Problem: Critically ill patients in Intensive Care Units often require mechanical ventilation and may require sedative and analgesic medications to optimize ventilator benefit. Mechanical ventilation, as well as sustained use of these medications, can influence duration of ventilation, length of stay and development of co-morbidities. Use of evidence based Clinical Practice Guidelines (CPGs), in the form of a protocol, can guide care of these patients. Communication and collaboration in the Registered Nurse (RN)/Respiratory Therapist (RT) team who care for these patients and apply this protocol is imperative. Purpose: The purpose of this project was to identify current levels of adherence to a CPG based protocol specific to mechanically ventilated patients at a specific community hospital and to determine barriers to that adherence, and develop a plan for improved adherence to the CPG based protocol. Goal: The goal of this project was to facilitate improved teamwork, communication and collaboration in the RN/RT team through development of a plan to improve adherence to a CPG based protocol for mechanically ventilated patients. Objectives: First, to describe current levels of adherence to a CPG based protocol specific to mechanically ventilated patients, compare those levels to published literature and communicate the information to staff. Second, to invite staff to identify barriers to protocol adherence. Third, to prioritize identified barriers. Fourth, to invite staff suggestions for improvement to identified barriers and outcome measures for success. Fifth, to compare these suggestions to literature. Sixth, to invite staff to develop a plan to improve adherence to the CPG based protocol. Plan: In this four phase quality improvement project current data regarding protocol adherence was considered, staff was engaged to identify barriers to adherence and make suggestions for improvement, their suggestions were compared to evidence-based literature and a new plan was developed. Outcomes and Results: Key findings revealed baseline adherence rates to the CPG based protocol ranging from 35.3 to 78.8%. Staff identified sixteen barriers to protocol adherence. Staff prioritized barriers of difficulty with process timing, concerns regarding absence of RTs during the process, prolonged ventilation related to timing of physician rounds, process disruption by morning X-Rays, and discontinuation of sedation. Staff made multiple suggestions for improvement in the process, centering around the themes of process timing, elements of safety screening for the spontaneous awakening trial, technique for discontinuing or decreasing sedation, technique for restarting sedation, and clarification of the description of agitation. Collaboration and communication in the RN/RT team resulted in development of a new process for application of a CPG based protocol, with the goal of improved adherence.
