Implementation of a Goal-Directed Mechanical Ventilation Order Set Driven by Respiratory Therapists Improves Compliance With Best Practices for Mechanical Ventilation

Misty A Radosevich; Brendan T Wanta; Todd J Meyer; Verlin W Weber; Daniel R Brown; Nathan J Smischney; Daniel A Diedrich

doi:10.1177/0885066617746089

Implementation of a Goal-Directed Mechanical Ventilation Order Set Driven by Respiratory Therapists Improves Compliance With Best Practices for Mechanical Ventilation

J Intensive Care Med. 2019 Jul;34(7):550-556. doi: 10.1177/0885066617746089. Epub 2017 Dec 5.

Authors

Misty A Radosevich¹, Brendan T Wanta¹, Todd J Meyer², Verlin W Weber², Daniel R Brown¹, Nathan J Smischney¹, Daniel A Diedrich¹

Affiliations

¹ 1 Department of Anesthesiology-Critical Care, Mayo Clinic, Rochester, MN, USA.
² 2 Department of Respiratory Care, Mayo Clinic, Rochester, MN, USA.

PMID: 29207907
DOI: 10.1177/0885066617746089

Abstract

Purpose: Data regarding best practices for ventilator management strategies that improve outcomes in acute respiratory distress syndrome (ARDS) are readily available. However, little is known regarding processes to ensure compliance with these strategies. We developed a goal-directed mechanical ventilation order set that included physician-specified lung-protective ventilation and oxygenation goals to be implemented by respiratory therapists (RTs). We sought as a primary outcome to determine whether an RT-driven order set with predefined oxygenation and ventilation goals could be implemented and associated with improved adherence with best practice.

Methods: We evaluated 1302 patients undergoing invasive mechanical ventilation (1693 separate episodes of invasive mechanical ventilation) prior to and after institution of a standardized, goal-directed mechanical ventilation order set using a controlled before-and-after study design. Patient-specific goals for oxygenation partial pressure of oxygen in arterial blood (Pao ₂), ARDS Network [Net] positive end-expiratory pressure [PEEP]/fraction of inspired oxygen [Fio ₂] table use) and ventilation (pH, partial pressure of carbon dioxide) were selected by prescribers and implemented by RTs.

Results: Compliance with the new mechanical ventilation order set was high: 88.2% compliance versus 3.8% before implementation of the order set ( P < .001). Adherence to the PEEP/Fio ₂ table after implementation of the order set was significantly greater (86.0% after vs 82.9% before, P = .02). There was no difference in duration of mechanical ventilation, intensive care unit (ICU) length of stay, and in-hospital or ICU mortality.

Conclusions: A standardized best practice mechanical ventilation order set can be implemented by a multidisciplinary team and is associated with improved compliance to written orders and adherence to the ARDSNet PEEP/Fio ₂ table.

Keywords: computerized physician order entry; protocols; quality improvement; respiratory therapist-driven protocols; ventilator management.

MeSH terms

Adult
Aged
Continuous Positive Airway Pressure*
Critical Care*
Female
Guideline Adherence*
Humans
Intensive Care Units
Male
Middle Aged
Positive-Pressure Respiration*
Practice Guidelines as Topic
Quality Improvement
Respiratory Distress Syndrome / physiopathology
Respiratory Distress Syndrome / therapy*
Tidal Volume / physiology*