August 18, 2024 • 38 mins
Dr. Colin Grissom is professor of medicine at Intermountain Healthcare as well as University of Utah. He discusses his experience with implementing best practices, specifically low tidal volume ventilation, across […]
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(00:00):
Welcome everybody to our Friday conference,
multidisciplinary
critical care,
conference. It's my pleasure today to introduce our
guest speaker,
doctor Colin Grissom. Doctor Grissom
grew up in Colorado and then came
out to the East Coast and did his
medical school training at the Yale University School
of Medicine.
(00:20):
After that, he went out back to the
West Coast to the University of Washington where
he did internal medicine
residency training followed by fellowship in pulmonary and
critical care medicine at the University of Utah.
He's been out in Utah ever since and
is a professor of medicine in Intermountain Health
and at the University of Utah.
Today,
Andy Levine invited doctor Grissom based on a
(00:41):
paper that was published and work that he's
been doing, and the title of our talk
is implementation of low tidal volume ventilation and
coordinated SAT SPT in a learning health care
system. Doctor Grissom, thank you for joining us
today.
Thanks.
Thanks for having me, and it's, I'm looking
forward to sharing my experiences with the implementation
with you.
(01:01):
I don't have any conflicts.
I work for Intermountain Healthcare,
and Intermountain Healthcare
now,
covers,
a large
section of the, Intermountain West across 7 or
8 states. And what I'm gonna focus on
initially is implementation of low tidal volume ventilation
(01:22):
adherence to a best practice in primarily Utah
and Idaho, which is the legacy,
Intermountain system. This was a multiyear,
project that went through,
a couple different phases, and I'll describe the
education that I,
experienced about implementing best practices across a health
(01:42):
care system.
2 years ago, we merged with a health
care company called SCL, a nonprofit in,
primarily Colorado, Wyoming, and Montana.
And,
I, one of my,
next,
objectives is to spread some of these best
practices into the tertiary
hospitals in in, Colorado and Montana.
(02:05):
So there's a process that,
I have learned through working with the health
care delivery institute at, Intermountain Health.
And as I go through,
the implementation of low tidal volume ventilation and
then where we're at with,
spontaneous awakening trials and spontaneous breathing trials, I'm
gonna
utilize
the components of this process, which is identify
(02:27):
initially identify the the evidence based best practice.
Then,
I
you need to determine if, it's worth it
to implement this. Is there an opportunity for
improvement,
and do you have the key leverage points
to drive
outcomes,
and improve,
care for patients?
(02:47):
And then something I learned,
very important is to have
a,
a measurement system with a metric
that is readily
available as a leading indicator, meaning, like, weekly
gets we updated weekly for local teams to
be able to to measure their progress
against the system goal. And very important
(03:09):
is to,
identify
barriers
and facilitators to implementations. This is most often
achieved by interviewing frontline providers.
And then,
do a pilot implementation
in 1 or a few hospitals and then
spread across the system,
utilizing what you learned from that. So I'm
gonna start with our,
(03:31):
project on implementing,
best practice for low tidal lung protective mechanical
ventilation.
So I'm not going to go into the
evidence behind it,
especially for ARDS.
The evidence is,
overwhelming
that,
low tidal volume ventilation improves outcomes, improves survivals,
and that goes back to the ARDS network
(03:51):
study in 2,000.
And
there's also evidence strong evidence that, for acute
hypoxemic respiratory failure, low tidal volume, lung protective
mechanical ventilation also improves outcomes.
Despite this,
evidence,
there's multiple studies that show that health systems
(04:12):
usually
aren't as adherent to low tidal volume ventilation
as they think. In other words,
everybody agrees it's the right thing to do.
But,
as you,
if you go and measure adherence,
it turns out that,
usually, in in multiple studies,
(04:35):
the adherence to the best practice is not
as high as, the the physician leaders thought
it would be. So the opportunity
arose in 2015
to develop a computerized ventilator protocol in our
new Cerner EMR.
We had a legacy,
EMR that was homegrown, and we did have
computerized ventilator protocols in it. But with our
(04:57):
transition to Cerner in 2016 to 2017,
it was an opportunity to revamp those protocols,
and we they we we'd used the logic
in the ARDS network protocol.
And then in a phased implementation,
we studied adherence,
to,
a protocol that drove, to best practice for
low tidal volume ventilation. So that's the first
(05:19):
experience that I had.
When I started this,
there was very high use at Intermountain Medical
Center and LDS Hospital, and that was because
these protocols had been developed in the legacy
EMR at LDS Hospital. There'd been a lot
of growth,
experiencing the protocols improvement among the physicians,
(05:41):
and respiratory therapists. And then when we opened
a a new tertiary medical center,
Intermountain Medical Center, a lot of the staff
from LDS Hospital went to Intermountain Medical Center,
so there was high use of computerized protocols.
The protocols were available to our other tertiary
trauma hospitals in the system in Utah, but
(06:01):
nobody used them
because,
they were available, but it hadn't been part
of their culture. They hadn't been part of,
the development of the protocols, and they just
didn't use them. So when we,
developed these
protocols in Cerner, it was, you know, an
an electronic decision support
in a computerized protocol,
(06:23):
with 4 different protocols, one that for ventilation
that drove,
respiratory
rate and tidal volume, oxygenation protocol that drove
FiO 2 and PEEP, a weaning assessment, and
then a pressure support CPAP weaning protocol.
We based the our protocols in the acute
respiratory distress syndrome, and they're open loop, so
they're opt in, meaning that,
(06:44):
the physician needs to order them,
and, but they don't have to. They can
they can achieve,
low tidal ion ventilation
using another mode, but, if they use the
computerized protocols,
it'll drive towards adherence to low tidal volume
ventilation.
And,
in
in discussing it with the physicians before we,
(07:05):
implemented this,
even those that were skeptical of utilizing the
computerized protocol, everybody agreed that this is something
unless there's a a good reason not to
use it on a patient, for example, status
asthmaticus
or increased intracranial pressure. This should just be
used on all mechanically ventilated patients and will
gain experience and and have a standard across
(07:27):
the system.
So,
physicians could opt in, and we did develop
I I won't talk about it, but we
did develop a separate neural ventilation protocol
for those patients with increased intracranial pressure that
instead of driving off pH, drove off,
p c o 2 using the lowest tidal
volume close to 6 mils per kilo that
(07:49):
that, maintain a normal, p c o 2
for those patients with increased intracranial pressure. We
studied our implementation
and, a study called the IMPROVENT, implementation of
lung protective ventilation.
It was a quality improvement study across Intermountain
Hospitals with IRB approval for waiver of informed
consent.
We measured adherence to initial set tidal volume.
(08:10):
That was our primary metric,
and,
as
6.5 mils per kilo or less in in
initial set tylenol volume.
We used a phased implementation
as,
the hospitals,
transitioned to the Cerner EMR
over about a year's time,
for the tertiary hospitals, and we tracked the
(08:30):
use of the computerized protocols.
For, education,
myself and, respiratory therapist did a lot of
site visits at the tertiary trauma hospitals. We
did site visits at the community hospitals
where we had a power presentation
showing the evidence behind low tidal volume, lung
protective mechanical ventilation.
And,
then we had a on the website, we
(08:52):
had on a Intermountain Intranet,
we had
a
video
with a talk that I gave, similar to
what we were given at the community and,
tertiary hospitals in the PowerPoint and all this
information and the logic behind the protocol. So
these are the hospitals in Legacy Intermountain as
we phased
in pre implementation,
(09:14):
beginning in about the Q2 of 2016 and
finishing in in the beginning of Q3 of
2017
with Intermountain Medical Center being the last hospital
to go. So adherence
to the protocol. So this chart shows that
metric. I said initial set tidal volume, 6.5
milliliters,
or less and then percent of, use of
(09:35):
the ventilation protocol.
