Ventilator-Respiratory: Queens, New York
Chronic Pulmonary Care : Wean from Ventilator
"If you want to make progress with ventilator patients, you can't work in a bubble."
This simple, but potent statement well describes the philosophy behind the operation and the extraordinary success of the
Silvercrest Ventilator Service... a 60
bed unit that is New York's largest, and arguably, the
most ground-breaking of its kind anywhere.
Begun as a 5 bed unit more than 15 years ago, the Ventilator Service has grown in size and complexity, becoming a model upon which other such units are based. Revolutionary from its beginning, the unit's mission and capabilities have grown as the talented team that called it into being has searched for better solutions for the ventilator patient.
Team members have, from the outset, recognized the need to consult and confer with one another about each patient's challenges. As their experience has grown, a new insight has coalesced, with the team now convinced that what has been described as "intractable" respiratory failure can be treated. As new protocols have emerged, so has a new goal... the expectation that patients should improve, rather than be maintained. How we breathe.
Arriving at Silvercrest's Vent Unit
When a new patient arrives on the Ventilator Unit, he is seen by every member of the treatment team within the first 24 hours. During the first five days, the team will assemble together with the patient's family to formulate the initial plan of care. Thereafter, that patient will be the focus of biweekly team meetings for 3 months, monthly meetings for 3 months and quarterly meetings thereafter. Sessions can also be convened at any time at the family's request.
Respiratory Videos
The Ventilator Unit is equivalent in capability to a full service hospital wing. All forms of medical treatment short of ICU care are provided. However, much that would never be found in the hospital environment is here as well.
Two geriatricians round daily on all the patients and are joined on Mondays, Tuesdays, Wednesdays and Fridays by the program's Pulmonologist. Nursing care is impeccable, and orders are picked up quickly and followed to the letter. The combination of attentive bedside care, nutritional support and aggressive mobilization therapy lead many from bed confinement to mobility and result in non-surgical solutions for the great majority of chronic pressure ulcerations.
Team members from Therapeutic Recreation (TR) evaluate patients at all function levels and design activities commensurate with both their abilities and their goals. Not infrequently, the insights of the TR staff are critical to the team's recognition of subtle, but important changes in the patient's capacity.
The Origins of Ventilator Dependency
Individuals can become dependent upon ventilator support for a variety of reasons. Often, hospitalized, elderly patients who are nutritionally depleted develop pneumonia that leads to respiratory failure. Failure to properly oxygenate the blood is even more likely to supervene when a patient has underlying lung disease such as emphysema or chronic bronchitis, (often called, Chronic Obstructive Pulmonary Disease, or COPD). When reversible conditions such as infection and malnutrition are properly and completely addressed, patients such as these, sick though they are, may be successfully weaned from their dependence upon the ventilator.
Some individuals have irreversible problems such as amyotrophic lateral sclerosis (ALS) that affects their ability to mount a respiratory effort. Although wean is not a realistic goal for this group, much can be done to improve the quality of their lives on the ventilator. The Silvercrest team employs a combination of compassion and cutting edge technology to ensure that these residents enjoy maximum quality of life.
Mechanical ventilation leads to substantial morbidity, mortality and financial cost. Since both premature and delayed ventilator liberation can cause harm, liberation that is both expeditious and safe is highly desirable.
During 2003, while planning for expansion of the Silvercrest ventilator unit, the facility's Performance Improvement Steering Committee, chartered the formation of the Respiratory Care Committee, (RCC). Comprised of both clinical and administrative staff, the RCC's mandate was to improve systems and processes in order to facilitate optimal patient outcomes.
Data collected by the RCC demonstrated a trend of ever increasing medical acuity in the patient group admitted to the ventilator unit, (see chart). These increasingly complex medical presentations demanded more extensive nursing care and more sophisticated equipment and instrumentation. Consequently, the RCC began a proactive, systematic quality improvement initiative to increase ventilator liberation rates, as well as the safety and quality of care delivered on the units.
