Tele Intensive Care Unit Nurse-Directed Low Tidal Volume Ventilator Rounds: A Quality Improvement Project

Abstract

Background: Mechanically ventilated critical ill patients are at an increased risk of developing ventilator induced lung injury. The use of high tidal volume (Vt) (12 to 15 ml/kg predicted body weight (PBW)) ventilation causes the alveoli to overstretch, which causes often irreversible injury to the lungs. A Meta-analysis found that about 4.22% of patients assigned to low Vt ventilation developed lung injury while 12.66% of patients developed lung injury with high Vt ventilation. The Acute Respiratory Distress Syndrome Network have recommended the use of low Vt (<8ml/kg PBW) ventilation for patients with Acute Respiratory Distress Syndrome (ARDS). Low Vt ventilation decreases mortality rate for ARDS patients. Low Vt ventilation also benefits critically ill patients without ARDS. Despite known benefits of low Vt ventilation, adherence is low. Adherence of low Vt ventilation in a major academic medical center was reported at 31.2%. An innovative way to increase adherence is the use of Tele-Intensive Care Unit (TeleICU) nurse-directed daily ventilator rounds. TeleICU ventilator rounds have been shown to increase adherence to low Vt ventilation for ARDS and non-ARDS patients. Methods: This DNP quality improvement project will use the descriptive study design to evaluate the use of the TeleICU nurse-directed ventilator rounds checklist for critically ill mechanically ventilated patients on: 1) usability, 2) effectiveness, and 3) adherence to low Vt ventilation protocol. The participants will be the TeleICU nurses who will be gathering data from ICU adult patients that require mechanical ventilator support for more than 24 hours. The total target number of TeleICU nurses would be about six and total number of patients would be 20. The DNP QI project will be done for two weeks. The setting will be the TeleICU department in Mesa, Arizona. Another setting is a rural hospital’s ICU unit, located in the state of Arizona. Results: The TeleICU low Vt ventilator rounds checklist was scored by the TeleICU nurses to be useful (Mean 80 points, Range 58 to 100). The TeleICU nurses also found the TeleICU low Vt ventilator rounds checklist to be easy to use (Mean 75.94 points, Range 45 – 100). The QI project also found that the TeleICU nurses are open to integrating the low Vt ventilator rounds checklist into their daily workflow (Mean 87.5%). The low Vt ventilator rounds checklist was successful at identifying patients not on low Vt ventilation protocol and that TeleICU intensivist made the necessary changes to the patients ventilator settings. Lastly, the QI project was able to make an improvement in the adherence of low Vt ventilation at Banner Casa Grande ICU. Conclusion: Low Vt ventilation benefits patients with ARDS and non-ARDS patients. The TeleICU low Vt ventilator rounds checklist is usable, effective and increased adherence to low Vt ventilation for ARDS and non-ARDS patients. The TeleICU are open to integrating the TeleICU low Vt ventilator rounds checklist on their daily workflow.