ProHealth Heart and Vascular Care in Waukesha, Wis., embarked on a multidisciplinary initiative to reduce ventilation times for isolated Coronary Artery Bypass Grafting patients at Waukesha Memorial Hospital. The goals: Reduce the risk of patient harm associated with mechanical ventilation and achieve significant improvements in teamwork and safety culture.

The Challenge

(L to R) James Mangerson, PA, and Jennifer Boyce, RN, BSN

Mechanical ventilation affects 800,000 hospitalized patients in the U.S. each year. Five to 10 percent of mechanically ventilated patients develop a ventilator-associated event. Historically, ventilator-associated pneumonia (VAP) was considered one of the most lethal healthcare-associated infections with a 35% mortality rate for ventilated patients, 24% for patients 15-19 years old, and 60% for patients 85 years and older.

ProHealth recognized the need to reduce ventilation times after reviewing data related to isolated CABG prolonged intubation, noticing trends, and identifying individual patient events. The health system reports 130 CT surgery cases per year on average to the ACSD. In 2022, the health system performed 81 isolated CABG surgeries.

Actions Taken Using the STS National Database

ProHealth understands that sustainable quality improvement involves partnerships from multiple stakeholders across the healthcare setting. It requires information-sharing and systematic actions that lead to the enhancement of healthcare services and health conditions of a target patient group. 

The healthcare system regularly convened a multidisciplinary team made up of hospital leadership, cardiothoracic surgeons, the director of heart and vascular outcomes, CT surgery physician assistants, advanced practice nurse practitioners with direct patient care, and the STS Database manager to review ventilation times data from the ACSD. The team identified trends and fallout events and shared intel with partnering departments, including surgery team staff, ICU staff, and heart care unit managers through the quarterly CT surgery dashboard. 

Given that the facility had lower patient volumes, even a single fallout could drastically impact the data. Using data to understand the narrow margin of error motivated the team to analyze the entire mechanical ventilation process. They found that some patients were being extubated just outside the STS quality window, leading to frequent fallouts. The data also led the health system to evaluate the skillsets of their care teams, particularly the Advanced practice practitioners responsible for overnight call coverage. Following a thorough skills assessment, ProHealth worked with one of their APPs to develop a learning tool that would arm on-call APPs with a system-based checklist for patient progress assessment, covering hemodynamics, neurologic status, chest tube output, and ventilation data, for hourly RN check-ins. This process not only improved the expertise and practice of the APP team, but also identified areas for improvement for the ICU staff.

The team at ProHealth also created an extubation protocol algorithm, defining care goals, criteria for weaning and extubation, and guidance for cases where patients failed to wean. They worked closely with critical care providers and RT/RN leaders to launch a 90-day pilot to test the new extubation protocol algorithm and gather feedback. After refining the protocol, they presented it to the Medical Executive Committee for approval. The protocol was published throughout the ICU and incorporated into the post-op order set.


The results of this initiative show a significant reduction in prolonged intubation cases from 2017 to 2022. The last prolonged intubation case for isolated CABG patients occurred in Q1 of 2021, and this positive trend continued through September 2023.

Isolated CABG Total Post-Op Ventilation Hours from 2020 to 2022
•    Initial ventilation hours (mean) from 7.15 to 5.54 
•    Initial ventilation < six hours from 55.5% to 69.1% 
•    Total ventilation hours (mean) from 10.17 to 5.54 
•    Reintubation from 3.7% to 0% 
•    Prolonged intubation from 3.7% to 0%

The success of ProHealth initiative to reduce ventilation times highlights the importance of accurate and reliable data from the STS National Database, collaboration, and leadership support. The multidisciplinary team’s dedication to ongoing quality improvement and attention to detail has not only improved patient outcomes, but also reinforced the vital role of every team member in achieving success.