And what I said before, Intermountain Medical Center
and LDS Hospital were high users of the
protocol
and had high adherence, and that's because they
were,
comfortable with the computerized protocols.
The other hospitals,
who that hadn't used computerized protocols before, what
I learned is,
(09:56):
you have to do more than just go
and show them the protocol and then provide
it to them. And
even with coaching,
they just
especially, this is St. George
Hospital. It was renamed several years ago, and
this is Utah Valley, very low adherence. Now
one,
strategy you can use to try to improve
adherence
(10:16):
is,
you know, just have the,
physician leader say this is the right thing
to do. And so the this is a
before and after. All these the blue is
before a conference that we had in the
fall of 2017.
The red is after. And we invited the
CEO of Intermountain to the conference, and he's
a pediatric intensivist, Mark Harrison. We have a
(10:37):
different CEO on that, but at the time,
it was Mark Harrison,
and he was really supportive of,
driving towards, low tidal volume lung protective mechanical
ventilation. So one of your implementation
strategies can be for the leader to say
this is the right thing to do, and
please do it. So that increased. After that
conference, we had increased,
(10:59):
use of the computerized protocols and increased adherence.
But here you can see at these trauma
hospitals, it's still, you know, 40 to 60%,
as and not as high as at Intermountain
Medical Center and LDS Hospital. We published our
experience with this in critical care medicine,
and we did improve. You can see that,
this is
(11:20):
the set initial set tidal volume with interquartile
range.
And, through the period of that phased implementation,
we did decrease variation
and lower tidal volume towards that target 6
mils per kilo, and we did have increased,
adherence to the to the computerized protocols
up to a lot but this is only
(11:41):
at 50% here. So we did see an
association.
Use of the protocols,
drove, adherence and a tighter,
less variation around that target of 6 mils
per kilo. And this is all patients. We
did in this paper, we separate out
ARDS from non ARDS, but,
(12:01):
the, this these are the results for all
patients combined. And for ARDS and non ARDS,
it was about the same adherence. So, you
know, why couldn't we
do better at this?
We have a large health care system of
4,300
about over 4,000 mechanically ventilated patients,
in the legacy Intermountain each year. We had
this electronic decision support tool that could be
(12:23):
used, and,
yet we we were incompletely successful
in, implementing. So
what what we did next was, I partnered
with the Health Care Delivery Institute, and this
was a a care process model that they,
supported.
And then we applied for an NIH grant.
There was an NIH grant for
(12:46):
pilot studies of implementation of best practices in
heart, lung, or blood disease. And our experience
fit with the request for applications, and, we
got the grant. So we had a grant
to study implementation
of, low tidal volume ventilation,
in our health care system. And I partner
with the Health Care Delivery Institute. And we
(13:07):
used implementation
science methods to,
try and improve our adherence. And that started
in 2019,
and our pilot study,
ended just, in early 2020,
and we spread that best practice across,
Intermountain. We had a large team,
with,
pulmonary critical care physicians, respiratory therapy, and data
(13:30):
analysts, and and the, implementation
scientists from, the Health Care Delivery Institute. So
we did a a mixed method study where
we,
had a baseline,
objectively measuring clinical care,
adherence to that low tidal volume ventilation and
use of the computerized protocols.
And then we did interviews with frontline providers
(13:52):
to assess barriers and facilitators to delivery of
low tidal volume ventilation for patients with ARDS.
And then we performed a pilot clinical trial
at 3 hospitals to test the interventions to
achieve high adherence,
for all patients with ARDS. So here's,
our our baseline measurement and, you know, the
previous,
data I showed,
(14:13):
adherence across the system to initial set tidal
volume of less than or equal to 6.5
mils kilo is 42%
with variation from 21 to 80% by ICU.
And,
use of the computerized protocol
was 28% with,
0 to 91% for using the ventilation component
of the protocol that drove towards
(14:34):
6 mils per kilo. So,
the the interviews with the respiratory therapist were
key. And anytime you do an implementation,
I found this is really important because the
things I learned, there's no way I would
have learned them,
if we hadn't gone to the frontline providers
and talked to them.
So there was, at the individual level,
(14:55):
it was interesting. Those respiratory therapists
that worked at LDS Hospital or Intermountain Medical
Center saw the computerized protocols as giving them
more autonomy,
giving them control over managing,
the patient,
and they were comfortable with it. They've done
it for a long time. Those,
respiratory therapists at the hospitals that hadn't used
(15:17):
computerized protocols
saw them. The computerized protocols, their perception was
it removed their autonomy.
They just became a conduit for a protocol
that, gave them it was open loop. So
they got the instructions, and they would
approve them or talk to the physician, and
then they would make the adjustments on the
ventilator.
So it was really interesting to see that
(15:38):
difference. And then there was not complete understanding
of, you know, why this was important.
And then I think
that we did we did not have a
a dashboard
with regular updates of how the system was
performing on the our metric of initial set
title volume,
and, we didn't have a goal. We didn't
(15:58):
have,
a system goal for what we defined as
success,
and we did not empower local teams,
to
work on improving their adherence,
with, their own,
local champions, physician and respiratory care champions,
giving them some control over how they could
(16:20):
achieve,
adherence. So we learned a lot from those,
and we performed a pilot clinical trial in,
3 hospitals, tertiary hospitals staffed by intensivists,
developed interventions to address the barriers that I
just discussed, and then we created a metric
as a leading indicator with a dashboard that
was updated weekly, and we identified local respiratory
care and physician champions
(16:40):
to lead process improvement teams and create system
goals. So I'll show you,
this this strategy.
So there's different terms used in implementation science,
daily snapshot audit of key indicators. That just
means on rounds,
you review the mechanical ventilation,
settings and whether you're on target. And if
you're not, is there a good reason not
(17:02):
to be,
or should this,
the protocols be ordered, or why aren't you
on 6 mils per kilo? You know, address
those questions on rounds. Then local process improvement
teams, that's the
physician champion, respiratory care champion who, come up
with experiments or rapid
PDSA cycles to,
(17:23):
try things to try and improve adherence,
and you have that audit and feedback from
a a a dashboard that's updated weekly. Rounding
to influence means those physician champions and respiratory
therapists
go around, while,
other respiratory therapists and physicians are on shift
to talk to them about use of the
protocol. We also developed a separate ARDS screening
(17:46):
tool within our EMR that was helpful too
that identified when a when a patient wasn't
if they had a ratio of less than
or equal to for us, it's 255, but
it's less than or equal to 300 at
c level.
And,
it it it tag tagged those, then we
had an NLP
program that identified when they had bilateral infiltrates,
(18:07):
and it would come up with an alert,
to the physician if they weren't on, the
gold tidal volume.
And that was well received too. So we
developed a new metric, and our new metric
was pretty,
patient centric and had and a high bar.
So while on volume control,
the tidal volume had to be set at
6.5 milliliters per kilogram or less for 90%
(18:28):
of the time while on volume control, and
we allowed the hybrid modes
of PRVC or VC plus.
Then,
the, when not on volume control,
if they weren't on adherent
CPAP or pressure support, meaning to wean the
patient, that means an FiO 2 of 50%
or less
with a PEEP of 10 or less, and
(18:49):
pressure support of 15 or less, then they
were nonadherent, and that time was added to
the denominator.
So, for example, airway pressure release ventilation did
not count as adherent,
but any volume control mode did. Unfortunately, pressure
control did not count as adherent. It had
to be a mode where you set the
the tidal volume. Our overall goal was to
have at least 85%
(19:11):
of encounters,
achieve that,
individual encounter goal.
