Long-Term Mechanical Ventilation Toolkit For Adult Acute Care Providers PDF
Long-Term Mechanical Ventilation Toolkit For Adult Acute Care Providers PDF
Long-Term Mechanical Ventilation Toolkit For Adult Acute Care Providers PDF
MECHANICAL
VENTILATION
Toolkit for Adult Acute Care Providers
Critical Care Services Ontario | November 2013
Developed by Critical Care Services Ontario (CCSO)
The Long-Term Mechanical Ventilation Toolkit for Adult Acute Care Providers is the result
of a collaborative effort between CCSO, led by Dr. Bernard Lawless [Provincial Lead,
Critical Care and Trauma], and a group of experts in the domain of long-term ventilation.
CCSO established the Long-Term Ventilation Planning Committee to identify issues
and priorities related to long-term ventilation in the province. Educational and training
materials were collated and curated to form this toolkit targeted to acute care providers.
Disclaimer: The contents of this toolkit may change over time. Clinicians should use sound
judgment for individual patient encounters. The provincial Prolonged-ventilation Weaning and
LTV Centres of Excellence [Toronto East General Hospital and West Park Healthcare Centre]
and Critical Care Services Ontario strongly recommend practices that are evidence-based.
This toolkit will be updated periodically as additional evidence becomes available.
CONTENTS
Long-Term Mechanical Ventilation: Toolkit for Adult Acute Care Providers
Critical Care Services Ontario | November 2013
SECTION 1 Introduction 7
1.1 Ontario’s Critical Care Strategy 8
1.2 The Unique Needs of Mechanically Ventilated Patients 10
1.3 Data Analysis: Mechanically Ventilated Patients in Ontario’s ICUs 11
1.4 Orientation to the Toolkit 13
SECTION 5 Conclusion 49
SECTION 6 Bibliography 51
SECTION 7 Appendices 55
A) LTV Planning Committee Membership 56
B) Family Questionnaire and Meeting Note Record 57
C) LTV Patient Flow 64
D) The Role of Tracheostomy 67
E) Alignment with other CCSO Initiatives 68
1
Introduction
Critical Care System-Level Critical Care Performance Health Human Surge Planning
Ethical Issues
Response Training Information Improvement of Access Resource & Capacity
Teams Initiatives System Collaborative Investments Management
Long-Term Mechanical Ventilation: Toolkit for Adult Acute Care Providers SECTION 1
Critical Care System-Level Critical Care Performance Ethical Issues Health Human Surge Planning
Response Training Information Improvement of Access Resource & Capacity
Teams Initiatives System Collaborative Investments Management
Improve System
Access Improve Integration
Quality
During its research, the Ontario Critical Care Steering Committee discovered that many intensive care
unit (ICU) beds were being occupied by mechanically ventilated patients who were otherwise medically
stable. These patients required access to rehabilitation and community support services, rather than critical
care services. Unfortunately, there appeared to be no adequate setting for these long-term ventilated (LTV)
patients outside the ICU.
Following the acceptance of the Ontario Critical Care Steering Committee’s Final Report, the MOHLTC
established the Ontario Critical Care Expert Advisory Panel to oversee all aspects of the Critical Care Strategy.
Critical Care Services Ontario remains committed to supporting LTV patients in Ontario and improving
access to care. Rehabilitation Community
Critical Care Services Ontario formed the Long-Term Ventilation Planning Committee in August 2012
with the initial goal of developing a Long-Term Ventilation strategy. The Long-Term Ventilation Planning
Committee examined issues across the continuum of care for LTV patients, recognizing the various sectors
with which this patient population may interface. It was agreed by the committee to focus initially on the
acute care sector and to develop this toolkit of resources and practices to help guide Ontario’s acute care
service providers in caring for mechanically ventilated patients.
Rehabilitation Community
Long-term mechanically ventilated patients in the ICU are either (a) medically stable and awaiting transfer
to an alternate care setting (outside the ICU), or (b) not medically stable and in need of critical care services.
Ultimately, the vision is to have no stable mechanically ventilated patients in any ICU in Ontario – only
those patients who require critical care services should be there. Still, quality care must be available for all
patients who are situated in the ICU.
LTV patients may require invasive or non-invasive ventilation. Some patients will require mandatory
or elective ventilation. For the medically stable LTV patient, the acute care setting is usually not an
appropriate environment.
Time Period Number of Patients Number of Patients Total Number Total Number Ratio: Average
Age: 18-64 Age: 64+ of Patients of Mechanically Mechanically
Ventilated Ventilated Days
Patient Days per Patient
Note: In CCIS, any patient that is mechanically ventilated for <1 day will be counted as 1 day.