Increased staff allocation and capital improvements in the ventilator unit were among the important commitments made by administration and the Board of Trustees to the effort.
Silvercrest maintains 48 ventilator unit beds at all times, with capacity for 62 in total. The technology and infrastructure required to properly undertake ventilator care is of considerable complexity. The Ventilator Unit sits on a central alarm system that issues instant audio and visual alarms for all events of concern. All individual systems have internal battery back-up, and the entire system is maintained by a large diesel generator. Silvercrest's own co-generation power system provides an extremely dependable source of electricity for the units. All electrical outlets in the vent unit as well as throughout the facility are connected to the same, central fail-safe mechanism.
The newest generation of ventilators provide pressure support and flow
triggers to assist in weaning. "Laptop" ventilator units (like
that formerly used by injured actor Christopher Reeves) are used to free many patients
from the confines of the 5 North unit. The access this provides to the
main therapy area, as well as to social and religious gatherings is of
inestimable value to residents.
The interdisciplinary ventilator team is focused upon providing the type of care needed to achieve successful liberation and improve the quality of life. Its members come from medicine (geriatrics and pulmonology), respiratory therapy, nursing, rehabilitation (physical/occupational therapy and speech-language pathology), therapeutic recreation, nutrition, social services and psychology.
The team assesses patients' care needs and liberation potential on admission, readmission, weekly during clinical rounds and at additional intervals as indicated. During clinical rounds, candidates for liberation are identified and the status of those already in the protocol reviewed. The vent team develops a comprehensive care plan for each individual. Patients themselves and their families are important team members as well, providing information with respect to goals and preferences as well as advance directives.
Silvercrest has developed an enormously successful protocol for the liberation of residents from ventilators. Initial elaboration of this new mechanism took place primarily in 2003 and 2004, and represented a shift from the acute care model to one that was more flexible. It gave the respiratory therapist more freedom to modify the wean process based upon individual clinical assessment.
The change resulted in a more malleable approach, accommodating patient/resident response to changing respiratory support, and allowing the therapist to create a unique, "fine-tuned" wean process for each patient.
In late 2005 and early 2006, the protocol was further modified to standardize assessments for the post-liberation phase and facilitate transfer of the patient/resident to a respiratory step-down unit. These protocol revisions proved invaluable in streamlining the patients safe progress though the entire liberation process.
The Silvercrest approach to ventilator liberation is one that is resident-driven, interdisciplinary, incorporates high standards of safety and clinical practice, and utilizes standard assessments universal to the long term care arena. As a result, it may be replicated in similar settings around the country and the world.
The Silvercrest "vent team" pioneered the importance of early involvement by the speech-language pathologist (SLP) with ventilator dependent residents. Early attention to speech and swallowing problems has benefited all patients, by:
- contributing to the overall success of the wean process
- making the wean process more tolerable for patients
- helping to develop skills of importance to quality of life in the un-weanable
Problems with speech and swallowing are of central concern for a ventilator population. Restoring the ability to communicate produces greater independence for the patient and adds enormously to the quality of life. In a related vein, the ability to swallow effectively not only makes the provision of adequate nourishment easier, but restores to the patient the sense of confidence that only the loss of an unconscious physiological skill can take away.
In pursuit of solutions for these problems, the Silvercrest
team has made discoveries that have become a part of the basis for our improved rehabilitation
and weaning protocols. Speech pathologists aggressively evaluate swallowing, and through the use of fiberoptic evaluations on site, are able to characterize the problems of
90% of patients without referral to the hospital. These diagnostics help eliminate the fear that oral feedings
will lead to aspiration and pneumonia, and allow the staff to eliminate
the use of tube feedings for many. Better nutrition translates quickly
into greater strength and more progress toward wean.
Additionally, the use of speaking valves for patients with tracheostomy has not only yielded better communications, but has, happily, led to lessening ventilator dependence and more rapid progress toward wean. As a result of this discovery, aggressive speech programs are being promulgated in other institutions.
