[MUSIC]
For years, those of us who have cared for mechanically
ventilated patients have taken a very narrow view of success.
Did we keep them free of complications,
including pneumonia?
Were we able to move them out of the ICU alive?
Historically, we keep patients on the ventilator heavily
sedated and
we rely on a physician's judgement to determine whether
patients can breathe well enough on their own.
Despite these good intentions,
we have learned that this approach carries risks.
Months or years after leaving the hospital
patients can be plagued with debilitating muscle weakness.
Many patients complain that they cannot climb up the stairs in
their home or get back to the activities that they enjoyed.
They often have recurrent nightmares
as their brains replay visions of horrible things that they
believe they saw when they were delirious in the hospital.
They can suffer from post traumatic stress disorder,
remembering the experiences of lying immobile and
not knowing what was happening to them.
They even have trouble thinking clearly at work or
simply balancing their checkbooks.
[MUSIC]
As these long term outcomes have come into focus,
we are beginning to redefine what it means to successfully
treat a ventilated patient.
All current therapies point to the importance
of reducing these complications by getting patients
off the ventilator as soon as possible.
Here at the Johns Hopkins Armstrong Institute,
we are drawing on published guidelines and have incorporated
three groups of interventions into our improvement approach.
And we're working with hospitals across the country to put
them into place.
The first set involves creating an overarching protocol to
address ventilated patient's pain, agitation, and delirium.
For example, once a day, we should assess the patient's
readiness to have their breathing tube removed.
We do this by interrupting their sedation and
allowing them to wake up, simultaneously
getting them to breathe on their own, without a ventilator.
Patients should also be screened every day for delirium, and
we should actively try to reverse that.
The next set of interventions focuses on getting
ventilated patients moving earlier in their ICU stay.
Every day we should evaluate the maximal level of mobility
that a patient can achieve safely.
And then we should strive to help them meet those goals.
This might mean turning the patient from side-by-side in
bed, dangling their legs from the edge of the bed, or
even walking the patient within the intensive care unit
while still on a ventilator.
The third area involves preventing acute lung injury
through the use of low tidal volume ventilation,
which ensures that the ventilator does not force
too much air into the patient's lungs.
For decades, we have known that decreasing the tidal volume that
patients receive on a ventilator is an effective
strategy to treat acute lung injury.
Now we know it's also a strategy to prevent complications that
can prolong the need for mechanical ventilation and
lead to significant morbidity and mortality.
We see that when we can perform these steps regularly,
patients benefit by reducing short term and
long term complications, but so do our hospitals.
Where we see gains in throughput and efficiency, by getting
patients off the ventilator and out of the hospital faster.
In 2014, the CDC reported that 12 ICUs had reduced
complications associated with ventilation through the use
of daily combined awakening and breathing trials.
The program decreased the duration of ventilation
by nearly two and a half days and
decreased hospital length of stay by more than six days.
[MUSIC]
Translating these steps into everyday practice is no simple
task.
It requires frontline care providers to coordinate
their efforts.
It involves changing attitudes and
accepting new ways of thinking about our role as healers.
That is where the Johns Hopkins Armstrong Institute comes in.
Together with Harvard, the Michigan Key Stone Center and
other collaborators, we have packaged the evidence into
a program that not only provides a practical approach to
implement these evidence-based interventions, it also provides
a framework to engage frontline staff and provide the training
and leadership support that they need to improve care.
We believe deeply that this work needs to be lead by
frontline staff.
So the program provides educational content and
guides teams to set up unit-based safety programs.
We give teams practical data collection tools and reports to
help them understand how they are performing over time and
compare to others participating in the program.
Ultimately, we strive to change the culture of critical care.
We need to look beyond the vital signs.
We need to think about more than just helping ventilated patients
to survive, but helping them to recover quickly and to thrive.
[MUSIC]