• As shown in the table above, 124,673 patients were mechanically ventilated during the specified time
period. Among them, 4,070 patients were mechanically ventilated for 21 days or more.
• ≥21 days is the point at which patients are considered to be “long-term mechanically
ventilated.” Patients in this category may be (a) medically stable and awaiting transfer to an alternate
care setting (outside the ICU), or (b) not medically stable and in need of critical care services.
Time Period Number of Patients Number of Patients Total Number Total Number Ratio: Average
Age: 18-64 Age: 64+ of Patients of Mechanically Mechanically
Ventilated Ventilated Days
Patient Days per Patient
• Those patients who were mechanically ventilated for <21 days typically stayed in ICUs for 5.75 days
(Average Length of Stay).
• Those patients who were mechanically ventilated for ≥21 days (LTV patients) required a total of
141,288 days of ventilation.
• During the time period, 81 patients were mechanically ventilated for ≥3 months and required 11,692
ventilated patient days. If these 81 patients could have been treated as short-term mechanical ventilation
patients, and transferred to an alternate care setting (outside the ICU) for additional ventilation support,
a minimum of 1,952 additional patient admissions could have been facilitated to acute care units.
Note
Number of Patient Admissions =
(Total Number of Mechanically Ventilated Days for Patients who were on ventilation for ≥3 months) /
(Average Length of Stay for Patients who were on mechanical ventilation for <21 days)
= 11,692/5.75 = 2,033
Additional Patient Admissions = 2,033 - 81 = 1,952
• During the time period, 18 patients were mechanically ventilated for ≥6 months and required 4,646
ventilated patient days. If these 18 patients could have been treated as short-term mechanical
ventilation patients, and transferred to an alternate care setting (outside the ICU) for additional
ventilation support, a minimum of 790 additional patient admissions could have been facilitated
to acute care units.
Note
Number of Patient Admissions =
(Total Number of Mechanically Ventilated Days for Patients who were on ventilation for ≥6 months) /
(Average Length of Stay for Patients who were on mechanical ventilation for <21 days)
= 4,646/5.75 = 808
Additional Patient Admissions = 808 - 18 = 790
Target Audience
This toolkit is intended for use by frontline healthcare providers, Unit Managers, Nursing Administrative
and Medical Directors who are directly or indirectly involved with patient care in a critical care environment.
Assessment of
Weaning Protocol Mobilization Protocol
At-Risk Patients
“De-medicalization”
Transfer to Alternate
Care Settings
Definitions
The tables below outline the key definitions that will be used throughout the toolkit.
Please note: there are various definitions of these terms in the literature. For the purposes of this
toolkit, the following definitions will be used.
Invasive Ventilation Any form of invasive mechanical/assisted Critical Care Information System Policy
ventilation. Guide [version 2.0]
Non-Invasive Any form of non-invasive mechanical/assisted Critical Care Information System Policy
Ventilation ventilation. Examples include BiPAP and CPAP. Guide [version 2.0]
“At Risk” Patient in Mechanically ventilated patients in the ICU CCSO Advisory Committee
the ICU who may progress to long-term mechanical
ventilation.
Long-Term Mechanical Ventilation for >21 days. Critical Care Unit Balanced Scorecard
Ventilation Toolkit
Please note: long-term mechanical ventilation may be referred to as “chronic ventilation” or “prolonged ventilation” in
the literature.
3. Processes Associated with Mechanical Ventilation
Term Definition Source
Weaning Weaning refers to the liberation from mechanical McConville, J.F.,Kress, J.P., “Weaning
ventilation with resumption of spontaneous patients from the ventilator”. N Engl J
sustainable breathing. (This may include Med 2012; 367:2233-2239
transition from invasive mechanical ventilation to
non-invasive modes of mechanical ventilation).
Mobilization Mobilization refers to passive and active range Schweiclkert, W.D., Kress, J.P.
of movement exercises, transfers, walking, and “Implementing early mobilization
bed mobility. The benefits of early mobilization interventions in mechanically ventilated
of mechanically ventilated patients have been patients in the ICU”. Chest. 2011:140(6):
reported in many publications. 1612-1617
Abbreviations
The table below outlines the main abbreviations that will be used throughout the toolkit.
Abbreviations
IV – Invasive Ventilation
Assessment of
Weaning Protocol Mobilization Protocol
At-Risk Patients
“De-medicalization”
Transfer to Alternate
Care Settings
Early identification of ICU patients who are at risk for LTMV is a key step in optimizing any possibility
of avoiding a need for prolonged ventilation. The tools provided in this section aim to assist acute
care providers in fulfilling this objective.
