Title: Standards of Care: Mechanical Ventilation Page 1 of 7 Original: 6
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Title: Standards of Care: Mechanical Ventilation Page 1 of 7 CentraCare Health (CCH) adopts the following policy/procedure for: St. Cloud Hospital Original: 6/84 Minor Revision: 9/12 Full Review: 2/15 Responsible Person: Department Director, Intensive Care Approving Committee(s): Intensive Care Nurse Practice Committee; Respiratory Care Practice Committee; CentraCare Heart and Vascular Center Nurse Practice Committee Category: Intensive Care; Cardiac Care Cross Reference: Extubation Policy; Endotracheal Tube Securement Device and Care; Oral Care Protocol for Ventilated Patients; Tracheostomy Care Policy; Patient Supplied Medical Equipment, Use of During Hospitalization Policy; Home Ventilator Use Policy; Tracheostomy/Endotracheal Cuff: Pressure Management Policy; Delirium: Prevention, Assessment, and Monitoring in the Intensive Care Unit Type: Standard I. PURPOSE: To provide guidelines to trained clinical nurses and Respiratory Therapists (RT) caring for patients requiring mechanical ventilation. II. POLICY: A. Mechanically ventilated patients will be cared for in the Intensive Care Unit (ICU) and the Cardiac Care Unit (CCU). B. Clinical nurses and RT will adhere to these standards for all patients receiving mechanical ventilation. C. Clinical nurses/RTs will be educated on the function of the mechanical ventilator, along with the process and outcome standards outlined in this document. D. Assessment findings, ventilator settings and alarms, interventions, progress towards goals, patient/family education, and other pertinent information will be documented in the electronic medical record (EMR). E. Providers will be notified with significant changes outside goals. III. GUIDELINES: OUTCOME STANDARDS (Goals) PROCESS STANDARDS (Interventions) Reduction of anxiety. • Perform initial and ongoing assessments of patient and family anxiety and level of knowledge related to mechanical ventilation. o Patient/family will be informed of reasons for mechanical ventilation. A mechanical ventilation education handout will be provided. o In collaboration with the provider, the patient/family will be informed of progress towards goals of care. • Patient/family will have opportunities to verbalize any fears, questions or concerns with nurses. • Establish means of communication with patient, if applicable. o A call light will be within reach or some type of communication system will be in place if unable to use call light. (i.e. bell) o A letter board or pad and pencil will be available, if appropriate. Maintenance of a patent airway. • Perform initial and ongoing assessment for ineffective C:\Users\csa630\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\HT97YTI9\Standards of Care-Mechanical Ventilation.doc Title: Standards of Care: Mechanical Ventilation Page 2 of 7 airway clearance related to secretions. o The nurse will assess the need and perform suctioning as the condition warrants. Routine suctioning will not be done. o The patient will be educated on the need for and practice of suctioning. o Pre-oxygenation with 100% oxygen will be performed prior to suctioning to prevent or minimize desaturation. o A closed suction system will be used on all patients. Either an in-line suction catheter for patients expected to be intubated for greater than 24 hours or a "PEEP Saver" device will be present on all adult ventilatory patients. o Support tubing and maintain endotracheal (ET) tube in proper alignment during suctioning. o Saline should not be routinely instilled into the ET tube before suctioning. • Perform initial and ongoing assessment for malposition of ET or tracheostomy (trach) tube. o A chest x-ray will be obtained following initial placement of the ET tube. o The ET/trach tube will be securely positioned. o Lungs will be auscultated after repositioning of the ET tube and as needed (prn) for the presence of bilateral air movement. o The chest will be visualized for symmetrical movement. o An assessment will be made for the need of an ET tube bite block, if not already in place. o Assessment and position of the ET/trach tube will be documented in the EMR. Adequate gas exchange. • Lung auscultation and respiratory pattern will be assessed every 4 hours, with ventilator changes, and prn for the presence of normal or abnormal/ adventitious sounds. • SpO2 and EtCO2 monitoring will be done on all ventilated patients. Notify provider if outside of ordered parameters. • Clinical nurses will be knowledgeable about signs and symptoms of hypoxia including respiratory rate (RR), use of accessory muscles, increased heart rate (HR) and blood pressure (BP), skin color, and change in level of consciousness (LOC). Maintenance of a properly • The clinical nurse will be