Strategies To Improve Weaning Outcomes in Long- term Care Gary W Mefford RRT, Respiratory Care Manager Regency Hospital of Fort Worth Director VentWorld.com

Objectives Understand the basic differences between weaning at STAC, LTAC, and LTC levels of care Recognize significant issues and elemental concepts that contribute to successful weaning in LTAC Recognize some new and potentially powerful tools that may have positive effect on weaning results

STAC, LTAC, LTC basic clinical differences described From PMV Consensus Statement, 2005

Weaning in each setting STACH LTACH LTC

Issues for consideration Passion Staffing Team building Identify and bolster weak links Protocols

Elements generally conducive to weaning protocol success Weaning (assessment) begins at intubation Early trach improves weaning time in difficult to wean Excellent assessment, airway, ventilator and secretion management practices Active weaning steps can usually start when pulmonary disease process begins resolving

Elements generally conducive to weaning protocol success No one can tell by looking No parameter has been devised that can predict every time No index better than the SBT

Elements generally conducive to weaning protocol success Flexibility Rigidity Pursue what usually works for most

All rest all work works best…usually Once a day SBT is best …usually Weaning to limits of the patient is better than time increments…usually Stepwise reduction in SIMV and PS when pt ready for unsupported SBT slows process …usually

Grand Rounds/Team Conference Daily case review by all disciplines can give big results Weekly refocus on teams goals, barriers and successes keeps everyone well directed and motivated

IHI 100,000 Lives Iniatives RRTs VAP Bundle Central Line Bundle Severe Sepsis Bundle Standardized Handoff Medication Reconciliation IHI.org: Great site for anyone interested in improving outcomes for their patients

Solid airway clearance process Difficult to wean patients are weak They generally can not succeed with obstructing secretions in their airways A planned and disciplined approach to proactive minimally traumatic maintenance of clear airways is an important key

New and potentially powerful Software based automated weaning Ventilator specific –PAV+ –Smart Care –Auto mode –ASV Volumetric CO2 analysis Non-invasive Cardiac Output TTAV/Cadence Documentation Driven facilitation –Paper –Electronic

Use the science The science works As important as good science is: Be there Be present in each moment and stay Passionate- fervent, ardent, zealous, avid, obsessive, fanatical Persistent- unrelenting, constant, determined, relentless, pushy Consistent- reliable, steady, unswerving, unfailing Recognize you can make a difference, but it takes a team approach to really do it right

Understand these basics You and your team will wean more of the difficult to wean And have more expeditious weaning outcomes