“At-risk patients” are those that have not yet advanced to the stage where LTMV is required. Some of the
conditions that put patients at-risk include:
• “Chronic disorders associated with recurrent respiratory failure including parenchymal lung
disease, the most common being COPD, thoracic restriction (kyphoscoliosis) and non-obstructive
ventilatory failure due to degenerative neuromuscular diseases.
• Repeated failure to wean following acute respiratory failure associated with critical illness.
Weaning failure may be the result of acquired neuromuscular weakness and acute lung injury/
acute respiratory distress syndrome (ARDS) for patients with no previous history of respiratory
disease, or in combination with previous morbidity.
• Absent or severely impaired spontaneous breathing such as obesity hypoventilation syndrome
and hypoventilation due to depressed central ventilatory drive and high spinal injury.”
Source: http://www.stmichaelshospital.com/crich/sru/sru-ventilation
Purpose of Tool To identify factors which are potentially reversible or medically optimized and may be
contributing to ventilator dependence.
Intended Use Identifying the etiology for ventilator dependence is important in designing strategies to
liberate patients from mechanical ventilation. It is evident that numerous factors contribute to
ventilator dependence, and acute care professionals may use this tool to identify potentially
reversible factors.
Source MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged
mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005;128:3937–3954
Purpose of Tool • To facilitate the early identification and assessment of at-risk patients
• To optimize successful weaning
• To confirm the need for long-term ventilation outside the ICU
Intended Use This tool can be used as a weekly checklist by the ICU inter-professional team to support
decision-making around high quality patient-centered care and enhance early identification,
support successful weaning and consider the need for long-term ventilation outside the ICU.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence [Toronto East General Hospital]
Purpose of Tool To identify those patients who are at risk of remaining long-term in the ICU and to prepare
appropriately for their care and management.
Intended Use This tool can be used to screen patients and identify actions or consults appropriate for those
medically stable patients whose actual or anticipated ICU stay is >/21 days or those patients
where need for a tracheostomy is anticipated.
Purpose of Tool To identify patients requiring prolonged mechanical ventilation who are at high risk of 1-yr mortality.
Intended Use This tool can be used on day 21 of mechanical ventilation. When paired with clinical judgment,
this model may increase clinicians’ ability to discuss the likely outcomes of treatment and to
tailor care to achieve patient-centered goals.
Source Carson SS, Kahn JM, Hough CL, Seeley EJ, White DB, Douglas IS, Cox CE, Caldwell E, Bangdiwala
SI, Garrett JM, Rubenfeld GD; ProVent Investigators. A multicenter mortality prediction model
for patients receiving prolonged mechanical ventilation. Crit Care Med. 2012 Apr; 40(4):1171-6
Purpose of Tool To identify factors which are potentially reversible or medically optimized and may be
contributing to ventilator dependence.
Intended Use Identifying the etiology for ventilator dependence is important in designing strategies to liberate
patients from mechanical ventilation. It is evident that numerous factors contribute to ventilator
dependence, and acute care professionals may use this tool to identify potentially reversible factors.
Source MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged
mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005;128:3937–3954
Mechanical factors
Iatrogenic factors
Recurrent aspiration
Infection (e.g., pneumonia, sepsis)
Stress ulcers
Deep venous thrombosis
Other medical problems developing in the PMV care venue
Psychological factors
Sedation
Delirium
Depression
Anxiety
Sleep deprivation
Purpose of Tool • To facilitate the early identification and assessment of at-risk patients
• To optimize successful weaning
• To confirm the need for long-term ventilation outside the ICU
Intended Use This tool can be used as a weekly checklist by the ICU inter-professional team to support
decision-making around high quality patient-centered care and enhance early identification,
support successful weaning and consider the need for long-term ventilation outside the ICU.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence [Toronto East General Hospital]
The checklist on the following page covers topics which are addressed in later sections of the toolkit
(i.e. weaning and transition protocols.) For assessment purposes, please focus on section 1 only.
