Jennifer Johnson, ACNP, MSN, APRN
Senior Care Signature Clinical Lead
Yale New Haven Health
New Haven, Connecticut
Disclosure information not submitted.
Mahmoud Ammar, BCCCP, PharmD, BCPS,
Critical Care Pharmacist
Yale New Haven Hospital
New Haven, Connecticut
Disclosure information not submitted.
Kent Owusu, BCCCP, BCPS, PharmD
Senior Care Signature Lead; Pharmacist, Critical Care
Yale New Haven Health
Arcadia, Florida
Disclosure information not submitted.
Deborah Rhodes, MD
Associate Chief Medical Officer, VP of Care Signature
Yale New Haven Health, United States
Disclosure information not submitted.
Jonathan Siner, MD
Associate Professor Term; Clinical Section Chief, Section of Pulmonary, Critical Care and Sleep Med
Yale-New Haven Medical Center, United States
Disclosure information not submitted.
Title: Clinical Pathway Program Development: Conception to Implementation
Introduction: Variable sedation and mechanical ventilation practices across providers and sites in our health system were noted on review of over 17,000 adult ICU patients admitted May 2019-April 2020, including variation in benzodiazepine use and adherence to lung-protective ventilation, defined as patients ventilated below 8 mL/kg of ideal body weight.
Methods: A multidisciplinary group representing all ICUs in our health system was convened to develop a clinical pathway to address unnecessary variations in care and to articulate and standardize best practice for ventilation and analgosedation. The group: 1) reviewed relevant literature and guidelines; 2) reviewed current internal and national data; 3) mapped all clinical steps in care to identify clinical decisions for which consensus was lacking, due to absence of evidence or variable application of the evidence, and/or process gaps; 4) developed consensus statements to guide clinical decisions for areas without consensus; 5) harnessed evidence, consensus, and clinical decision support into clinical pathways seamlessly integrated into the electronic medical record (EMR). We compared benzodiazepine use and lung-protective ventilation before and after pathway launch.
Results: Since implementation of the initial pathways in February 2021, pathways have been accessed over 600 times. Pathways have been utilized in all seven of our hospitals, nineteen ICUs, non-traditional ICU space like procedural areas, emergency departments, and general medical/surgical floors. Mean midazolam exposure (mg) per patient per day decreased 29% (pre-intervention 169 mg and post-intervention 119 mg, p=0.027) and lung protective ventilation increased 21% (pre- and post-intervention mean 63.4% and 77.1%, respectively, p=0.033). Pre-intervention period of July-December 2019 was selected to exclude any COVID effect.
Conclusions: A statistically significant improvement in benzodiazepine use and adherence to lung-protective ventilation was observed after implementation of an EMR-accessible clinical pathway. Additional study is needed to determine whether pathway utilization leads to improved patient outcomes.