And,
we set it at 85%
after a parietal analysis where
about 15% of the time, the reasons for
not using the protocol were were,
legitimate. And on our dashboard, we also had
a filter
for cardiac. We could remove cardiac surgery patients
(19:31):
or ECMO patients. But even if we left
them in, we we,
achieved adherence. So this is,
our experience at the 3 pilot
sites, Saint George, MacKady, and Utah Valley, and
the the, data starts when they, go live
with the new Cerner EMR. And you can
see that adherence,
according to that metric that I just showed
you, was really low.
(19:52):
It was below 50%.
And then,
at this time, I was
an academic
physician
and
director of, pulmonary and critical care research,
and I was leading this across the system.
This is when we had the conference that
the CEO attended and it emphasized adherence to
low tidal volume ventilation.
(20:14):
And then, my position changed,
in 2018.
We, reorganized
and,
created a critical care operating lane, and I
became the senior medical director for critical care
across the whole system. So now I wasn't
just the, academic critical care physician from Salt
Lake City,
promoting this. I was now the physician leader
(20:35):
for critical care,
promoting it.
And we continue to improve. This is where
our grant began,
and, we
did those,
analysis of barriers, and then we implemented what
I just described. So I'm gonna show you
the next, I'll show you the the results
from the pilot study.
So we did improve.
Now,
(20:56):
in a interrupt interrupted
time series analysis,
there was actually a secular trend the whole
time towards improvement, so we couldn't clearly say
that the methods that we used resulted in
this improvement. But, nevertheless, it's we continued to
improve is the point during that pilot. And
we finished that pilot trial
in early 2020. So this now goes this
(21:18):
is the same,
metric for adherence.
This is the baseline for the pilot trial,
and this is the intervention
period at those 3 hospitals.
But this is now all hospitals across the
system. So this is all mechanically ventilated patients,
ARDS, non ARDS,
and,
we improved adherence.
(21:38):
And when we then were able to spread
this across the whole system, we had
greater than 90% adherence, and then COVID hit.
And, so it was fortunate. The timing was
fortunate, so we had many more COVID ARDS
patients, and we maintained that adherence
to low tidal volume ventilation.
And it and it wasn't easy. This this
was challenging, especially at Utah Valley where
(22:01):
they relied,
almost exclusively on airway pressure release ventilation for,
their severe ARDS,
and they just weren't comfortable because they hadn't
used volume control for those severe ARDS patients
in a long time or or even a
hybrid mode. And I went down there, and
I gave them a talk, and this is
just, anecdote of the experience,
(22:23):
that what it takes sometimes
to be persistent
and,
to to achieve
success at adherence to best practice. But I
gave my talk on the reasons why we
were gonna go to the standard low tidal
volume ventilation across the system with the with
the protocol. And one of the senior physicians
there listened to my talk. He goes, you
know, Colin, that that really sounds great.
(22:45):
Very impressive. But but I had a really
sick patient with ARDS last night, and I
put him on, airway pressure release ventilation, and
he's better today. And I was like, okay.
You know, how do I respond to that?
And so what I said to him is
I said, well, Clark,
I had a really sick patient last night
with severe ARDS, and I put him on
low tidal volume lung protective mechanical ventilation with
(23:07):
volume control, and he's better today. So,
and then I tried to emphasize the point
that that we should base our practice on
on,
clinical trials and evidence and and not on
our most recent successful experience with something. And
I would also emphasize to him that, yeah,
there are different ways. There there are different
ways to achieve,
(23:28):
low tidal volume ventilation, but as a system,
we we should agree on one way, and
then we should try to improve that process
through, protocol. So that was our philosophy.
Now did we influence mortality? This is raw
mortality, and we're just starting to look at
this. It it it's hard because these two
peaks right here, increases in mortality. That's the
COVID pandemic.
(23:49):
So, there's no clear,
signal for, decreasing raw mortality
in mechanically dillated patients. Now we are in
the process of looking at mortality
and other outcomes, and what we found is
that there's the after adjustment for all,
thing all factors that may contribute to length
(24:10):
of stay, we achieved,
a decrease in,
ICU length of stay
as there was that was associated with the
increasing adherence to the to the,
low tidal volume ventilation and the protocols. And
even a half a day across the system
I'll show you some data that our our
finance,
(24:31):
financial analyst prepared, and this is our,
five
hospitals in Legacy Intermountain that are staffed by
Intensivists.
And, achieving even a half day,
to a day,
results in in,
1,000,000 of dollars of of, savings,
cost savings,
which,
we operate with, in legacy Intermountain,
(24:54):
close to 50%
value based care,
and and so this is important for us,
meaning that we are,
paid upfront for a cohort of patients, and,
we need to take care of them with
the highest quality and the lowest cost.
So important for us. So the the last
thing that we need to do now, I
showed you the the map, and we have,
(25:15):
6 hospitals
in, Montana and Colorado
that are now part of Intermountain
that have no mechanical dental, ventilation
mechanical ventilation database.
They all say this is the right thing
to do, adherence to low tidal volume ventilation,
but they don't know,
whether they have an opportunity for improvement. So
we're starting
(25:36):
with one of those hospitals
in, Denver,
and oh, I I don't have it. But
we're starting to build a mechanical ventilation database,
and,
we've so far, the initial data looks like
there's about 50 to 60% adherence using that
metric that I showed you.
And so,
(25:57):
the differences are, we're we're gonna move to
an EPYC EMR,
and they're on EPIC, but it's gonna take
a year and a half to build the
protocols in EPIC. So they're gonna start out
with paper protocols,
and we'll pilot it at, one of the
hospitals in Denver
and,
start working towards improving the adherence
so that, we can, across those hospitals in,
(26:20):
Montana and Colorado that are now part of
Intermountain.
So that's my experience with low tidal volume
ventilation, and we're in the middle
of,
implementation
of coordinated spontaneous awakening trials and spontaneous breathing
trials.
And
a lot of the same principles that
(26:40):
we learned through low tidal volume ventilation,
we applied to,
implementation of, spontaneous awakening breathing trials. And this
is also, funded by the NHLBI
as a,
implementation study. We're actually doing a clinical trial
as part of this implementation. I'll explain that.
The clinical trial is as testing the hypothesis
(27:03):
as to whether
real time,
support from telecritical
care respiratory therapist and nurses can improve
adherence to coordinated spontaneous awakening trials and spontaneous
breathing trials.
So we went into this,
with,
having had the experience with low tidal volume
ventilation, and we chose
coordination of spontaneous awakening trials and spontaneous breathing
(27:25):
trials because it's a well proven,
process that improves outcomes
in mechanically ventilated patients
and has,
incomplete adherence,
including in our system.
So the objectives,
were to use,
that telehealth enabled real time audit and feedback,
(27:47):
which is the intervention,
to improve adherence to coordinated spontaneous awakening trials
and spontaneous breathing trials in evasively
and mechanically ventilated patients. And we compare that
to control. This is a randomized
step wedge design
and
that's ran where the unit of randomization is
(28:08):
to hospital.
And we, are comparing you know, half the
hospitals are getting the the, telecritical
care intervention, the teach intervention,
but the other half still get all those
things that I showed you that we use
for low tidal volume ventilation,
which is audit and feedback, meaning access to
a dashboard that's updated weekly, but it's they
don't get the support from telecritical
(28:29):
care. So that's what we're testing. So the
type 2 hybrid is hybrid effectiveness implementation,
means that we are testing both, an effectiveness
outcome that's ventilator free days to day 28,
and an implementation outcome, which is adherence to
CSAT and SVT.