The Silvercrest protocol led to higher odds for ventilator liberation in every year following its original implementation. As the chart here demonstrates, a significantly higher adjusted odds ratio is found in 2006 when compared t0 2003, (p=0.003). Patients/residents in 2006 were 2.7 times more likely to be ventilator liberated than in 2003, even after controlling for the increased number of patients requiring more support in 2006. A clear and significant upward trend in ventilator liberations is evident over time, (overall adjusted p- value= 0.01).
However, are there indicators that might help one predict the likelihood of success ahead of time?
Silvercrest administrators and clinicians had the insight to look at the data being routinely collected for quality purposes. The "Minimum Data Set" (MDS), is a standardized assessment tool utilized in long term care facilities to track resident care problems and to measure quality of care. A review of all admissions to the ventilator unit between Jan 1, 2003 and Dec. 31, 2005 was conducted. The admitted patients were divided into ventilator "liberated" and "non-liberated" groups, and admission MDS were analyzed for statistical differences.
Six elements of the admission MDS showed statistically significant differences between these groups. The non-liberated group was more likely to have:
- edema (p=0.0001)
- higher number of medications in past week (p=0.0012)
- unstable cognitive, mood and behavior patterns (p=0.0044)
- stage 4 decubitus ulcer (p=0.0278)
- difficulty making self understood (p=0.0232)
- difficulty understanding others (p=0.0412)
These findings, as presented to the American Thoracic Society in May of 2007, function as helpful criteria in prognostication. However, the Silvercrest team does not use them in determining qualification for entry into weaning protocols. Every reasonable candidate is given the chance to succeed.
Although
the protocols used at Silvercrest have produced a remarkable wean rate,
other forms of success short of full wean are important as well. Each
discipline represented on the vent team works to optimize functional
status and quality of life for each patient resident. Those who cannot
be liberated can still benefit from an individualized plan of care that
emphasizes obtainable goals. These may include reducing ventilator support,
facilitating vocal or non-vocal communications, , initiating oral feedings,
and increasing independence with activities of daily living and recreational
endeavors.
Silvercrest also prepares patients and families for home ventilator care, and brings in home care nurses and home care company staff for pre-discharge training.
Additional references from Silvercrest experts:
Ventilator/Respiratory Care
Fleming, R., Sobol E., Chua R., “Long Term Care Weaning Outcome Utilizing a Respiratory Therapist Driven Protocol.” [Abstract] American Journal of Respiratory Critical Care Medicine 1997;155(supplement):A411.
Fleming, R., Sobol, E., “Weaning Outcomes and Survival on a Ventilator Unit in a Long Term Care Facility.” [Abstract] Chest, 1997;112(supplement):129S.
Fleming, R., Brady, T.,et al. “Respiratory Failure in Octogenarians in the ICU: Wean Outcomes, Survival and Disposition. [Abstract] American Journal of Respiratory Critical Care Medicine, 2000(supplement).
Fleming, M., Fleming, R., Guastella, P., “Diaphragmatic Fatigue Following High Intensity Exercise in Trained Athletes vs Sedentary Subjects. [Abstract] American Journal of Respiratory Critical Care Medicine 2001;163(supplement):A155.
Palumbo, F., Fleming, F., Lucrezia, J., Karbowitz, S., “Outcome and Survival in Hypercarbic Respiratory Failure from COPD Treated With Non-invasive Ventilation.” [Abstract] American Journal of Respiratory Critical Care Medicine 2002;165(supplement)A797.
Dave, R., Fleming, R., Paluimbi, F., Karbowitz, S., Gumpeni, R., “Delayed Failure of Non-invasive Ventilation in Patients with Hypercarbic Respiratory Failure: Is it Predictable?” [Abstract]Chest 2002;122(supplement):145S.
George, P., Fleming, R., Sha, K., “Disposition and Outcome of Tracheostomy Patients Enrolled in a Decannulation Protocol. [Abstract] American Journal of Respiratory Critical Care Medicine 2003;167(supplement):A456.
