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Policies,Clinical,UW Health Clinical,General Care and Procedures,Procedures

Administration of Mechanical Ventilation Via Artificial Airway (2.3.33)

Administration of Mechanical Ventilation Via Artificial Airway (2.3.33) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.33


UW HEALTH CLINICAL POLICY 1
Policy Title: Administration of Mechanical Ventilation via Artificial Airway
Policy Number: 2.3.33
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 28, 2017

I. PURPOSE

A. To define proper placement, observation and monitoring of patients requiring mechanical ventilation by
experienced personnel.
B. To ensure adequate monitoring and documentation of physiological, and mechanical parameters of patients
receiving respiratory support.
C. To provide for medical supervision and direction of respiratory care practitioners working with patients
requiring mechanical ventilation
D. To ensure reasonable and appropriate utilization of mechanical ventilation.

II. DEFINITIONS

A. The “Advanced Ventilator Management” privilege is granted to Adult Medical Critical Care physicians who
have completed advanced ventilator competency training with Respiratory Care Services. See UW Health
clinical policy #2.3.28, Ventilator Parameter Adjustments.
B. The “Ventilator Management” privilege is granted to physicians privileged in Adult Critical Care,
Anesthesiology, Emergency Medicine, Pediatric Critical Care, Pediatric Pulmonology,
Pediatrics/Neonatology, and Adult or Pediatric Pulmonary Medicine.
C. The privilege of “Ventilator Management of Intermediate Care Patients” is granted to Hospitalists providing
care for ventilator patients on D6/5 at University Hospital.
D. “GME trainees” are residents and fellows who are graduates of approved schools in graduate training
programs as defined by UW Medical Staff Bylaws.

III. POLICY ELEMENTS

A. All patients receiving mechanical ventilation must have active orders in Health Link that are reflective of the
patient’s current ventilator settings.
B. Per UW Health clinical policy #3.4.2, Patient Care Orders, orders for mechanical ventilation may be placed
by the following disciplines.
i. Physicians privileged in Management of Mechanical Ventilation and Ventilator Management of
Intermediate Care Patients.
ii. A graduate medical education (GME) trainee approved by or formally affiliated with UW Health
within the scope of their training program.
iii. A physician assistant with a supervising physician and acting within the scope of professional
privileges approved under Article V of the Medical Staff Bylaws, and in accordance with UW Health
Administrative Policy #8.75, Credentialing and Professional Privileging of Advanced Practice
Providers.
iv. An advanced practice nurse prescriber acting within the scope of professional privileges approved
under Article V of the Medical Staff Bylaws, and in accordance with UW Health Administrative
Policy #8.75, Credentialing and Professional Privileging of Advanced Practice Providers.
v. Registered nurses - verbal orders only.
vi. Respiratory therapist -verbal orders and delegated orders.
C. Mechanical ventilation can be initiated on patients with artificial airways in the Emergency Departments,
Intensive Care Units (ICUs), Recovery rooms, D6/5 Intermediate Care Unit (IMC), and designated areas at
American Family Children’s Hospital (AFCH).
D. A patient may initially be placed on mechanical ventilation during an emergency outside an ICU, however,
transfer to an appropriate ICU or IMC is subsequently required.
E. Mechanical Ventilation may be provided outside of the above listed areas for the situations listed below.
i. Stable pediatric patients with tracheostomy tubes that have been on ventilation at home may be
placed on the Universal Care Unit at AFCH.
ii. On F6/5 at University Hospital in the event it is opened as a surge capacity unit.
iii. Intubated patients with non-survivable injuries and comfort measure only goals may be transferred
from the Emergency Department (ED) to a general care floor for end of life care. Per UW Health
clinical policy #2.1.21, Care of Intubated Patients at the End of Life, the respiratory therapist and



UW HEALTH CLINICAL POLICY 2
Policy Title: Administration of Mechanical Ventilation via Artificial Airway
Policy Number: 2.3.33

