Respiratory therapists at the Hospital for Special Care in New Britain, Conn., perform the high-risk, high-volume process of ventilator setups and checks many times over each and every day. Their consistent approach keeps them focused on maximizing patient safety.
HSC is a private, not-for-profit 228-bed rehabilitation, long-term acute and chronic care hospital. Within the hospital, there are patient care units that specialize in the care and management of long-term adult and pediatric ventilator patients, as well as units that specialize in ventilator weaning. RTs care for up to 100 ventilator-dependent patients, in addition to a large number of patients with other complex medical needs. HSC incorporates the use of American Association for Respiratory Care Clinical Practice Guidelines in their policies and procedures to ensure best practices.
Ventilator circuit setup is not customized for individual patients. Although more than one type of ventilator is used to meet the varied ventilation needs of our adult and pediatric patients, the standard setup includes a single limb, double lumen circuit and a heat moisture exchanger (HME). The single limb circuit contributes to less tubing at the bedside and less weight on the airway.
For humidity, a high efficiency HME is used, unless contraindicated by the patient's condition. The HME is more cost effective than an active humidification system and provides a more consistent level of humidification at body temperature. The patient's airway resistance is closely monitored as an indicator of the need to change out the HME.
A closed circuit in-line suction system is standard practice at HSC, in an effort to prevent contamination, promote infection control, and to reduce tissue injury and excessive alveolar collapse associated with open suctioning. Closed suctioning also is cost conservative when compared to open suctioning.
An equipment change schedule is utilized, and ventilator circuits are changed every other month. Routine maintenance is important to achieve optimal ventilator performance and patient safety. Policies are in place dictating the proper care of the ventilator while in use. Ventilators are wiped down with disinfectant weekly. Filters are cleaned once per week, and every ventilator has a preventive maintenance schedule based on the manufacturers' guidelines.
Before placing any patient on mechanical ventilation, the RT performs a self test for that particular ventilator and then programs the initial settings based on the physician's order for mechanical ventilation. Once the patient is placed on the ventilator, the RT evaluates the patient, confirms the ventilators settings, measures patient parameters, and verifies alarms. Additionally, the RT checks cuff pressures utilizing the minimal leak technique on the adult units, and records actual pressures daily on the pediatric unit.
The RT completes subsequent assessments twice per eight hour shift. These assessments include routine inspection to ensure that the ventilator is plugged into an emergency outlet that is generator-powered in the event of a power loss. The HSC ventilator fleet also is equipped with extended battery life capabilities.
All ventilator patients are connected to a remote monitoring system. RTs carry pagers and have access to desktop and laptop computers that alert them to ventilator alarms that may be signaling changes in a patient's condition.
Initial and ongoing evaluation of RTs' competency in the use of mechanical ventilators and associated assessments are vital to safe and efficient clinical practices. HSC RTs are required to complete an initial and annual (at minimum) psychomotor and oral competency test on performing an assessment of the patient-ventilator interface. The RT must demonstrate critical thinking skills and articulate the entire process from verifying physician orders to proper documentation.
A rigorous approach to VAP
Minimizing Ventilator Associated Pneumonias (VAPs) poses challenges for any institution. This is particularly true in long-term care institutions such as HSC. Patients in this type of facility are at increased risk due primarily to the fact that they have an artificial airway in place far beyond 48 hours. The additional risk factors of indwelling urinary catheters, lines and tubes for nutritional purposes, impaired swallowing, and limited mobility due to age and disability, provide additional challenges at HSC.
Despite all these factors, HSC maintains a low VAP rate of 1.05 percent. This is in tribute to our rigorous infection control policy, specifically with regards to hand washing and gloving. Other contributing factors include minimizing circuit/patient disconnects, closed suctioning, and thorough oral cleansing routines.
The single limb, double lumen ventilator circuit and HME setup reduces the frequency of circuit changes to every other month, as described above. Since the ventilator circuit stays dry, patients receiving bronchodilator therapy via a small volume nebulizer can keep it in line, again reducing circuit/patient disconnects. The use of unit-dose vials are standard practice at HSC.
Maintenance of the patient's nutritional status also is of great importance. Proper nutrition improves the patient's ability to defend against pathogens.
Looking forward, HSC is exploring trachesostomy tubes that provide for the aspiration of the subglottic secretions that collect above the tracheostomy tube cuff. This may further reduce the current VAP rate.
As outlined here, many factors come into play when performing ventilator setups and checks. No one is any less important than any other. It is the sum of all these elements that assures the utmost in patient safety.
Lorraine Cullen, BA, RRT, is night shift respiratory care services supervisor. Connie C. Dills, MBA, RRT, RPFT, is clinical educator respiratory care services. Mary Turley, MS, RRT, is director of respiratory care services. All three work at the Hospital for Special Care, New Britain, Conn.