(53) Identifying Who Should Be Weaned: A First Step in a Ventilator Weaning Quality Improvement Project

Background: Increasing evidence supports using minimal support for critically ill patients in the PICU, as targeting "normal" physiology can be harmful. Higher hemoglobin thresholds for transfusions and oxygen saturation goals have been shown to reduce mortality. During mechanical ventilation, pediatric patients experience rapid diaphragmatic atrophy. Evidence suggests minimizing ventilator support reduces the risk of diaphragmatic injury and promotes quicker ventilator liberation.

Objectives: To develop an appropriate measure for a quality improvement project to enhance ventilator liberation in a Pediatric ICU (PICU).

Design/Methods: Using the Model for Improvement, we conducted a stakeholder analysis and developed a high-level process map for ventilator liberation. Identifying the time to wean a patient as a key improvement opportunity, we developed an operational definition of a weanable patient. Our first iteration used weaning criteria from an existing, but rarely used, protocol developed by provider and respiratory therapy (RT) leadership. With this criteria, we established our baseline for time from a "weanable moment" until a ventilator wean (or until no longer met weaning criteria) using an I-chart. After presenting this data to stakeholders, we iteratively refined our process measure to better identify patients who should be weaned.

Results: Baseline data identified 388 "weanable moments" from 61 patients between 5/2023 and 12/2023. The I-chart for this data is shown in Figure 1. The average duration of these weanable moments was 232 minutes, with an upper control limit of 1,075 minutes. Stakeholder discussions revealed not all providers would wean patients meeting these criteria. We therefore led iterative discussions to reach a consensus on weaning criteria. We refined the frequency of weans to align with current RT workflows, increasing the level of reliability (LOR) of the interventions. Additionally, we established maximal ventilator rates for age groups below which weans were deemed unnecessary, as these patients met criteria for spontaneous breathing trials.

Conclusion: Establishing consensus on the importance of ventilator weaning and defining which patients should be weaned is crucial for improving ventilator liberation in the PICU. By integrating weaning with existing workflows, we increase the LOR of interventions. Next steps involve interventions to decrease the average time from identifying a patient who should be weaned to initiating the wean.