So this is, the protocol that was published
in implementation science
(28:50):
and let led, to Andy Levine reaching out
to our group about talking to you.
So aim 1,
so, again, getting back to the the basics
of that process I described, evaluate barriers and
facilitators to CSAT SVT.
And what we identified right away was that
our charting was not good to track our
(29:11):
adherence.
So before we even did baseline measurements,
we totally
revamped the nurse and respiratory care charting for
SATs and SBTs,
and, I'll show you how we did that.
And then we developed a metric for adherence
to CSAT,
SBT. Now
this metric is more about
(29:33):
documenting that you that the respiratory therapist and
the nurse the nurses evaluated the patient for
an SAT, and either they're eligible or not
eligible. If they're eligible, they do it, and
that the therapist has documented
whether the patient is eligible for an SBT.
And if they are,
then they perform it. If they're not, then
they document the reason why. And we I'll
(29:54):
show you those drop down menus. Then we're
in the middle of aim 2 right now,
which is to actually test,
the implementation
of teach versus the standard audit and feedback,
in a in
a randomized clinical trial
across our health system.
So, with the experimental intervention and control intervention,
(30:14):
a little more about that, experimental intervention. So
telehealth enabled support, it's the teach intervention,
real time identification of patients eligible for, coordinated
spontaneous awakening trials and spontaneous breathing trials. So
there's input from telehealth based respiratory therapists. So
we we have respiratory therapists. We started out
telecritical care with nurses and physicians,
(30:36):
and now we have,
we cover all the hospitals in Legacy Intermountain,
plus we have other hospitals outside our system
that we cover. And,
we have, pharmacists during the daytime, respiratory,
care,
always during the daytime and into the night,
and, APPs
also help out in there. And so we
(30:57):
have,
in Legacy Intermountain,
5 hospitals that are staffed by intensivist.
They don't have,
daily support. They are as needed, but for
for the teach intervention, they do get daily
support. Then we have,
8 community hospitals that are staffed by hospitals
at the bedside, and telecritical
(31:18):
care physicians
round on all the patients in those ICUs
every day.
So
the control interventions, the usual audit and feedback.
So this is how we revamped the,
SAT. So, there was reasons in a safety
screen if s if the SAT was contraindicated,
then they could document that so we can
(31:39):
track
the reasons why we wouldn't do a spontaneous
awakening trial. And then,
if there was a failure during the trial,
we had these criteria for, failing during the
trial. And same for the SBT, we could,
the respiratory therapist could document
why an SBT was contraindicated
or whether they failed the SBT or passed
(31:59):
it,
and here is failure criteria. So we really
revamped the charting, and we didn't we revamped
the charting and told the,
nurses and respiratory therapists there was new charting.
They had some education on it, but we
didn't push it like it was an implementation.
We just said we were,
revamping charting for to get gain clarity. And
then we developed truth tables on what is
(32:22):
adherence to,
evaluating for an SAT. So I won't go
through each of these, but we looked at
different conditions.
And
we also defined at SAT what we also
found was that there was multiple ways the
nurses did SATs.
Some of them titrated down the propofol.
Some of them turned it off. Some of
(32:42):
them turned the propofol off, but not the
Fentanyl.
And so
we made an SAT. You turn off all
the sedation and you monitor the patient,
and they restart it at half the dose.
So we used the the,
critical Society of Critical Care Medicine
Wake Up and Breathe
kind of protocol,
and
as a standard for the way we did
(33:04):
our SATs.
So this is the truth table for SVTs.
Ultimately, if the patient was extubated before
noon, it didn't that that was a success.
So, then there was, you know, the different
conditions of spontaneous parameters charted,
if they were extubated. And so pretty much,
they had to chart the reason they didn't
(33:24):
do it or they were doing it and
then chart the spontaneous parameters.
And then for coordinated
SAT, SBT,
they had to be done within 2 hours
of each other,
and then
or,
document SAT that passed the documented SPT with
the qualification that the patient was awake and
responding to commands from the SPT was done.
(33:46):
So we created new rules,
and we had,
the these are how we randomized the hospitals.
Now we have
big tertiary hospitals down to very small community
hospitals. So,
we did a block randomization
with the,
2 busiest hospitals
randomized first, and then then the next 2
(34:06):
busiest hospitals randomized next, and then the community
hospitals. LDS Hospital is staffed by intensives,
but it's not a trauma hospital. So this
is the way the randomization
fell
out, from very, you know, big busy trauma
centers down to community hospitals that just don't
have that many mechanically ventilated patients.
And,
(34:26):
the key barriers that we identified was lack
of clarity around definitions and or requirements
for SATs and SBTs.
Professional judgment overrode standard of care. In other
words,
there was sometimes just a decision not to
do it, for not good reason, so we
tried to improve the charting.
(34:47):
Concern for self per patient. This is a
legitimate one. I mean,
especially,
you know, you have to watch the patients
closely during the SAT, and you terminate the
SAT if the patient,
is, looks like they're gonna get out of
their restraints and extubate extubate themselves. And,
the time burden. Now the time burden turns
out not to be as great. We did
(35:08):
these interviews at the end of the COVID
pandemic, and there was a lot of concern
about the time burden,
for, the nurse and respiratory therapist to really
coordinate this before noon and do the right
thing, but that hasn't been as much of
an issue in our post COVID. We're still
we're really busy, but we're back to patient
populations that are more like pre COVID. So
our implementation
(35:28):
strategies to,
is very similar to what we did with
low tunnel volume ventilation.
Provide our RNs and RTs with new definitions
and expectations. That was through that charting.
We identified,
respiratory
therapy, nursing, and physician champions at each site.
We had education sessions.
(35:48):
Physicians were, educated to play a supportive role.
We developed a dashboard
that's updated weekly so that we have that
audit and feedback mechanism for adherence.
And,
on our dashboards, and this is in our
low tidal volume ventilation and our SAT SVT,
we have panels
where it's not just the overall metric that
(36:10):
I've showed you, but we have other pages
in the dashboard where
the,
RT or the nurse manager can actually drill
down to individual patient encounters
and see whether they were adherent to the
SAT or SVT
and then look for opportunities for educating,
providers to improve either nurses or respiratory therapists.
(36:32):
We also have, system wide best practice sharing
forums where we do those,
the teach sites and the non teach sites,
but they get together and they talk about
their experience
improving their adherence and what worked and what
didn't work,
and,
then posters and screensavers in the hospitals, and
then then it's assistance from the telecritical care
(36:52):
nurses for those. So this is,
randomized. So this is where we're at right
now.
We did our, improved the charting late in
2021.
Then we,
educated on the charting, but did not educate
that this was, you know, implementation
of coordinated SAT and SVT.
So we were down here with our combined
(37:13):
SAT, SVT around 40% adherence.
And then,
we ed began a a education
and run-in period, and you can see that
all it took was we just started telling
people we're measuring this, and we want you
to be adherent. This is best practice. You
know, went over the evidence behind it, and
then,
how we you know, it's important to evaluate
(37:35):
every patient every day mechanically
ventilated patient every day. There was different education
for the teach sites versus non teach. And
then we improved adherence, and we've been able
to sustain adherence. Now this is aggregate data.
I'm blinded to,
the performance by arm.
We have a DSMP meeting coming up
in a couple months. That'll be an interim
(37:57):
analysis
about halfway through the trial, and,
there'll be a session with a biostatistician,
and, our biostatistician
presents,
open session, which just aggregate data like this,
not by arm, but then the DSMB will
look at the treatment by arm. We've enrolled
(38:17):
over 5,000 patients,
since, we started the run-in period,
and we have, you know, 1700 patients,
in the baseline period.