Iatrogenic factors
Acute to Prolonged Ventilation • Failure to recognize withdrawal potential
Key Criteria* • Inappropriate ventilator settings leading to excessive loads/
(1) Physiologically stable patient discomfort
(2) Repeatedly unsuccessful weaning attempts • Imposed work of breathing from tracheotomy tubes
(3) Consideration of the patient’s wishes • Medical errors
Other Considerations*
• Patient characteristics (underlying disease, presence of Complications of long-term hospital care
comorbidity and cognitive status) • Recurrent aspiration
• Diagnosis & prognosis • Infection (e.g., pneumonia, sepsis)
• Anticipated quality of life • Stress ulcers
• Consideration of patient & family motivation • Deep venous thrombosis
• Establishment of a ventilator weaning plan • Other medical problems developing in the PMV care venue
Psychological factors
Prolonged to Long-term Ventilation • Sedation
Key Criteria* • Delirium
(1) Physiologically stable patient • Depression
(2) Establishment of a transition plan • Anxiety
(3) Option of withdrawal of care is discussed • Sleep deprivation
(4) Acceptance and motivation of the patient based on
informed choice Process of care factors
Other Considerations* • Absence of weaning & sedation protocols
• Recognition that the need for mechanical ventilation (either • Inadequate nursing staffing
invasive or non-invasive) is indefinite • Insufficient physician experience
• Redefinition of the goals of care
• Ability of the team to provide care including adequate Reference: MacIntyre NR, Epstein SK, Carson S, et al. Management
resources and a transition placement of patients requiring prolonged mechanical ventilation: report of a
• Patient prognosis, diagnosis and quality of life NAMDRC consensus conference. Chest. 2005;128:3937–3954.
• Patient care needs that could be managed in the community
or a long-term care facility Extubation to Continuous Non-invasive Ventilation
• Family motivation Bach JR, Goncalves MR, Hamdani I MD, Joao Carlos Winck JC
Extubation of patients with neuromuscular weakness: a new
*derived from Canadian delphi consensus 2013 management paradigm, Chest 2010 137(5):1033-9
The checklist is structured for weekly completion by the inter-professional ICU team to standardize and
implement best practices in care.
NOTE: If the patient is acutely critically ill or palliative end-of-life care is being provided, then this should be the
focus of care and the team should defer use of this checklist.
1 MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus
conference. Chest. 2005;128:3937–3954
2 Carson, S. S., J. M. Kahn, et al. A multicenter mortality prediction model for patients receiving prolonged mechanical ventilation. Critical Care Medicine
2012;40(4: 1171-1176 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3395423/
Purpose of Tool To identify those patients who are at risk of remaining long-term in the ICU and to
prepare appropriately for their care and management.
Intended Use This tool can be used to screen patients and identify actions or consults appropriate for those
medically stable patients whose actual or anticipated ICU stay is >/21 days or those patients
where need for a tracheostomy is anticipated.
Section B: Any ONE of the following disease categories present? Morbidity Present
Section C: Any THREE of the following disease categories present? Morbidity Present
Comments/Notes:
Purpose of Tool To identify patients requiring prolonged mechanical ventilation who are at high risk of
1-yr mortality.
Intended Use This tool can be used on day 21 of mechanical ventilation. When paired with clinical judgment,
this model may increase clinicians’ ability to discuss the likely outcomes of treatment and to
tailor care to achieve patient-centered goals.
Source Carson SS, Kahn JM, Hough CL, Seeley EJ, White DB, Douglas IS, Cox CE, Caldwell E, Bangdiwala
SI, Garrett JM, Rubenfeld GD; ProVent Investigators. A multicenter mortality prediction model for
patients receiving prolonged mechanical ventilation. Crit Care Med. 2012 Apr; 40(4):1171-6
Age ≥ 65 years 2
Age 50 - 65 years 1
Vasopressors 1
Hemodialysis 1
Total
Once the ProVent Score is generated, use the table below to determine 1-yr mortality for patients according
to their ProVent score.
0 72 20 (10-29)
1 60 36 (24-48)
2 78 56 (45-68)
3 36 81 (67 -94)
4 or 5 14 100 (77-100)
*Note: the values shown under the heading “Number of Patients” are for demonstrative purposes only.
Assessment of
Weaning Protocol Mobilization Protocol
At-Risk Patients
“De-medicalization”
Transfer to Alternate
Care Settings
• In patients with neuromuscular disease and intact bulbar function, an alternative weaning strategy
to be considered is extubation to continuous non-invasive ventilation.3 The CANVent program at the
University of Ottawa has extensive experience with this approach.
• A carefully documented patient-focused individualized care plan should be developed which addresses
specific components of a successful weaning program, including not only weaning strategies but also
communication, mobilization, nutrition, minimal sedation and management of the patient’s psychological
state (i.e. anxiety, delirium, depression, sleep). New evidence now suggests tracheostomy mask weaning
as opposed to pressure support weaning may reduce the duration of ventilation for this sub-population
of patients.4 Examples of weaning and mobilization protocols from the Provincial Prolonged-ventilation
Weaning Centre of Excellence are provided in Sections 3 and 4 (see Tools 3.1 and 4.1).
• The ventilator associated pneumonia (VAP) and central line infection (CLI) toolkit (see Appendix E
for further information) provides a summary of patient safety interventions that should be continued
in this group of patients.
