Improving Adherence to an Integrated Spontaneous Awakening and Spontaneous Breathing Trial Protocol

BACKGROUND: Integration of nursing-driven spontaneous awakening trial (SAT) and respiratory therapy-driven spontaneous breathing trial (SBT) protocols for patients on mechanical ventilation in the intensive care unit (ICU) is associated with fewer ventilator days, shorter ICU stays, and reduced hospital length-of-stay. However, institutional adherence is often suboptimal due to the complexity and multidisciplinary nature of these integrated protocols. This project aims to describe baseline compliance with our institution's SAT/SBT protocol, identify factors influencing compliance, and increase adherence to the existing SAT/SBT protocol in the ICU to a goal of greater than 95% compliance by August 2023. LOCAL PROBLEM: Data from a retrospective chart review indicated a SAT screen rate of 63.8% and a SBT screen rate of 85%. Therefore, the SAT/SBT protocol adherence at our institution is sub-optimal. METHODS: Initially, we determined baseline adherence rates through a retrospective chart review of SAT and SBT documentation. Specifically, we identified the rates of correctly performed SAT and SBT screenings for all eligible patients and the subsequent rates of correct SAT and SBT performance for patients who passed the appropriate screening. We then sought to identify factors influencing adherence to the SBT/SAT protocol by employing an ethnographic approach, including: (a) process mapping of the integrated SAT/SBT protocol, (b) literature-driven surveys using the Likert scale to assess potential barriers to protocol adherence, (d) informal interviews with nurses and respiratory therapists, and (e) direct observation in the medical ICU. Individual factors identified were organized using the Systems Engineering Initiative for Patient Safety (SEIPS) sociotechnical framework. The SEIPS model allowed for further design of targeted interventions to improve protocol adherence. RESULTS: Factors influencing adherence were identified from survey responses by 63 nurses and 26 respiratory therapists, 30 hours of direct observation, and tabulated comments from surveys and informal interviews. Prominent factors influencing compliance included knowledge of the protocol, protocol variation across intensive care units, accessibility of the protocol, ease of documentation in the electronic medical record (EMR), and the exclusion of nurses and respiratory therapists in physician-led ICU rounds. CONCLUSION: Data from a retrospective chart review and ethnographic investigation of SAT/SBT protocols indicated sub-optimal adherence. Further investigation into the specific factors influencing adherence allowed us to propose specific interventions to improve performance. Such future interventions will include: (a) EMR redesign using feedback obtained in our investigation to improve accessibility and allow reliable surveillance of protocol adherence, (b) enhanced, standardized multidisciplinary ICU rounds, (c) protocol education sessions, (d) continuous monitoring of protocol metrics with intermittent feedback provided to staff, and (e) a Quality Assurance and Performance Improvement Workgroup dedicated to regular engagement of key stakeholders for process improvement.