Background: As the acuity of hospitalized patients increases, there have been an increasing number of patients requiring mechanical ventilation on the general medical units (GMU). Ventilated patients in intensive care units (ICUs) have a standardized approach to minimize the risks for complications such as ventilator associated events (VAE), GI bleeding and VTE. When patients requiring continued mechanical ventilation are transferred out of ICU, this standardized approach is not continued routinely. In addition, there are many chronically ventilated patients admitted to the GMUs who presently may not receive this bundle of care. These patients commonly have a prolonged length of stay (LOS).We hypothesized that a multidisciplinary pulmonology, infectious diseases, and internal medicine team conducting independent “Vent Rounds” could optimize antimicrobial use and LOS for mechanically ventilated patients on GMUs.
Methods: Ventilated adult patients admitted to GMUs were retrospectively reviewed via electronic health records. Pre-intervention patients (Dec 2016-Mar 2017) received standard medical care while post-intervention patients (Apr-Sept 2017) received standard medical care plus pulmonary, antimicrobial, and discharge planning recommendations twice a week during “Vent Rounds”. The primary outcomes were GMU LOS, total days of systemic antimicrobials and VAE incidence as defined by NHSN (National Healthcare Safety Network) surveillance criteria. DATA MANAGEMENT AND ANALYSIS We compared the demographic and clinical characteristics of patients admitted before and after the intervention using t-tests, Chi-squared tests, and non-parametric tests, as appropriate. Next, examined the associations between the intervention and each of the outcome measures using generalized estimating equations (GEE) with identity link for normally distributed continuous outcomes, logit link, binomial distribution for dichotomous outcomes, and log link, Poisson distribution for non-normally distributed continuous outcomes, accounting for clusters of multiple admissions within patients. Finally, to determine the independent association between the intervention and each of the outcomes, we constructed GEE models including demographic and clinical characteristics as adjustment variables.
Results: There were no differences between the pre and post intervention groups with regard to age (mean 68.5 vs 69.5 years, p=0.68), gender (43.7% female vs 57.9% female p=0.11), and race/ethnicity (p=0.44). The majority of patients in both the pre and post intervention groups were chronic vent dependent respiratory failure (60 vs 67% p=0.41). The rest of the patients were new respiratory failure requiring tracheostomy. There were fewer VAEs (as defined by strict NHSN criteria) in the pre-intervention group than the post, however it was not statistically significant and the numbers were small. (2 vs 8 events, p=36) There was tremendous and statistically significant reduction in LOS in the post intervention group (23.9 vs 16.7 days, p=0.0089).The post intervention group also had significantly fewer antibiotic days (17.5 vs 11.6 days, p= 0.0466).
Conclusions: Multidisciplinary GMU vent rounds are feasible in a similar setting. Vent Rounds can decrease LOS and antimicrobial use, which can substantially reduce healthcare costs.