Microsoft PowerPoint - TWweaning for website [Compatibility Mode]Ventilation
success:
Definition of Prolonged Mechanical Ventilation (PMV)
Various definitions:
Small amount of patients VERY costly
E.G. 125 patients LOS >20 days used 4788 level 3 bed days >£8m
Here to stay
Prevalence
All UK ICU’s will have a cohort of PMV
patients who are a challenge
Estimate 12-20% of all ICU admissions
Negative Effects of prolonged ITU Stay
Physical
Some comorbidity
Psychological impairment
• Paucity of specialist weaning and
rehabilitation units
– Waiting list
– Transfer costs
• Long term ventilation facilities are few
and far between
Organisational Philosophy & management
The individual patient Specific problems
Specific clinical staff problems Lack of expertise in chronically critically
ill
No written evidence of weaning plan
Reluctance of the “team” to:
Downsize trache
Specific problems & challenges
Muscle weakness Reduced endurance Fatigue Anxiety and fear Delirium Sensation of dyspnoea Septic showers Lack of investment
Specific problems & challenges
How are these patients managed?
• Keep on trying in local unit
– Some or no structure
– Frustration
– Waiting list
• Sporadic continuity
the patient as a regular ICU patient
• Communication
– Busy with all other critically ill pts
– Only really need to be involved when pt medically unstable
What can ICU’s do?
• Identify those patients who will require
MV >21 days
manage these patients effectively
– Investment
– Continuity
not just concentrate exclusively on
weaning
Whole person rehabilitation (Ubaldo et al (2005), Cook et al (2001), NICE Guidelines (2009))
Weaning & Rehabilitation Pathway (WRP)
Development of an individual rehabilitation programme
Long term and short term MDT/patient goals agreed
& set
Energy management
Psychological profile
DF/2004
What makes them tick / who they are
Communication established
What have we done that has been effective and good
What have we done that was not good or effective
What do we need to do for the future Goal setting
contracting
Allows creativity
setting
needs
In line with the NICE guidelines
Difficult task that cannot be accomplished alone
Compassion Companion on a journey Coach Comedian
Continuity Knowing the pt Trust
Common sense Equal terms Other ways of knowing
Collaboration Holistic
Admitted in April 2016 for LVRS
Had 4 episodes of weaning
3rd episode at day 65 put onto WRP
Yesterday was decannulated – day 93!
Weaning trends over >50 days
Average RR 29bpm Average Vt 290mls
What we and Shirley planned
Intensive physio; strength and endurance
>2 weeks
Increasing daily SBT (2 weeks)
Speaking valve
Trial off at night
Change focus
Weekly MDT reviews
is not rocket science, its all about:
Common sense
Compassion
Commitment and continuity – a unified team focused on the patient
Collaboration offering a holistic approach. Use expertise inside and outside the acute setting
The future
group
to home.
It can be done