knowledgeable of ventilator functioning ventilator system. settings, including mode, rate, FiO2, tidal volume (TV), positive end expiratory pressure (PEEP), and pressure support. • RT will perform initial ventilator setup and subsequent ventilator changes. C:\Users\csa630\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\HT97YTI9\Standards of Care-Mechanical Ventilation.doc Title: Standards of Care: Mechanical Ventilation Page 3 of 7 • RT will be notified if ventilator setting changes are necessary. o In collaboration with RT, the clinical nurse may make changes in FiO2 settings. o Clinical nurses can make mode changes if necessary for patient safety. When mode changes are made the RT personnel must be contacted to evaluate the need for flow rate and alarm adjustments. • Observation and validation of settings will be done by the clinical nurse or RT. Prevention of ventilator-associated • All patients on mechanical ventilation will be placed on events. the Ventilator Bundle. • Monitor for potential infective breathing pattern related to barotrauma. o Maintain low tidal volumes and normal peak pressures. o Be aware of high risk patients, especially those with COPD, emphysematous blebs, intrinsic PEEP and elevated prescribed PEEP. o Observe for patient and ventilator asynchrony. Minimize through the use of sedation and/or notify RT to make possible ventilator adjustments. o Monitor patient for an increase in airway rub pressures, subcutaneous emphysema, decreased/absent breath sounds, sudden restlessness, or a decrease in SpO2. o If signs of a tension pneumothorax are present; notify provider immediately and request RT to assist with possible need to disconnect from ventilator and manually ventilate. Prepare for chest tube insertion. • Monitor for potential decrease in cardiac output related to increased intrathoracic pressure related to positive pressure ventilation and/or PEEP resulting in decreased venous return. o BP, HR, and SpO2 will be monitored within 15 minutes after increases in RR, TV, or PEEP. o Monitor intake and output, skin color, temperature, and moisture. o Observe for patient and ventilator asynchrony. Minimize through the use of sedation. o Notify provider of significant changes in patient condition. • Monitor for potential altered gastrointestinal (GI) function related to stress ulcers and bleeding, swallowed air with gastric distention, and ileus. o GI assessment will be completed every 12 hours and prn. o Monitor for abdominal pain, nausea, vomiting, and signs of bleeding. C:\Users\csa630\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\HT97YTI9\Standards of Care-Mechanical Ventilation.doc Title: Standards of Care: Mechanical Ventilation Page 4 of 7 o Note color, amount, consistency, and frequency of stools. o Stress ulcer prophylaxis should be considered for mechanically ventilated patients. • Monitor for potential development of delirium. Refer to the Delirium: Prevention, Assessment, and Monitoring in the Intensive Care Unit policy. o Minimize sedation; titrate or administer the least amount of sedation to meet clinical goals. o Clinical nurses will complete a sedation vacation (SV) each shift to assess for patient neurological function and the continued need or reduction of sedative medications. Do not complete SV if patient on neuromuscular blockade or per provider order. o Clinical nurse, RT, and PT will collaboratively implement early exercise and progressive mobility. Refer to Critical Care Progressive Mobility Guideline. • Prevention of ventilator-associated pneumonia through application of best practices. o Head of bed (HOB) elevated to 30-45⁰ unless contraindicated to prevent aspiration of secretions. o Complete meticulous hand hygiene prior to and maintain sterile technique while suctioning ET/trach tube. o Perform hand hygiene before and after donning gloves and ventilator management. o Cleanse “PEEP Saver” with betadine solution after suctioning, if applicable. o Provide oral care and suctioning according to the Oral Care Protocol for Ventilated Patients. o Resuscitator bags are for single patient use. They will be stored by capping the end or in a plastic bag. Dispose if become soiled or malfunction. o Change canister, tubing, and Yankauer every 24 hours; coordinate with change in 24 hour oral care kits. Oral care kits will be dated and timed. o Change closed in-line suction catheter every 72 hours. o Change the heat, moisture exchange filter (HMEF) every 48 hours and prn. o Individual suction catheters (non in-line) will be used once and discarded. o Sterile water will be used for rinsing suction tubing. o Do not routinely change ventilator circuits; change when visibly soiled or a mechanical malfunction has occurred. o Periodically drain and discard condensation in tubing of the mechanical ventilation circuit, if active humidification