• In keeping with the recommendations for a daily ICU checklist, setting of daily targets and ongoing
documentation of weaning progress that is accessible to the inter-professional team ensures continuity
of approach and readily identifies changes in patient status. This may involve the use of a whiteboard,
weaning graphic chart (see Tool 3.2) or electronic health record equivalent. Early morning daily review
of progress towards the previous day’s targets for weaning and mobilization will also optimize weaning.
• Documentation of reasons for failed weaning trials will identify reversible factors, prevent repetition of
unsuccessful strategies and support determination of prognosis. No evidence supports the number of
failed optimized weaning trials that predicts the inability to wean, although an increasing number of
failed trials indicates potential unweanability.
• If you have any questions about optimizing weaning or facilitating transfer to a specialized centre, you
can obtain expert advice from the Provincial Prolonged-ventilation Weaning Centre of Excellence (416-
469-6580 x 6841, fax 416-469-6611, email: pwc@tegh.on.ca, website: www.tegh.on.ca)
• The purpose of the Mobilization Protocol (see Tool 4.1) is to safely mobilize patients requiring
ventilation to their maximum capacity, in order to improve their probability of successful weaning and
functional recovery, helping to reduce their stay in an acute care hospital.
3 Bach JR, Goncalves MR, Hamdani I MD, Joao Carlos Winck JC Extubation of patients with neuromuscular weakness: a new management paradigm, Chest
2010 137(5):1033-9
4 Jubran A, Grant BJB. Duffner LA, Collins EG, Lanuza DM, Hoffman LA, Tobin MJ Effect of Pressure Support vs Breathing Through a Tracheostomy Collar
on Weaning Duration in Patients Requiring Prolonged Mechanical Ventilation: A Randomized Trial JAMA 2013: 309(7):doi:10.1001/jama.2013.159
Purpose of Tool To detail a sequence of steps and strategies to reduce the duration of mechanical ventilation
for patients.
Intended Use These protocols are intended to provide clinicians with guidance on steps to follow in the
process of discontinuing mechanical ventilation and giving a patient a chance to demonstrate
they can breathe on their own.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence (Toronto East General Hospital)
Intended Use The chart may be used by clinicians to document daily evaluation of readiness to reduce the
duration of mechanical ventilation.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence (Toronto East General Hospital)
Purpose of Tool To detail a sequence of steps and strategies to reduce the duration of mechanical
ventilation for patients.
Intended Use These protocols are intended to provide clinicians with guidance on steps to follow in the
process of discontinuing mechanical ventilation and giving a patient a chance to demonstrate
they can breathe on their own.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence (Toronto East General Hospital)
No
Legend
PT to assess & start
PS = Pressure support
mobilizing (sitting,
PT = Physiotheraphy
standing, walking)
TM = Tracheostomy Mask
Legend
TM trial LT = Long-term Ventilation
(once daily) TM = Tracheostomy Mask
No
Palliative
End-of-life LTV required
Care No
Tolerating
TM Trial
Yes Increments
No
+/- Downsize
Trach tube
Legend
TM = Tracheostomy Mask
Legend
ABG = Arterial Blood Gas
NIV = Non-invasive Ventilation
TM tolerated
SLP = Speech Language Pathology
10-16 hours
TM = Tracheostomy Mask
No
No TM as
Increased tolerated x 24
PaCO2 + Low pH hours
(+/- Night NIV)
Yes
No Yes
Night NIV
Candidate NIV overnight
Step 5: Decannulation
Legend
Downsize & NIV = Non-invasive Ventilation
Change to OSA = Obstructive Sleep Apnea
Cuffless tube SLP = Speech Language Pathology
Tolerates No
Permanent
Corking Corking Tracheostomy
x 7 days
Yes
Yes
Requires Trach
for suctioning
or OSA Stop NIV
No
No
Yes
Continued Transition to
SLP to re-assess Decannulate need for NIV? NIV at home
Intended Use The chart may be used by clinicians to document daily evaluation of readiness to reduce the
duration of mechanical ventilation.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence (Toronto East General Hospital)
10
11
12
13
14
15
16
17
18
19
Example of Weaning Chart and Linear Graph Drawn for an LTV Patient
PWC Weaning Chart
Example of Weaning Chart and linear graph drawn for a typical PWC patients.
