Daily AM Wake Up Assessment Decreases Unplanned Extubation and Ventilator Associated Pneumonia (VAP) in the ICU

Purpose:
Unplanned extubation and ventilator associated pneumonia (VAP) were identified as clinical issues in the Trauma ICU. A multidisciplinary daily AM wake up assessment protocol was developed and implemented to decrease the number of unplanned extubations and VAP rate.

Significance:
Unplanned extubation and VAP are significant clinical factors that can lead to increased morbidity and mortality. In addition, the financial impact associated with these factors, extended ventilator days, ICU length of stay (ICULOS), and hosptial length of stay (HLOS), can have a negative impact.

Strategy and Implementation:
The daily AM wake up protocol was developed by a multidisciplinary trauma team and included the weaning of sedation and the use of the Richmond Agiation Sedation Scale (RASS). All ventilated patients admitted to the Trauma ICU from 2010 (non-protocol group) to 2011 (protocol group) were compared. The following data points were collected for both groups: unplanned extubation, need for re-intubation, VAP, injury severity score (ISS), injury type (blunt/penetrating), age, use of tracheotomy, ventilator days, ICULOS, HLOS, and discharge status (live/die). We compared the non-protocl group (181 patients) versus the protocl group (191 patients). For the protocol group we also reviewed the following indicators to determine their impact on the ability to extubate: seizure activity (new onset/history of), alcohol (level > .08 on admission/history of), hemodynamic instability, and intracranial pressure (ICP) if measured.

Evaluation:
The need for re-intubation decreased from 50% to 13% and was statistically significant (p value <.001). VAP decreased from 3% to 1% and unplanned extubations decreased from 8% to 4%. Ventilator days decreased from 6.8 to 5.5, ICULOS decreased from 9.9 to 8.5 and HLOS decreased from 16.4 to 15.1.

Implications for Practice:
The most significant impact was decreasing the need for re-intubation. Given the risks and costs of unplanned extubations, VAP extended ICULOS and HLOS, we plan on implementing the daily AM wake up assessment to all ventilated patients in all ICU's. Will monitor protocol compliance for all ICU's.