We hypothesized that the protocol driven process would decrease ICU length of stay.
An increased Length of Stay (LOS) in Surgical Intensive Care Unit (SICU) requires increased resource utilization and increases patient risk for possible infections and complications. The SICU implemented protocols and programs encompassing inter-professional collaboration with surgical attendings, residents, pharmacists, respiratory therapists, and ancillary staff to increase communication and build team morale. The aim of these initiatives was, and continues to be, for better patient outcomes, thus decreasing length of stay in the ICU. The first protocol to be initiated was the “Wake-Up” Assessment which uses sedation interruption and spontaneous breathing trials. These interventions have led to early extubation and decreases in unplanned extubation, ventilator days, and hospital length of stay (Girard, 2008) (Mendez, 2013). The Wake-Up Assessment standardized the process of early extubation through the collaboration of Register Nurses (RN), respiratory therapy, pharmacy, and physicians. The night shift RN assesses based on the criteria checklist for the appropriateness of a Wake-Up Assessment. Day shift RNs hold sedation and reassess based on the chart developed by pharmacy for an appropriate response and notify respiratory therapists for the initiation of ventilator weaning. The second protocol involving pharmacy, nurses, and physicians was the Modified Minnesota Detoxification Scale (MINDS) protocol. Education was provided by the SICU Pharmacists and Clinical Nurse Educators on MINDS protocol steps. The SICU was the trial unit for this protocol. The MINDS enables early treatment of patients with suspected alcohol withdrawal and provides nurses and physicians a guide to determine benzodiazepine treatment of withdrawal patients. The literature has shown a significant decrease in the time needed to control symptoms and overall decrease in usage of sedatives (Dixit, 2016) (Ycaza-Guiterrez) .
Study Design: Retrospective
Method: LOS data was collected prior to implementation of the Wake-Up Assessment and MINDS protocol, and compared to LOS data collected after those protocols were implemented. Ventilator days and self-extubation incidents were collected for the evaluation of Wake-Up Assessment protocol. In addition, benzodiazepine usage was reviewed for the MINDS protocol.
Results: For the Wake-Up assessment, we have seen a decrease from 9.9 days to 8.5 days in the ICU LOS pre and post initiation, respectively (n=24). For the MINDS protocol, we have seen a decrease in ICU LOS from 10.5 days to 8.7 days, pre and post initiation respectively (n=42). While these numbers were not statistically significant at the time of collection, continuing evaluation will result in a larger sample size.
Limitation: Barriers to LOS results were the inability to capture whether an increase was due to clinical conditions versus bed availability.
Conclusion: The two protocols demonstrate how interdisciplinary collaboration is used to achieve improved patient outcomes. Decreases in LOS in both patient populations are being achieved with the standardization of care. The need for continuing education in an academic medical/nursing institution is an ongoing challenge. The successful trials of Wake-Up Assessment and MINDS have led to the implementation of these protocols in all of our critical care units.