So that's that's all I have today, and,
I'm happy to,
answer any questions.
Welcome everybody to our Friday conference,
multidisciplinary
critical care,
conference. It's my pleasure today to introduce our
guest speaker,
doctor Colin Grissom. Doctor Grissom
grew up in Colorado and then came
out to the East Coast and did his
medical school training at the Yale University School
of Medicine.
(00:20):
After that, he went out back to the
West Coast to the University of Washington where
he did internal medicine
residency training followed by fellowship in pulmonary and
critical care medicine at the University of Utah.
He's been out in Utah ever since and
is a professor of medicine in Intermountain Health
and at the University of Utah.
Today,
Andy Levine invited doctor Grissom based on a
(00:41):
paper that was published and work that he's
been doing, and the title of our talk
is implementation of low tidal volume ventilation and
coordinated SAT SPT in a learning health care
system. Doctor Grissom, thank you for joining us
today.
Thanks.
Thanks for having me, and it's, I'm looking
forward to sharing my experiences with the implementation
with you.
(01:01):
I don't have any conflicts.
I work for Intermountain Healthcare,
and Intermountain Healthcare
now,
covers,
a large
section of the, Intermountain West across 7 or
8 states. And what I'm gonna focus on
initially is implementation of low tidal volume ventilation
(01:22):
adherence to a best practice in primarily Utah
and Idaho, which is the legacy,
Intermountain system. This was a multiyear,
project that went through,
a couple different phases, and I'll describe the
education that I,
experienced about implementing best practices across a health
(01:42):
care system.
2 years ago, we merged with a health
care company called SCL, a nonprofit in,
primarily Colorado, Wyoming, and Montana.
And,
I, one of my,
next,
objectives is to spread some of these best
practices into the tertiary
hospitals in in, Colorado and Montana.
(02:05):
So there's a process that,
I have learned through working with the health
care delivery institute at, Intermountain Health.
And as I go through,
the implementation of low tidal volume ventilation and
then where we're at with,
spontaneous awakening trials and spontaneous breathing trials, I'm
gonna
utilize
the components of this process, which is identify
(02:27):
initially identify the the evidence based best practice.
Then,
I
you need to determine if, it's worth it
to implement this. Is there an opportunity for
improvement,
and do you have the key leverage points
to drive
outcomes,
and improve,
care for patients?
(02:47):
And then something I learned,
very important is to have
a,
a measurement system with a metric
that is readily
available as a leading indicator, meaning, like, weekly
gets we updated weekly for local teams to
be able to to measure their progress
against the system goal. And very important
(03:09):
is to,
identify
barriers
and facilitators to implementations. This is most often
achieved by interviewing frontline providers.
And then,
do a pilot implementation
in 1 or a few hospitals and then
spread across the system,
utilizing what you learned from that. So I'm
gonna start with our,
(03:31):
project on implementing,
best practice for low tidal lung protective mechanical
ventilation.
So I'm not going to go into the
evidence behind it,
especially for ARDS.
The evidence is,
overwhelming
that,
low tidal volume ventilation improves outcomes, improves survivals,
and that goes back to the ARDS network
(03:51):
study in 2,000.
And
there's also evidence strong evidence that, for acute
hypoxemic respiratory failure, low tidal volume, lung protective
mechanical ventilation also improves outcomes.
Despite this,
evidence,
there's multiple studies that show that health systems
(04:12):
usually
aren't as adherent to low tidal volume ventilation
as they think. In other words,
everybody agrees it's the right thing to do.
But,
as you,
if you go and measure adherence,
it turns out that,
usually, in in multiple studies,
(04:35):
the adherence to the best practice is not
as high as, the the physician leaders thought
it would be. So the opportunity
arose in 2015
to develop a computerized ventilator protocol in our
new Cerner EMR.
We had a legacy,
EMR that was homegrown, and we did have
computerized ventilator protocols in it. But with our
(04:57):
transition to Cerner in 2016 to 2017,
it was an opportunity to revamp those protocols,
and we they we we'd used the logic
in the ARDS network protocol.
And then in a phased implementation,
we studied adherence,
to,
a protocol that drove, to best practice for
low tidal volume ventilation. So that's the first
(05:19):
experience that I had.
When I started this,
there was very high use at Intermountain Medical
Center and LDS Hospital, and that was because
these protocols had been developed in the legacy
EMR at LDS Hospital. There'd been a lot
of growth,
experiencing the protocols improvement among the physicians,
(05:41):
and respiratory therapists. And then when we opened
a a new tertiary medical center,
Intermountain Medical Center, a lot of the staff
from LDS Hospital went to Intermountain Medical Center,
so there was high use of computerized protocols.
The protocols were available to our other tertiary
trauma hospitals in the system in Utah, but
(06:01):
nobody used them
because,
they were available, but it hadn't been part
of their culture. They hadn't been part of,
the development of the protocols, and they just
didn't use them. So when we,
developed these
protocols in Cerner, it was, you know, an
an electronic decision support
in a computerized protocol,
(06:23):
with 4 different protocols, one that for ventilation
that drove,
respiratory
rate and tidal volume, oxygenation protocol that drove
FiO 2 and PEEP, a weaning assessment, and
then a pressure support CPAP weaning protocol.
We based the our protocols in the acute
respiratory distress syndrome, and they're open loop, so
they're opt in, meaning that,
(06:44):
the physician needs to order them,
and, but they don't have to. They can
they can achieve,
low tidal ion ventilation
using another mode, but, if they use the
computerized protocols,
it'll drive towards adherence to low tidal volume
ventilation.
And,
in
in discussing it with the physicians before we,
(07:05):
implemented this,
even those that were skeptical of utilizing the
computerized protocol, everybody agreed that this is something
unless there's a a good reason not to
use it on a patient, for example, status
asthmaticus
or increased intracranial pressure. This should just be
used on all mechanically ventilated patients and will
gain experience and and have a standard across
(07:27):
the system.
So,
physicians could opt in, and we did develop
I I won't talk about it, but we
did develop a separate neural ventilation protocol
for those patients with increased intracranial pressure that
instead of driving off pH, drove off,
p c o 2 using the lowest tidal
volume close to 6 mils per kilo that
(07:49):
that, maintain a normal, p c o 2
for those patients with increased intracranial pressure. We
studied our implementation
and, a study called the IMPROVENT, implementation of
lung protective ventilation.
It was a quality improvement study across Intermountain
Hospitals with IRB approval for waiver of informed
consent.
We measured adherence to initial set tidal volume.
(08:10):
That was our primary metric,
and,
as
6.5 mils per kilo or less in in
initial set tylenol volume.
We used a phased implementation
as,
the hospitals,
transitioned to the Cerner EMR
over about a year's time,
for the tertiary hospitals, and we tracked the
(08:30):
use of the computerized protocols.
For, education,
myself and, respiratory therapist did a lot of
site visits at the tertiary trauma hospitals. We
did site visits at the community hospitals
where we had a power presentation
showing the evidence behind low tidal volume, lung
protective mechanical ventilation.
And,
then we had a on the website, we
(08:52):
had on a Intermountain Intranet,
we had
a
video
with a talk that I gave, similar to
what we were given at the community and,
tertiary hospitals in the PowerPoint and all this
information and the logic behind the protocol. So
these are the hospitals in Legacy Intermountain as
we phased
in pre implementation,
(09:14):
beginning in about the Q2 of 2016 and
finishing in in the beginning of Q3 of
2017
with Intermountain Medical Center being the last hospital
to go. So adherence
to the protocol. So this chart shows that
metric. I said initial set tidal volume, 6.5
milliliters,
or less and then percent of, use of
(09:35):
the ventilation protocol.