Lee,H., Khan, R., Fleming., Sierros, V., “Inhalation Performance Index in Asthmatics Instructeed by Various Providers.” [Abstract] American Journal of Respiratory Critical Care Medicine 2004.
Kwok, Y., Lin, E., Fleming, R., Brady, T., “Outcome Survival in Hypercarbic Respiratory Failure from COPD Treated with NON-Invasive Ventilation.” [Abstract] Chest 2005;128(supplement):2565.
Zolotarevskaya, I., Fleming, R., Brady, T., “Physician Prative Patterns Post Gold Guidelines in Patients Admitted for COPD Exacerbation.” [Abstract] Chest 2006;130(supplement):1715.
Sierros, V., Fleming, R., et al., “The Minimum Data Set as a Predictor of Ventilator Liberation in a Subacute Care Facility.” [Abstract] American Journal of Respiratory Critical Care Medicine 2007; (supplement).
Salehmohamed, M., Fleming, R., Mousa, T., “Diagnositc Accuracy of Pleural Fluid NT pro-BNP in Identifying Pleural Effusion Caused by Congestive Heart Failure.” [Abstract] American Journal of Respiratory Critical Care Medicine 2008;177(supplement):A123.
Patsis, T., Sierros, V., Fleming, R., “The Role of Procalcitonin in Patients with Suspected Pulmonary Tuberculosis.” [Abstract] Chest 2008; 134:1540015.
Mousa, T., Salehmohamed, M., Yim, K., Brady, T., Fleming, R., “Unexpected Breakthrough.” North American Society for Cardiovascular Imaging Case in Point Website. June 2008. NASCI.
John, B., Luo, J., Lee, P., Fleming, R., “Choriocarcinoma: An Unusual Cause of Hemoptysis.” The Journal of Respiratory Diseases 2008;Vol.29:376-382.
Sobel, E., Fleming, R., Chua, R., “Age as a Predictor of Weaning Outcomes and Survival on a Ventilator Unit in a long Term Care Facility.” American Geriatric Society 1998;P224.
Williams, L., Fleming, R., Lucreza, J., Weinbaum, R., Danek, F., “Financial Impact and Clinical Outcomes in Developing a Respiratory Disease Management Unit for Post ICU Wean.” American Association of Respiratory Therapist 2002.
Speech-Language Pathology
Dikeman, K., & Kazandjian, M. (2008, June). Managing Voice and Communication for Tracheostomized and Ventilator Dependent Patients: Clinical Case Studies. In American Speech-Language-Hearing Association Special Interest Division 3 Newsletter, 2, pp. 31-35.
Robbins, J., Gensler, G., Hind, J., Logemann, J., Lindblad, A. S., Brandt, D., Baum, H., Lilienfeld, D., Kosek, S., Lundy, D., Dikeman, K., Kazandjian, M., Graminga, G., McGarvey-Toler, S., & Miller Gardner, P. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized trial. Annals of Internal Medicine, 148, 509-518.
Logemann, J., Gensler, G., Robbins, J., Lindblad, A., Brandt, D., Hind, J.A., Kosek, S., Dikeman, K., Kazandjian, M., Gramingna, G., Lundy, D., McGarvey-Toler, S., and Miller-Gardner, P. (2008, February). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. Journal of Speech, Language and Hearing Research, 51, 173-183.
Dikeman, K. & Kazandjian, M. (2008, in press). Guillian Barre Syndrome. In Encyclopedia of Oropharyngeal Dysphagia in Rare Conditions. Plural Publishing Inc. San Diego, CA.
Kazandjian, M. & Dikeman, K. (2008) Communication Options for Tracheostomized and Ventilator Dependent Patients. In Tracheotomy: Airway Management, Communication and Swallowing (2nd ed). Plural Publishing, Inc. San Diego, CA.
Dikeman, K. & Kazandjian, M. (2004). Managing Tracheostomized and Ventilator-Dependent Adults: Current Concepts. ASHA Leader, pp. 6-7, 19-20.
