ABSTRACT
Introduction: In common with many aspects of critical illness recovery, there is no universally accepted formula for "weaning," the term used to describe the process of liberating patients from mechanical ventilation.1-3 Understanding a patient's progress during a prolonged wean can be difficult and requires integration of various datasets. Therefore, it is good practice to ensure that weaning prescriptions are clear, easy to follow and adhered to and that weaning-associated data and meta data are recorded accurately and are easy to interpret. The prototype Digitally Enhanced Liberation from VEntilation (DELVE) system has been designed to be used in combination with the Puritan Bennett(TM) 980 (PB980) ventilator (Covidien, USA). DELVE is an open-loop system which provides an interactive weaning chart, combining the weaning prescription entered by the clinical staff, with actual settings recorded from the ventilator in order to display compliance with the prescription (Figure 1). DELVE also collects measured data from the ventilator which could be used to display respiratory performance, both real-time and historical. Figure 1. DELVE set up with the PB980 ventilator (in the simulation suite). Objective(s): This feasibility study was designed to inform development of the first DELVE prototype and a future clinical trial to determine clinical effectiveness and usefulness. The study objectives were to determine whether DELVE could: 1. Present a digital weaning chart that staff could use effectively and would be superior to the current paper version. 2. Record and display the patients' ventilatory performance, both real time and historical, during liberation from mechanical ventilation. Method(s): This was a mixed-methods, prospective feasibility study of a complex intervention.4 Ventilated patients with a tracheostomy, commencing the weaning process, were recruited from an adult intensive care unit. DELVE was used alongside the current paper-based system for weaning planning and data collection. Patients remained in the study until they no longer required the support of the PB980 ventilator. Result(s): Twenty patients were enrolled for between 25 and 270 hours each. There were no safety incidents or data breaches. DELVE was successfully operated by staff, who were able to connect DELVE to the ventilator, prescribe weaning plans and analyse adherence. The digital weaning chart user interface was intuitive and easy to navigate. It was clearer, more complete and easier to interpret when compared to the paper weaning charts (Figure 2). DELVE reliably collected data every ten seconds and safely stored over six million items of measured data and 25000 events, such as alarm triggers and setting changes, in a form that could allow analysis and pictorial or graphical presentation. Conclusion(s): This study supported the feasibility of this and future versions of DELVE to present both a digital weaning chart and to facilitate visual and numerical data presentation. Future iterations of the system could include a user-friendly dashboard representing patient progress during the weaning process. Assimilation of large volumes of data could be used to enhance understanding and inform decision making around the prolonged wean.
ABSTRACT
Keywords: unicompartmental, pathway, outcomes Purpose: Unicompartmental knee replacement (UKR) is the gold standard surgical management of patients with unicompartmental osteoarthritis of the knee. As UKR surgery is less invasive, this potentially allows patients to be discharged quicker than those patients undergoing total knee replacement. During the COVID-19 pandemic, elective surgeries were postponed and new ways of working were required to restart procedures. In order to minimise the risk of exposure to COVID-19, we established a new multicomponent recovery pathway (MRP) for patients undergoing UKR to facilitate earlier discharge. Objective: To evaluate the impact of the MRP on length of stay. Methods: The MRP was introduced in August 2020 to provide day-case surgery where possible. All patients undergoing UKR at St Cross Hospital, Rugby were eligible for inclusion in the trial. Exclusion criteria was lack of support at home and uncontrolled co-morbidities. Patients who were assessed preoperatively, but unsuitable for the day-case service followed all other aspects of the enhanced recovery pathway (ERP). The ERP included a new anaesthetic protocol of prilocaine spinal anaesthesia, limiting tourniquet use, and multimodal postoperative analgesia. From a physiotherapy perspective, new individualised pre-operative assessment and education sessions were introduced, with mobilisation commencing on the day of surgery. Patients were discharged with their knee in full extension and returned at day 4 for postoperative review and initiation of flexion. Data was collected prospectively for patients receiving the MRP and compared to a historical cohort from the previous year. Primary outcome was hospital length of stay (LOS). LOS data was assessed for normality and analysed using the students t-test. Results: Following introduction of the MRP 30 patients underwent UKR and were included in the analysis. Patients in the MRP group were significantly older (65.6 vs. 60.1 years, p < 0.05), although no other baseline differences were observed. Whilst there was a reduction in the use of general anaesthesia (30% vs 59%, p = 0.0917) and tourniquets (53% vs 68%, p = 0.3925), this did not reach statistical significance although there was a significant increase in the use of Prilocaine (30% vs 0%, p < 0.01). Following the introduction of the MRP, LOS reduced significantly (1.4 vs 2.9 days, p < 0.001), with no significant differences observed in joint range of motion (ROM) between groups. Within the MRP group, 9 patients (30%) received all key components (prilocaine spinal anaesthesia, no tourniquet and enhanced physiotherapy), 8 of which were discharged as day-case. Conclusion(s): The MRP was successful in reducing LOS in patients undergoing UKR, with no impact on joint ROM. The biggest impact was observed for those patients who received all components. Future work should explore methods to improve compliance with the pathway to maximise patient benefit. Impact: The positive results seen through introducing the MRP has a number of potential benefits. Alongside a reduction in LOS with benefits to patients and cost savings to the trust, the additional bed capacity released will allow increased throughput of patients which could be significant for the waiting list accrued as a result of the cessation of elective surgery due to Covid-19. Funding acknowledgements: n/a