And what I said before, Intermountain Medical Center
and LDS Hospital were high users of the
protocol
and had high adherence, and that's because they
were,
comfortable with the computerized protocols.
The other hospitals,
who that hadn't used computerized protocols before, what
I learned is,
(09:56):
you have to do more than just go
and show them the protocol and then provide
it to them. And
even with coaching,
they just
especially, this is St. George
Hospital. It was renamed several years ago, and
this is Utah Valley, very low adherence. Now
one,
strategy you can use to try to improve
adherence
(10:16):
is,
you know, just have the,
physician leader say this is the right thing
to do. And so the this is a
before and after. All these the blue is
before a conference that we had in the
fall of 2017.
The red is after. And we invited the
CEO of Intermountain to the conference, and he's
a pediatric intensivist, Mark Harrison. We have a
(10:37):
different CEO on that, but at the time,
it was Mark Harrison,
and he was really supportive of,
driving towards, low tidal volume lung protective mechanical
ventilation. So one of your implementation
strategies can be for the leader to say
this is the right thing to do, and
please do it. So that increased. After that
conference, we had increased,
(10:59):
use of the computerized protocols and increased adherence.
But here you can see at these trauma
hospitals, it's still, you know, 40 to 60%,
as and not as high as at Intermountain
Medical Center and LDS Hospital. We published our
experience with this in critical care medicine,
and we did improve. You can see that,
this is
(11:20):
the set initial set tidal volume with interquartile
range.
And, through the period of that phased implementation,
we did decrease variation
and lower tidal volume towards that target 6
mils per kilo, and we did have increased,
adherence to the to the computerized protocols
up to a lot but this is only
(11:41):
at 50% here. So we did see an
association.
Use of the protocols,
drove, adherence and a tighter,
less variation around that target of 6 mils
per kilo. And this is all patients. We
did in this paper, we separate out
ARDS from non ARDS, but,
(12:01):
the, this these are the results for all
patients combined. And for ARDS and non ARDS,
it was about the same adherence. So, you
know, why couldn't we
do better at this?
We have a large health care system of
4,300
about over 4,000 mechanically ventilated patients,
in the legacy Intermountain each year. We had
this electronic decision support tool that could be
(12:23):
used, and,
yet we we were incompletely successful
in, implementing. So
what what we did next was, I partnered
with the Health Care Delivery Institute, and this
was a a care process model that they,
supported.
And then we applied for an NIH grant.
There was an NIH grant for
(12:46):
pilot studies of implementation of best practices in
heart, lung, or blood disease. And our experience
fit with the request for applications, and, we
got the grant. So we had a grant
to study implementation
of, low tidal volume ventilation,
in our health care system. And I partner
with the Health Care Delivery Institute. And we
(13:07):
used implementation
science methods to,
try and improve our adherence. And that started
in 2019,
and our pilot study,
ended just, in early 2020,
and we spread that best practice across,
Intermountain. We had a large team,
with,
pulmonary critical care physicians, respiratory therapy, and data
(13:30):
analysts, and and the, implementation
scientists from, the Health Care Delivery Institute. So
we did a a mixed method study where
we,
had a baseline,
objectively measuring clinical care,
adherence to that low tidal volume ventilation and
use of the computerized protocols.
And then we did interviews with frontline providers
(13:52):
to assess barriers and facilitators to delivery of
low tidal volume ventilation for patients with ARDS.
And then we performed a pilot clinical trial
at 3 hospitals to test the interventions to
achieve high adherence,
for all patients with ARDS. So here's,
our our baseline measurement and, you know, the
previous,
data I showed,
(14:13):
adherence across the system to initial set tidal
volume of less than or equal to 6.5
mils kilo is 42%
with variation from 21 to 80% by ICU.
And,
use of the computerized protocol
was 28% with,
0 to 91% for using the ventilation component
of the protocol that drove towards
(14:34):
6 mils per kilo. So,
the the interviews with the respiratory therapist were
key. And anytime you do an implementation,
I found this is really important because the
things I learned, there's no way I would
have learned them,
if we hadn't gone to the frontline providers
and talked to them.
So there was, at the individual level,
(14:55):
it was interesting. Those respiratory therapists
that worked at LDS Hospital or Intermountain Medical
Center saw the computerized protocols as giving them
more autonomy,
giving them control over managing,
the patient,
and they were comfortable with it. They've done
it for a long time. Those,
respiratory therapists at the hospitals that hadn't used
(15:17):
computerized protocols
saw them. The computerized protocols, their perception was
it removed their autonomy.
They just became a conduit for a protocol
that, gave them it was open loop. So
they got the instructions, and they would
approve them or talk to the physician, and
then they would make the adjustments on the
ventilator.
So it was really interesting to see that
(15:38):
difference. And then there was not complete understanding
of, you know, why this was important.
And then I think
that we did we did not have a
a dashboard
with regular updates of how the system was
performing on the our metric of initial set
title volume,
and, we didn't have a goal. We didn't
(15:58):
have,
a system goal for what we defined as
success,
and we did not empower local teams,
to
work on improving their adherence,
with, their own,
local champions, physician and respiratory care champions,
giving them some control over how they could
(16:20):
achieve,
adherence. So we learned a lot from those,
and we performed a pilot clinical trial in,
3 hospitals, tertiary hospitals staffed by intensivists,
developed interventions to address the barriers that I
just discussed, and then we created a metric
as a leading indicator with a dashboard that
was updated weekly, and we identified local respiratory
care and physician champions
(16:40):
to lead process improvement teams and create system
goals. So I'll show you,
this this strategy.
So there's different terms used in implementation science,
daily snapshot audit of key indicators. That just
means on rounds,
you review the mechanical ventilation,
settings and whether you're on target. And if
you're not, is there a good reason not
(17:02):
to be,
or should this,
the protocols be ordered, or why aren't you
on 6 mils per kilo? You know, address
those questions on rounds. Then local process improvement
teams, that's the
physician champion, respiratory care champion who, come up
with experiments or rapid
PDSA cycles to,
(17:23):
try things to try and improve adherence,
and you have that audit and feedback from
a a a dashboard that's updated weekly. Rounding
to influence means those physician champions and respiratory
therapists
go around, while,
other respiratory therapists and physicians are on shift
to talk to them about use of the
protocol. We also developed a separate ARDS screening
(17:46):
tool within our EMR that was helpful too
that identified when a when a patient wasn't
if they had a ratio of less than
or equal to for us, it's 255, but
it's less than or equal to 300 at
c level.
And,
it it it tag tagged those, then we
had an NLP
program that identified when they had bilateral infiltrates,
(18:07):
and it would come up with an alert,
to the physician if they weren't on, the
gold tidal volume.
And that was well received too. So we
developed a new metric, and our new metric
was pretty,
patient centric and had and a high bar.
So while on volume control,
the tidal volume had to be set at
6.5 milliliters per kilogram or less for 90%
(18:28):
of the time while on volume control, and
we allowed the hybrid modes
of PRVC or VC plus.
Then,
the, when not on volume control,
if they weren't on adherent
CPAP or pressure support, meaning to wean the
patient, that means an FiO 2 of 50%
or less
with a PEEP of 10 or less, and
(18:49):
pressure support of 15 or less, then they
were nonadherent, and that time was added to
the denominator.
So, for example, airway pressure release ventilation did
not count as adherent,
but any volume control mode did. Unfortunately, pressure
control did not count as adherent. It had
to be a mode where you set the
the tidal volume. Our overall goal was to
have at least 85%
(19:11):
of encounters,
achieve that,
individual encounter goal.
