pathway and guideline adherence. The OMs performed focused weaning assessments using the Burns Wean Assessment Program to identify impediments to weaning, then communicated and collaborated with other key professionals on the team, formulating a plan to address the issues identified for each patient.13 The OMs also performed short-cycle evaluations of specific pathway elements (e.g., head of bed elevated 30°, sedation weaning) to ensure that compliance was consistently high.
The OM team was able to meet the challenges associated with implementing the new initiative, and the hospital has successfully decreased LOS and time spent on the ventilator. Staff turnover and the need for staff re-education always can complicate protocol implementation. The OMs played an important role by guiding the use and application of the protocols and maintaining a consistent plan of care across different ICU staffing and practice settings. This team also worked to gain administrative and multiprofessional “buy in” for the initiative. The positive results of the clinical outcomes data, which were sustained over time, increased the acceptance and perceived value for the OM role. Effectively implementing evidence-based practice changes at the institutional level usually is a challenge when introducing any new process. The OM roles in this situation included regular informal and formal education of house staff, nurses and other members of the ICU team on the scientific basis for pathway elements.
Data for the first year after implementation of this systematic institutional approach to the care of LTMV patients demonstrated statistically significant improvements in all major outcome variables, including ventilator duration, ICU and hospital LOS and mortality rate (see Table 1). Since then, the care team has worked on sustaining the gains. At the heart of this program’s success is the multiprofessional team, including the unique roles of the OMs, who worked together to improve outcomes in this complex and vulnerable patient population.
Table 1. Five-year LTMV data results UVA Health System.
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|
LTMV
Patients
All Adult icus |
% Weaned
Alive
&
discharged |
Mean
Vent
Days
|
Mean
Hospital
LOS
|
Mean
ICU
LOS
|
N
(%)
Mortality
|
|
Post OM Data |
N = 2589 |
96.4% |
12.10 |
16.9
|
26.43
|
34.4 |
|
P Value |
|
0.0001 |
0.0001 |
0.003 |
0.0001 |
0.005 |
|
Pre OM Data |
N = 592 |
90.7% |
13.98 |
21.94 |
29.45 |
38.4 |
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