Save Our Shift (SOS) nurse will stay with the patient and perform the extubation within two hours of
arrival on the unit.
F. Ventilator adjustments throughout UW Health will be made by a respiratory therapist in accordance with
provider orders with the following exceptions per UW Health clinical policy #2.3.28, Ventilator Parameter
Adjustments.
i. Physicians privileged in advanced ventilator management. These changes may only occur in the
Trauma and Life Support Center (TLC).
ii. Fellows with subspecialities in Anesthesiology/Critical Care and Pulmonary/Critical Care who have
been endorsed by their supervising attending and have completed the advanced ventilator
competency. These changes may only occur in the Trauma and Life Support Center (TLC).
iii. Registered nurses can make adjustments to FiO2 for suctioning or in the event of an emergency.
G. All mechanically ventilated patients with an artificial airway are eligible for implementation of the appropriate
weaning protocol. Please see Respiratory Care policy 1.53 for unit-specific weaning protocols
H. A complete ventilator system check and patient assessment will be performed by a respiratory therapist a
minimum of every four hours.
I. Appropriate alarm systems will be utilized to assure that the alarms are audible with respect to distance and
competing noise. Devices that have a built in, audible, low pressure alarm will be linked to the nurse call
system to signal.
J. All patients receiving invasive ventilation must have a manual resuscitator or flow inflation bag at bedside
with a dedicated flowmeter.
K. All mechanical ventilators must be will be plugged into red emergency outlets and be equipped with battery
back-up. In the event of electrical and battery power failure, the ventilator-dependent patient should be
manually ventilated with a resuscitator bag until alternate power is available. If all power sources have been
interrupted, prepare to relocate affected patients to an unaffected adjacent area.
L. If the medical gas distribution system is interrupted, Respiratory Care will provide a back-up system
according to Respiratory Care policy 1.25, Emergency Plan for Loss of Piped Gas Pressure.
M. In the event of ventilator failure or depletion of all electrical/battery sources, patients must be ventilated with
a manual resuscitator until a solution is found or equipment is replaced.
N. Patients who require respiratory/ventilatory support must use a hospital-owned device provided through the
Respiratory Care department unless an exception has been granted such as:
i. It is used for a stable, chronic condition and no adjustments in settings are anticipated. If it
becomes necessary to make adjustments the patient may be required to use a hospital owned
device. This will be determined by Respiratory Care Services and will be based on staff familiarity
with the patient owned device.
ii. Patient is transitioning to the home setting and it is necessary to use the device for purposes of
patient/family instruction. Respiratory Care personnel must be trained on the operation of these
devices prior to use.
iii. All patient owned or rented devices must pass the equipment safety check prior to use.
O. An exception to this policy can be made by the Medical Director, Assistant Medical Director, or a designee in
the absence of the Medical Director.
P. The Medical Director for Respiratory Care is the contact for all patient concerns on adult units. The Assistant
Medical Director for Respiratory Care is the contact for all patient concerns on the Pediatric units. In the
absence of the Medical Director, Respiratory Care will contact:
i. University Hospital and the American Center
a. The attending physician on the Pulmonary Consult Service from 0700-1700.
b. The Critical Care attending covering the Critical Care Service in the Trauma Life Support
Center 1700-0700.
ii. The American Family Children’s Hospital or pediatric situations in the adult hospitals
a. The attending physician on the Pediatric Pulmonary Service.
iii. The Medical Directors for Respiratory Care or designee as listed above may approve exceptions to
this policy upon request of the provider if:
a. The exception will not present a hazardous situation for the patient.
b. The patient is stable and does not require extensive monitoring or close observation.
c. Nursing service and respiratory therapy can provide adequate staffing support.
Q. Review by the Medical Director of Respiratory Care or designee is appropriate under the following
circumstances:
i. FIO2> 0.6 for 24 hours
ii. PEEP 10 cm H2O or greater for 24 hours



UW HEALTH CLINICAL POLICY 3
Policy Title: Administration of Mechanical Ventilation via Artificial Airway
Policy Number: 2.3.33

iii. Use of unconventional modes of ventilation
iv. Ventilation that includes adjunctive therapy such as helium, nitric oxide, or continuous
bronchodilator treatment
v. Difficult weaning and/or at request of respiratory therapist

IV. COORDINATION

Author: Director of Respiratory Care and ECMO Services
Senior Management Sponsor: Chief Nursing Officer, Inpatient
Reviewers: Medical Director Respiratory Care Services
Approval committees: Respiratory Care Committee, UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: July 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

A. SAFE INITIATION AND MANAGEMENT OF MECHANICAL VENTILATION." American Association for
Respiratory Care, 2016.
B. Related Policies & Procedures:
i. Respiratory Care Services Departmental Policy
a. 1.25: Emergency Plan for Loss of Piped Gas Pressure.
b. 1.53: Respiratory Care Protocols
c. 2.02: Mechanical Ventilation: Adult & Pediatric
d. 2.03. High Frequency Oscillatory Ventilation (HFOV).
e. 2.05: Transportation of Patients Supported by Non-Invasive (NIV) or Mechanical
Ventilation (MV)
ii. UW Health Clinical Policy
a. 2.1.21 Care of the Intubated ED Patients at the End of Life
b. 2.3.28 Ventilator Parameter Adjustments
c. 3.4.2 Patient Care Orders
iii. UW Health Administrative Policy
a. 8.75 Credentialing and Professional Privileging of Advanced Practice Providers

VII. REVIEW DETAILS

Version: Revision
Last Full Review: August 28, 2017
Next Revision Due: August 2020
Formerly Known as: UWHC policy #8.14, Guidelines for Administration of Continuous Invasive and Non-
Invasive Respiratory Support