And,
we set it at 85%
after a parietal analysis where
about 15% of the time, the reasons for
not using the protocol were were,
legitimate. And on our dashboard, we also had
a filter
for cardiac. We could remove cardiac surgery patients
(19:31):
or ECMO patients. But even if we left
them in, we we,
achieved adherence. So this is,
our experience at the 3 pilot
sites, Saint George, MacKady, and Utah Valley, and
the the, data starts when they, go live
with the new Cerner EMR. And you can
see that adherence,
according to that metric that I just showed
you, was really low.
(19:52):
It was below 50%.
And then,
at this time, I was
an academic
physician
and
director of, pulmonary and critical care research,
and I was leading this across the system.
This is when we had the conference that
the CEO attended and it emphasized adherence to
low tidal volume ventilation.
(20:14):
And then, my position changed,
in 2018.
We, reorganized
and,
created a critical care operating lane, and I
became the senior medical director for critical care
across the whole system. So now I wasn't
just the, academic critical care physician from Salt
Lake City,
promoting this. I was now the physician leader
(20:35):
for critical care,
promoting it.
And we continue to improve. This is where
our grant began,
and, we
did those,
analysis of barriers, and then we implemented what
I just described. So I'm gonna show you
the next, I'll show you the the results
from the pilot study.
So we did improve.
Now,
(20:56):
in a interrupt interrupted
time series analysis,
there was actually a secular trend the whole
time towards improvement, so we couldn't clearly say
that the methods that we used resulted in
this improvement. But, nevertheless, it's we continued to
improve is the point during that pilot. And
we finished that pilot trial
in early 2020. So this now goes this
(21:18):
is the same,
metric for adherence.
This is the baseline for the pilot trial,
and this is the intervention
period at those 3 hospitals.
But this is now all hospitals across the
system. So this is all mechanically ventilated patients,
ARDS, non ARDS,
and,
we improved adherence.
(21:38):
And when we then were able to spread
this across the whole system, we had
greater than 90% adherence, and then COVID hit.
And, so it was fortunate. The timing was
fortunate, so we had many more COVID ARDS
patients, and we maintained that adherence
to low tidal volume ventilation.
And it and it wasn't easy. This this
was challenging, especially at Utah Valley where
(22:01):
they relied,
almost exclusively on airway pressure release ventilation for,
their severe ARDS,
and they just weren't comfortable because they hadn't
used volume control for those severe ARDS patients
in a long time or or even a
hybrid mode. And I went down there, and
I gave them a talk, and this is
just, anecdote of the experience,
(22:23):
that what it takes sometimes
to be persistent
and,
to to achieve
success at adherence to best practice. But I
gave my talk on the reasons why we
were gonna go to the standard low tidal
volume ventilation across the system with the with
the protocol. And one of the senior physicians
there listened to my talk. He goes, you
know, Colin, that that really sounds great.
(22:45):
Very impressive. But but I had a really
sick patient with ARDS last night, and I
put him on, airway pressure release ventilation, and
he's better today. And I was like, okay.
You know, how do I respond to that?
And so what I said to him is
I said, well, Clark,
I had a really sick patient last night
with severe ARDS, and I put him on
low tidal volume lung protective mechanical ventilation with
(23:07):
volume control, and he's better today. So,
and then I tried to emphasize the point
that that we should base our practice on
on,
clinical trials and evidence and and not on
our most recent successful experience with something. And
I would also emphasize to him that, yeah,
there are different ways. There there are different
ways to achieve,
(23:28):
low tidal volume ventilation, but as a system,
we we should agree on one way, and
then we should try to improve that process
through, protocol. So that was our philosophy.
Now did we influence mortality? This is raw
mortality, and we're just starting to look at
this. It it it's hard because these two
peaks right here, increases in mortality. That's the
COVID pandemic.
(23:49):
So, there's no clear,
signal for, decreasing raw mortality
in mechanically dillated patients. Now we are in
the process of looking at mortality
and other outcomes, and what we found is
that there's the after adjustment for all,
thing all factors that may contribute to length
(24:10):
of stay, we achieved,
a decrease in,
ICU length of stay
as there was that was associated with the
increasing adherence to the to the,
low tidal volume ventilation and the protocols. And
even a half a day across the system
I'll show you some data that our our
finance,
(24:31):
financial analyst prepared, and this is our,
five
hospitals in Legacy Intermountain that are staffed by
Intensivists.
And, achieving even a half day,
to a day,
results in in,
1,000,000 of dollars of of, savings,
cost savings,
which,
we operate with, in legacy Intermountain,
(24:54):
close to 50%
value based care,
and and so this is important for us,
meaning that we are,
paid upfront for a cohort of patients, and,
we need to take care of them with
the highest quality and the lowest cost.
So important for us. So the the last
thing that we need to do now, I
showed you the the map, and we have,
(25:15):
6 hospitals
in, Montana and Colorado
that are now part of Intermountain
that have no mechanical dental, ventilation
mechanical ventilation database.
They all say this is the right thing
to do, adherence to low tidal volume ventilation,
but they don't know,
whether they have an opportunity for improvement. So
we're starting
(25:36):
with one of those hospitals
in, Denver,
and oh, I I don't have it. But
we're starting to build a mechanical ventilation database,
and,
we've so far, the initial data looks like
there's about 50 to 60% adherence using that
metric that I showed you.
And so,
(25:57):
the differences are, we're we're gonna move to
an EPYC EMR,
and they're on EPIC, but it's gonna take
a year and a half to build the
protocols in EPIC. So they're gonna start out
with paper protocols,
and we'll pilot it at, one of the
hospitals in Denver
and,
start working towards improving the adherence
so that, we can, across those hospitals in,
(26:20):
Montana and Colorado that are now part of
Intermountain.
So that's my experience with low tidal volume
ventilation, and we're in the middle
of,
implementation
of coordinated spontaneous awakening trials and spontaneous breathing
trials.
And
a lot of the same principles that
(26:40):
we learned through low tidal volume ventilation,
we applied to,
implementation of, spontaneous awakening breathing trials. And this
is also, funded by the NHLBI
as a,
implementation study. We're actually doing a clinical trial
as part of this implementation. I'll explain that.
The clinical trial is as testing the hypothesis
(27:03):
as to whether
real time,
support from telecritical
care respiratory therapist and nurses can improve
adherence to coordinated spontaneous awakening trials and spontaneous
breathing trials.
So we went into this,
with,
having had the experience with low tidal volume
ventilation, and we chose
coordination of spontaneous awakening trials and spontaneous breathing
(27:25):
trials because it's a well proven,
process that improves outcomes
in mechanically ventilated patients
and has,
incomplete adherence,
including in our system.
So the objectives,
were to use,
that telehealth enabled real time audit and feedback,
(27:47):
which is the intervention,
to improve adherence to coordinated spontaneous awakening trials
and spontaneous breathing trials in evasively
and mechanically ventilated patients. And we compare that
to control. This is a randomized
step wedge design
and
that's ran where the unit of randomization is
(28:08):
to hospital.
And we, are comparing you know, half the
hospitals are getting the the, telecritical
care intervention, the teach intervention,
but the other half still get all those
things that I showed you that we use
for low tidal volume ventilation,
which is audit and feedback, meaning access to
a dashboard that's updated weekly, but it's they
don't get the support from telecritical
(28:29):
care. So that's what we're testing. So the
type 2 hybrid is hybrid effectiveness implementation,
means that we are testing both, an effectiveness
outcome that's ventilator free days to day 28,
and an implementation outcome, which is adherence to
CSAT and SVT.
So this is, the protocol that was published
in implementation science
(28:50):
and let led, to Andy Levine reaching out
to our group about talking to you.