1 0 0
2 1 1
3 3 3
4 4 4
5 6 5
6 8 7.5
7 10 9.5
8 12 10
9 14 14
10 18 18 30
11 20 19
25
12 22 21.5
Target (hours)
13 24 24 20
TM Time (hours)
14 24 24
15
15 24 24
16 24 24
10
17 24 24
18 24 24 5
19 24 24 Weaning
0
after 7 days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Assessment of
Weaning Protocol Mobilization Protocol
At-Risk Patients
“De-medicalization”
Transfer to Alternate
Care Settings
Transition
For most LTMV patients, the ICU should not be the end point in their continuum of care. There are many
examples of successfully transitioned patients who are enjoying improved quality of life in alternate care
settings. It is important to have meaningful engagement of the patient and family regarding potential next steps.
A medically stable, ventilator-dependent patient can be transitioned successfully from the ICU to home,
supportive housing or a long-term health care facility. At this stage in the patient’s care, there is a need to
ensure that the patient and caregivers are comfortable with leaving the ICU and that there are appropriate
rehabilitation services to accept these patients. A successful transition requires careful planning, and plenty
of patient and family education.
Purpose of Tool The purpose of the Mobilization Protocol is to safely mobilize patients, requiring ventilation,
to their maximum capacity, in order to improve their probability of successful weaning and
functional recovery, helping to reduce their stay in an acute care hospital.
Intended Use This protocol may be used by clinicians to: identify considerations prior to mobilization; and to
describe a pathway for the mobilization of a ventilated patient.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence (Toronto East General Hospital)
Purpose of Tool The purpose of this tool is to provide guidance on the decrease of invasive & continuous
hemodynamic monitoring, with a view to reminding ICU teams to initiate “de-medicalizing” the
patient once they are medically stable.
Intended Use The guidelines should be followed once the patient is deemed medically stable. The applicability
of the guidelines ought to be reassessed with any changes in the patient’s medical status.
Purpose of Tool Modifications to the treatment plan that include enabling speech, increasing sitting tolerance,
initiating a wheelchair prescription and establishment of regular routines can encourage
independence and foster a rehabilitation focus. Whenever possible, family involvement
should be supported and actively encouraged. These elements, when combined, may serve to
motivate both the patient and family in regards to discharge planning.
Intended Use This tool offers guidance to ICU teams that are preparing patients to transition to alternate settings.
Purpose of Tool To support the ICU team to consider all aspects of care for the LTV patient.
Intended Use This tool may be used by clinicians to ensure they are considering all aspects of care for the
LTV patient, as well as transition of the patient to an alternate care setting.
Purpose of Tool The purpose of the Mobilization Protocol is to safely mobilize patients, requiring ventilation,
to their maximum capacity, in order to improve their probability of successful weaning and
functional recovery, helping to reduce their stay in an acute care hospital.
Intended Use This protocol may be used by clinicians to: identify considerations prior to mobilization; and to
describe a pathway for the mobilization of a ventilated patient.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence (Toronto East General Hospital)
Bed Mobility Turning side to side Same as phase 1 Gradual withdrawal of Promote
training Bridging assistance independence or
Supine-sit Promote family training on
Dangling independence selected issues as
appropriate
Walking Stand with walker Initiation of walking Gradual increase in Gradual withdrawal
program Attempt pregait reeducation with distance & endurance, of assistive device is
activities walker and assistance gradual withdrawal appropriate
of assistive device if Wheelchair mobility
appropriate training if still unable
to walk
Purpose of Tool The purpose of this tool is to provide guidance on the decrease of invasive & continuous
hemodynamic monitoring, with a view to reminding ICU teams to initiate “de-medicalizing” the
patient once they are medically stable.
Intended Use The guidelines should be followed once the patient is deemed medically stable. The applicability
of the guidelines ought to be reassessed with any changes in the patient’s medical status.
• Remove arterial lines, nasogastric tube and other invasive lines/tubes. If patient cannot have oral
intake, switch NG tube to G-tube or J-tube
• Cap or remove PICC lines (if appropriate)
• Reduce blood work frequency
• Decrease PEEP to lowest level
• Decrease oxygen to lowest level
• Try to avoid using continuous monitoring including pulse oximetry once arterial blood gases and
oximetry have established oxygen requirements. Use periodic non-invasive assessments of SpO2
and CO2 (techniques such as end-tidal or transcutaneous CO2 monitoring)
• If weaning is considered an option, consult/refer to Toronto East General Hospital Provincial
Prolonged-ventilation Weaning Centre of Excellence as any ventilator free time increases
patient’s safety in case of accidental disconnection from ventilator as well as it increases patient’s
sense of independence and decreases caregiver anxiety
Purpose of Tool Modifications to the treatment plan that include enabling speech, increasing sitting
tolerance, initiating a wheelchair prescription and establishment of regular routines can
encourage independence and foster a rehabilitation focus. Whenever possible, family
involvement should be supported and actively encouraged. These elements, when combined,
may serve to motivate both the patient and family in regards to discharge planning.
