Outcomes in post-ICU mechanical ventilation - A therapist-implemented weaning protocol

Background: Therapist-implemented protocols have been used to extubate or w ean patients in the ICU setting. Barlow Respiratory Hospital (BRH) function s as a center for weaning patients from prolonged mechanical ventilation (P MV) in the post-ICU setting of a long-term acute-care (LTAC) facility. A th erapist-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 w eaning was developed using available scientific evidence and expert consens us. After training of staff, collection and analysis of pilot data, and rev isions and refinement of the protocol, the TIPS protocol was implemented ho spital-wide. It was monitored for outcome, variance, and respiratory care p ractitioner (RCP) and physician compliance. Results: Forty-six RCPs worked with eight pulmonologists treating 271 conse cutive patients admitted for weaning from PMV during an 18-month period. Ni neteen patients were excluded from weaning attempts by any method after ini tial physician evaluation. The remaining 252 patients (9,135 total ventilat or days) were compared with a group of 238 patients treated by the same phy sicians 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 dischar ge) were comparable for the two groups (TIPS group vs control group): weane d, 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 pro tocol at BRH, an LTAC facility specializing in weaning, had significantly s horter time to weaning than historical control subjects, with comparable ou tcomes. The weaning outcome data collected after the implementation of the TIPS protocol are in fact attributable to its use, as we found a high degre e of compliance with the protocol.