So aim 1,
so, again, getting back to the the basics
of that process I described, evaluate barriers and
facilitators to CSAT SVT.
And what we identified right away was that
our charting was not good to track our
(29:11):
adherence.
So before we even did baseline measurements,
we totally
revamped the nurse and respiratory care charting for
SATs and SBTs,
and, I'll show you how we did that.
And then we developed a metric for adherence
to CSAT,
SBT. Now
this metric is more about
(29:33):
documenting that you that the respiratory therapist and
the nurse the nurses evaluated the patient for
an SAT, and either they're eligible or not
eligible. If they're eligible, they do it, and
that the therapist has documented
whether the patient is eligible for an SBT.
And if they are,
then they perform it. If they're not, then
they document the reason why. And we I'll
(29:54):
show you those drop down menus. Then we're
in the middle of aim 2 right now,
which is to actually test,
the implementation
of teach versus the standard audit and feedback,
in a in
a randomized clinical trial
across our health system.
So, with the experimental intervention and control intervention,
(30:14):
a little more about that, experimental intervention. So
telehealth enabled support, it's the teach intervention,
real time identification of patients eligible for, coordinated
spontaneous awakening trials and spontaneous breathing trials. So
there's input from telehealth based respiratory therapists. So
we we have respiratory therapists. We started out
telecritical care with nurses and physicians,
(30:36):
and now we have,
we cover all the hospitals in Legacy Intermountain,
plus we have other hospitals outside our system
that we cover. And,
we have, pharmacists during the daytime, respiratory,
care,
always during the daytime and into the night,
and, APPs
also help out in there. And so we
(30:57):
have,
in Legacy Intermountain,
5 hospitals that are staffed by intensivist.
They don't have,
daily support. They are as needed, but for
for the teach intervention, they do get daily
support. Then we have,
8 community hospitals that are staffed by hospitals
at the bedside, and telecritical
(31:18):
care physicians
round on all the patients in those ICUs
every day.
So
the control interventions, the usual audit and feedback.
So this is how we revamped the,
SAT. So, there was reasons in a safety
screen if s if the SAT was contraindicated,
then they could document that so we can
(31:39):
track
the reasons why we wouldn't do a spontaneous
awakening trial. And then,
if there was a failure during the trial,
we had these criteria for, failing during the
trial. And same for the SBT, we could,
the respiratory therapist could document
why an SBT was contraindicated
or whether they failed the SBT or passed
(31:59):
it,
and here is failure criteria. So we really
revamped the charting, and we didn't we revamped
the charting and told the,
nurses and respiratory therapists there was new charting.
They had some education on it, but we
didn't push it like it was an implementation.
We just said we were,
revamping charting for to get gain clarity. And
then we developed truth tables on what is
(32:22):
adherence to,
evaluating for an SAT. So I won't go
through each of these, but we looked at
different conditions.
And
we also defined at SAT what we also
found was that there was multiple ways the
nurses did SATs.
Some of them titrated down the propofol.
Some of them turned it off. Some of
(32:42):
them turned the propofol off, but not the
Fentanyl.
And so
we made an SAT. You turn off all
the sedation and you monitor the patient,
and they restart it at half the dose.
So we used the the,
critical Society of Critical Care Medicine
Wake Up and Breathe
kind of protocol,
and
as a standard for the way we did
(33:04):
our SATs.
So this is the truth table for SVTs.
Ultimately, if the patient was extubated before
noon, it didn't that that was a success.
So, then there was, you know, the different
conditions of spontaneous parameters charted,
if they were extubated. And so pretty much,
they had to chart the reason they didn't
(33:24):
do it or they were doing it and
then chart the spontaneous parameters.
And then for coordinated
SAT, SBT,
they had to be done within 2 hours
of each other,
and then
or,
document SAT that passed the documented SPT with
the qualification that the patient was awake and
responding to commands from the SPT was done.
(33:46):
So we created new rules,
and we had,
the these are how we randomized the hospitals.
Now we have
big tertiary hospitals down to very small community
hospitals. So,
we did a block randomization
with the,
2 busiest hospitals
randomized first, and then then the next 2
(34:06):
busiest hospitals randomized next, and then the community
hospitals. LDS Hospital is staffed by intensives,
but it's not a trauma hospital. So this
is the way the randomization
fell
out, from very, you know, big busy trauma
centers down to community hospitals that just don't
have that many mechanically ventilated patients.
And,
(34:26):
the key barriers that we identified was lack
of clarity around definitions and or requirements
for SATs and SBTs.
Professional judgment overrode standard of care. In other
words,
there was sometimes just a decision not to
do it, for not good reason, so we
tried to improve the charting.
(34:47):
Concern for self per patient. This is a
legitimate one. I mean,
especially,
you know, you have to watch the patients
closely during the SAT, and you terminate the
SAT if the patient,
is, looks like they're gonna get out of
their restraints and extubate extubate themselves. And,
the time burden. Now the time burden turns
out not to be as great. We did
(35:08):
these interviews at the end of the COVID
pandemic, and there was a lot of concern
about the time burden,
for, the nurse and respiratory therapist to really
coordinate this before noon and do the right
thing, but that hasn't been as much of
an issue in our post COVID. We're still
we're really busy, but we're back to patient
populations that are more like pre COVID. So
our implementation
(35:28):
strategies to,
is very similar to what we did with
low tunnel volume ventilation.
Provide our RNs and RTs with new definitions
and expectations. That was through that charting.
We identified,
respiratory
therapy, nursing, and physician champions at each site.
We had education sessions.
(35:48):
Physicians were, educated to play a supportive role.
We developed a dashboard
that's updated weekly so that we have that
audit and feedback mechanism for adherence.
And,
on our dashboards, and this is in our
low tidal volume ventilation and our SAT SVT,
we have panels
where it's not just the overall metric that
(36:10):
I've showed you, but we have other pages
in the dashboard where
the,
RT or the nurse manager can actually drill
down to individual patient encounters
and see whether they were adherent to the
SAT or SVT
and then look for opportunities for educating,
providers to improve either nurses or respiratory therapists.
(36:32):
We also have, system wide best practice sharing
forums where we do those,
the teach sites and the non teach sites,
but they get together and they talk about
their experience
improving their adherence and what worked and what
didn't work,
and,
then posters and screensavers in the hospitals, and
then then it's assistance from the telecritical care
(36:52):
nurses for those. So this is,
randomized. So this is where we're at right
now.
We did our, improved the charting late in
2021.
Then we,
educated on the charting, but did not educate
that this was, you know, implementation
of coordinated SAT and SVT.
So we were down here with our combined
(37:13):
SAT, SVT around 40% adherence.
And then,
we ed began a a education
and run-in period, and you can see that
all it took was we just started telling
people we're measuring this, and we want you
to be adherent. This is best practice. You
know, went over the evidence behind it, and
then,
how we you know, it's important to evaluate
(37:35):
every patient every day mechanically
ventilated patient every day. There was different education
for the teach sites versus non teach. And
then we improved adherence, and we've been able
to sustain adherence. Now this is aggregate data.
I'm blinded to,
the performance by arm.
We have a DSMP meeting coming up
in a couple months. That'll be an interim
(37:57):
analysis
about halfway through the trial, and,
there'll be a session with a biostatistician,
and, our biostatistician
presents,
open session, which just aggregate data like this,
not by arm, but then the DSMB will
look at the treatment by arm. We've enrolled
(38:17):
over 5,000 patients,
since, we started the run-in period,
and we have, you know, 1700 patients,
in the baseline period.
So that's that's all I have today, and,
I'm happy to,
answer any questions.
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