Intended Use This tool offers guidance to ICU teams that are preparing patients to transition to alternate settings.
Purpose of Tool To support the ICU team to consider all aspects of care for the LTV patient.
Intended Use This tool may be used by clinicians to ensure they are considering all aspects of care for the
LTV patient, as well as transition of the patient to an alternate care setting.
Patient/family
participation in ADLs?
5. Conclusion
According to demographic data, the number of patients at risk for, or requiring, LTMV is expected to
increase, placing a burden on existing resources that are already constrained. Available resources must be
used appropriately and strategically to offer the greatest benefit to this vulnerable patient population.
The resources provided in this toolkit can help acute care providers to implement best practices in care for
mechanically ventilated patients in three areas:
Critical Care Services Ontario will continue to provide support to acute care providers caring for this
population. As the toolkit is targeted to the acute care sector, there is also a need to address other sectors across
the continuum of care. CCSO will continue working with our partners to optimize care for LTMV patients.
6. Bibliography
Section 2: Early Identification of Patients at Risk for LTMV
Tools included in this section:
2.1) Factors Associated with Ventilator Dependence
MacIntyre NR, Epstein SK, Carson S, et al. Management of patients requiring prolonged mechanical
ventilation: report of a NAMDRC consensus conference. Chest. 2005;128:3937–3954
7. Appendices
Appendix A: LTV Planning Committee Membership
LTV Planning Committee Members
Donna Renzetti
West Park Healthcare Centre [Long-Term Ventilation Centre of Excellence]
Regina Pizzuti
Kingston General Hospital
Lisa Malbrecht
Parkwood Hospital
Sally McMackin
Toronto Central Community Care Access Centre
Rachel Solomon
Toronto Central Local Health Integration Network
Donna Thomson
CritiCall Ontario
Maureen Williams
Ministry of Health and Long-Term Care
Purpose of Resource To provide supportive care for patients by gaining a detailed understanding of their needs.
Intended Use This form is used to document patient needs upon admission to the Provincial Prolonged-
ventilation Weaning Centre of Excellence.
Source Provincial Prolonged-ventilation Weaning Centre of Excellence (Toronto East General Hospital)
Tell me about the patient (family/social situation, personal interests previous health status):
Intials Date
Do you need more information? Is there anyway we can make it easier for you to understand with is
happening?:
Intials Date
What are the religious and cultural beliefs that are important to patient/family?
Are there objects you can bring to the hospital that the patient would find comforting?
Intials Date
Who does the patient rely on for support / is this person (s) available?
Are you and the rest of the family in agreement with how things are going?
Intials Date
Have you met the members of your health care team? Yes No
Intials Date
Meeting 1
Meeting 2
Meeting 3
Patient SDM/POA:
RN: APN:
SW: PT:
Chaplain:
Purpose of Meeting
i.e. What are your concerns today? Do you have specific questions for the physicians?
Family Responses:
Outstanding Issues:
Signature: Date:
Addendum
Purpose of Resource Highlights the flow of a patient at risk for long-term ventilation through the continuum of care.
Source Long-Term Ventilation Service Inventory Program, Final Summary Report, July 31, 2008
1. Categories of Services
Note: Each category is linked to the flow map on the following pages.
At-risk population
1. Counseling and disease management for at-risk population and families/caregivers
Emergency Department
2. Identification and appropriate referral of patients at risk for long-term ventilation
Critical Care
3. Education of patient’s primary care practitioners and specialists (e.g., neurologists)
4. ICU capacity
5. Early identification and management of ICU patients at risk for long-term ventilation
6. Early identification and management of ICU patients who cannot be weaned and are eligible for LTV bed
7. Early identification and management of ICU patients eligible for community-based care and services
Weaning
8. Weaning services
1
Go
Education program
to A
Acute Event
(e.g., Trauma) Respiratory Failure
2
Emergency
Department visit
3
No Does the Yes 4, 5
individual
choose to go to ICU admission
the ICU?
Choose to
die at home Patient
stays
in ICU Is the
No individual
medically stable
and ventilator
dependent?
Yes
6, 7
No
Can patient Go
be weaned? to B
Yes
8
Admission to a
weaning program
Was
Go Yes individual No Go
to C successfully to B
weaned?
C
No No No Was Yes
individual
weaned?
Discharge to Discharge to
community community
(vented) (unvented)
CAVC 10
11, 12, 13, 14
Admission
A Refer to support services
Patient as indicated:
stays - outreach/outpatient
in - elettive ventilation
CAVC - CCAC
- attendant services
No Has individual - ADP/VEP
recovered sufficiently - charitable organization
to be discharged?