Dikeman, K., & Riquelme, L. (2002, October). Ethnocultural Concerns in Dysphagia. American Speech-Language-Hearing Association Special Interest Division Newsletter, 11, 3, pp. 31-35.
Dikeman, K., & Kazandjian, M. (2002). Communication Management of the Tracheostomized and Ventilator Dependent Adult, 2nd Edition. Albany: Delmar-Thomson Learning.
Shaker, R., Easterling, C., Tern, M., Nitschke, T., Massey, B., Daniels, S., Grande, B., Kazandjian, M., & Dikeman, K. (2002). Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122, pp.1314-1321.
Villa, M., Newman, S., Kazandjian, M., Belozerco-Tracey, L., Dikeman, K., & Logemann, J., (2001, October). American Speech-Language-Hearing Association Special Interest Division Newsletter, 10, 3, pp.20-22.
Kazandjian, M., Dikeman, K., and Chua, R. (2000). Evaluation of the Patient with Impaired Pulmonary Function and Dysphagia. In, R.H. Mills, (Ed.), Dysphagia Evaluation in Adults. Pro-Ed, Austin: TX.
Kazandjian, M., and Dikeman K. (1998). Communication Options for Tracheostomy and Ventilator Dependent Patients. In Meyers, E., Johnson, J. and Murray T. (Ed), Tracheostomy Airway Management Communication and Swallowing. Singular Publishing Group, San Diego, CA.
Dike man, K., and Kazandjian, M. (1998). The Speech-Language Pathologist: Bridging the Communication Gap. In Sife, W. (Ed.), Loss, Grief Care: A Journal of Professional Practice. The Hawarth, Press, Inc., New York, New York
Willig, T.N., Gilardeau, C., Kazandjian, M.S., Bach, J.R., Varille, V., Navarro, J. and Dikeman, K.J. (1996) Dysphagia and Nutrition in Neuromuscular Disorders. In Bach, J. (Ed)., Pulmonary Rehabilitation: The Obstructive and Paralytic Conditions, Hanley and Belfus, Philadelphia, PA, 353-370.
Dikeman, K.J., and Kazandjian, M.S. (1995). Communication and Swallowing Management of the Tracheostomized and Ventilator Dependent Adult. Singular Publishing Group, San Diego, CA.
Gilardeau, C., Kazandjian, M.S., Dikeman, K.J., Bach, J.R. & Tucker, L.M. (1995). The Evaluation and Management of Dysphagia in Duchenne Muscular Dystrophy. Seminars in Neurology, 15 (1) , 46-51
Kazandjian, M.S., Dikeman, K.J. & Bach, J.R. (1995). Assessment and Management of Communication Impairment in Neurological Disease. Seminars in Neurology 15, (1), 52-57.
Kazandjian, M., and Dikeman, K. (1993). Α Trandisciplinary Team Approach. In Mason, M (Ed.), Clinical Speech Pathology with Tracheostomized and Ventilator Dependent Patients. Voicing!, Irvine, CA.
Dikeman, K., and Kazandjian, M. (1990). Communication Intervention with the Patient with Advanced Pulmonary Disease. Published in Conference Proceedings, Psychosocial Aspects of Advanced Pulmonary Disease and its Prevention. Foundation of Thanatology, Columbia Presbyterian Medical Center, New York, New York
Kazandjian, M., and Dikeman, K. (1990). Communication Intervention with the Ventilator Dependent Patient. Published in Conference Proceedings, The Ventilator: Psychosocial and Medical Aspects. Foundation of Thanatology, Columbia Presbyterian Medical Center, New York, New York
Dikeman, K., and Bayone, I. (1984). The Effect of Semantic Redundancy on Tense Discrimination in Aphasia. Published in the Queens College Working Papers
With a desire to reach beyond the walls of Silvercrest
to ventilator-dependent patients everywhere, team members have been active
in education, sharing protocols and techniques through professional meetings,
speaking engagements and a variety of publications, (see
side bar). The energy of our founding core of professionals now
infects a large, enthusiastic staff who will help find tomorrow's solutions
for those with advanced respiratory disease.
