title: Liberal Manipulation of Ventilator Settings and Its Impact on Tracheostomy Rate and Ventilator-Free Days.
abstract: BACKGROUND
  The utilization of checklists, bundles, and protocols attempts to provide standardization in the delivery of patient care. Despite important progress obtained in the prevention of hospital-acquired infections, the daily management of mechanical ventilation is still prone to heterogeneity, depending on the number of providers manipulating the ventilator. Whether the number of changes made on ventilator parameters impacts clinical outcomes remains unknown.
  
  
  METHODS
  A quality improvement project was designed to assess whether liberal manipulations of ventilator settings affect the rate of tracheostomy and 28 ventilator-free days. Over the course of 7 d, respiratory therapists recorded all ventilator changes in newly ventilated subjects. Ventilator changes were considered as major changes if manipulations included changes in the mode of ventilation. Minor changes included manipulations of settings within the same mode of ventilation. We evaluated whether the number of total and major changes affected clinical outcomes. Logistic regression was used for multivariate analysis.
  
  
  RESULTS
  One-hundred seventeen ventilator manipulations were recorded among 54 subjects. Of those 117 ventilator changes, 35% were major manipulations. For every major ventilator manipulation, the odds of requiring tracheostomy increased 4.95 times. Furthermore, for every major ventilator change, there was an 18.6% decrease in 28 ventilator-free days. These associations were found after adjustments by APACHE (Acute Physiology and Chronic Health Evaluation) II score, body mass index, and type of ICU. The total number of changes was not associated with either primary outcome measure.
  
  
  CONCLUSIONS
  The number of major ventilator manipulations is associated with rate of tracheostomy and stay on the ventilator.
authors.affiliation: Respiratory Care Department, Baylor University Medical Center, Dallas, Texas. ariel.modrykamien@baylorhealth.edu.
authors.forename: Ariel M
authors.initials: AM
authors.lastname: Modrykamien
authors.affiliation: Respiratory Care Department, Baylor University Medical Center, Dallas, Texas.
authors.forename: Lori
authors.initials: L
authors.lastname: Killian
authors.affiliation: Division of Clinical Research and Evaluative Science, Creighton University School of Medicine, Omaha, Nebraska.
authors.forename: Ryan W
authors.initials: RW
authors.lastname: Walters
mesh_terms: D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D058996:Quality Improvement; D012121:Respiration, Artificial / Q000379:methods* / Q000592:standards*; D013997:Time Factors; D014139:Tracheostomy / Q000706:statistics & numerical data*; D012122:Ventilators, Mechanical
keywords: mechanical ventilation; outcomes; protocols; tracheostomy