- other services (e.g., ODSP)
- education programs
- respite
Yes
15
Go Reassess periodically
Go
to B as inpatient or
to B
outpatient
(if indicated)
Palliative Care 16
CCAC = Community Care Access Centre ADP = Assistive Devices Program VEP = Ventilator Equipment Pool
ODSP = Ontario Disability Support Program CAVC = Chronic Assisted Ventilatory Care ICU = Intensive Care Unit
“Community” includes long-term care homes, supportive housing and private homes.
Purpose of Resource To provide background information about the role of tracheostomy in the ICU.
Source • Bickenbach, J, M Fries, et al. Impact of early vs. late tracheostomy on weaning: a
retrospective analysis. Minerva Anestesiologica. 2011;77(12): 1176-83.
• Brook, A. D., et al. Early versus late tracheostomy in patients who require prolonged
mechanical ventilation. American Journal of Critical Care.2000; 9(5):352-59.
• Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies
of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ.
2005;330:1243–7
• Young D, Harrison DA, Cuthbertson BH, Rowan K, et al. Effect of Early vs Late Tracheostomy
Placement on Survival in Patients Receiving Mechanical Ventilation: The TracMan
Randomized Trial. JAMA. 2013;309(20):2121-2129.
The benefits and disadvantages of tracheostomy are well documented in the literature on critical care
medicine. Some of the benefits and disadvantages of tracheostomy are outlined below:
• “Reduced laryngeal ulceration and respiratory resistance; • “Complications resulting from the [tracheostomy]
• “[Tracheostomy] improves [patients’] capacity to procedure include stomal infections, stomal
communicate; haemorrhage, pneumomediastinum, pneumothorax,
• “[Tracheostomy] makes for easier nursing care” and occasionally death”
The timing of when a tracheostomy is performed may or may not have an impact on patients undergoing
mechanical ventilation. Some sources in the literature suggest it is beneficial to perform early tracheostomy
(rather than late tracheostomy), while other sources indicate that timing does not have an impact on
patients. Examples of different perspectives on the timing of tracheostomy are outlined below:
Clinicians should assess the potential benefits and disadvantages of tracheostomy on an individual basis.
Purpose of Resource In addition to the LTMV Toolkit, acute care providers may be interested in reviewing the
resources outlined in this section (which are also produced by CCSO).
Source CCSO
Critical care unit peer groups and scorecard indicator reports have also been developed. The new scorecards,
created by CCSO in collaboration with the Critical Care LHIN Leads and CritiCall Ontario, are designed
to help promote system wide learning and improvement by providing critical care stakeholder with
information to:
• Evaluate the performance of their critical care units relative to similar units
• Identify opportunities to learn from other critical care units
• Set strategic directions for critical care quality improvement
• Establish achievement targets for critical care units
All hospitals will receive an ICU scorecard report summarizing each critical care unit’s data based on the
peer groups and unit-specific annual trends.
For information about the ICU Scorecard Toolkit, please contact Critical Care Services Ontario at:
Phone: 416-340-4800 x 5577
Email: ccsadmin@uhn.ca
VAP/CLI Toolkit:
Distributed to hospitals in May 2012 by CCSO, the VAP/CLI Toolkit provides tools to support hospitals in
the reduction of ventilator associated pneumonia (VAP) and Central line infection (CLI) incidents. Reducing
rates of VAP and CLI are part of the MOHLTC Patient Safety Indicator initiative. The toolkit addresses best
practices for surveillance and prevention of these infections, and provides local examples of successful tools
and strategies that may assist hospitals with quality improvement initiatives.
For information about the VAP/CLI Toolkit, please contact Critical Care Services Ontario at:
Phone: 416-340-4800 x 5577
Email: ccsadmin@uhn.ca
The principles of Canadian “just society” imply that treatment decisions must respect individual autonomy,
and cultural, ethnic and religious diversity. To that end, the toolkit seeks to:
• Clarify the legal and ethical obligations embedded in the consent process;
• Address the complex clinical challenges that arise in critical care; and
• Provide tools to enhance communication between healthcare providers, patients, SDMs and family
members at end-of-life (EOL) through consistent language.
The toolkit was developed by CCSO, in collaboration with a group of Subject Matter Experts proficient in
the area of critical care and ethics, who informed the development of the document and the inclusion of
tools considered as best practice in addressing the issues of consent and decision-making.
For information about this toolkit, please contact Critical Care Services Ontario at:
Phone: 416-340-4800 x 5577
Email: ccsadmin@uhn.ca