To reduce hospital mortality and length of stay for patients with acute respiratory distress syndrome (ARDS) by improving lung protective ventilation (LPV) and standardized daily spontaneous breathing trials (SBTs) in UNC's medical, surgical and neuroscience ICUs.
Patients requiring mechanical ventilation have the highest risk for mortality and are the most resource intensive patient population in the hospital. Care of the mechanically-ventilated patient is complex, and requires coordination of care among physicians, nurses, respiratory therapists, pharmacists, and dieticians. One particular challenge is adhering to lung protective ventilation (LPV), defined as tidal volumes <6 ml/kg ideal body weight (IBW). Implementation of LPV is the only intervention proven by randomized controlled trials to reduce mortality in patients with the acute respiratory distress syndrome (ARDS). Even for patients without pre-existing ARDS, every 1 ml/kg of tidal volume over 6 ml/kg IBW doubles the odds of developing nosocomial ARDS, which increases hospital length of stay and mortality.
A policy of LPV for all patients is challenging to implement because it requires a series of patient assessments and ventilator adjustments that are time consuming and may temporarily increase discomfort for the patient. Previous efforts to overcome barriers in our medical intensive care unit (MICU) have included a daily rounds care checklist. However, recent research has confirmed that unprompted checklists do not perform as well as daily prompted reminders. Prior to July 2013, the average tidal volume for mechanically ventilated patients in the UNC MICU was 7.6 ml/kg IBW, well above the goal of <6.5 ml/kg IBW. Over 50% of women were receiving >8 ml/kg IBW, including those with ARDS. Preliminary data indicate that patients in the surgical ICU (SICU) and neurosciences ICU (NSIU) similarly have average tidal volumes >7 ml/kg.
Thomas Bice, MD
July 2014 - June 2015