Dataset Information

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study.

ABSTRACT: Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation.

Design

Multi-ICU proof-of-concept study and a single ICU before-after study.

Setting

University hospital ICUs.

Patients

Adult patients receiving mechanical ventilation.

Interventions

An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers.

Measurements and main results

We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01-1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03-1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09-4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13-5.16 d; p = 0.040) shorter, compared with the expected durations without the application.

Conclusions

Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

SUBMITTER: Anderson BJ

PROVIDER: S-EPMC7063891 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Publications

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study.

Anderson Brian J BJ Do David D Chivers Corey C Choi Katherine K Gitelman Yevgeniy Y Mehta Shivan J SJ Panchandam Venkat V Gudowski Steve S Pierce Margie M Cereda Maurizio M Christie Jason D JD Schweickert William D WD Gabrielli Andrea A Huffenberger Ann A Draugelis Mike M Fuchs Barry D BD

Critical care explorations 20191030 10

Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation.<h4>Design</h4>Multi-ICU proof-of-concept study and a single ICU before-after study.<h4>Setting</h4>University hospital ICUs.<h4>Patients</h4>Adult patients receiving mechanical ventilation.<h4>Interventions</h4>An automated application consisting of ...[more]

PMID: 32166237

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Project description:This study aimed to assess the potential impact of implementing an electronic alert system (EAS) for systemic inflammatory syndrome (SIRS) and sepsis in pediatric patients mortality. This retrospective study had a pre and post design. We enrolled patients aged ≤ 14 years who were diagnosed with sepsis/severe sepsis upon admission to the pediatric intensive care unit (PICU) of our tertiary hospital from January 2014 to December 2018. We implemented an EAS for the patients with SIRS/sepsis. The patients who met the inclusion criteria pre-EAS implementation comprised the control group, and the group post-EAS implementation was the experimental group. Mortality was the primary outcome, while length of stay (LOS) and mechanical ventilation in the first hour were the secondary outcomes. Of the 308 enrolled patients, 147 were in the pre-EAS group and 161 in the post-EAS group. In terms of mortality, 44 patients in the pre-EAS group and 28 in the post-EAS group died (p 0.011). The average LOS in the PICU was 7.9 days for the pre-EAS group and 6.8 days for the post-EAS group (p 0.442). Considering the EAS initiation time as the "zero time", early recognition of SIRS and sepsis via the EAS led to faster treatment interventions in post-EAS group, which included fluid boluses with median (25th, 75th percentile) time of 107 (37, 218) min vs. 30 (11,112) min, p < 0.001) and time to initiate antimicrobial therapy median (25th, 75th percentile) of 170.5 (66,320) min vs. 131 (53,279) min, p 0.042). The difference in mechanical ventilation in the first hour of admission was not significant between the groups (25.17% vs. 24.22%, p 0.895). The implementation of the EAS resulted in a statistically significant reduction in the mortality rate among the patients admitted to the PICU in our study. An EAS can play an important role in saving lives and subsequent reduction in healthcare costs. Further enhancement of systematic screening is therefore highly recommended to improve the prognosis of pediatric SIRS and sepsis. The implementation of the EAS, warrants further validation in multicenter or national studies.

Project description:BackgroundCommon, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices.Research questionCan we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches?Study design and methodsA panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions.ResultsIn eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support.InterpretationWe propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

Project description:ImportanceThere is limited evidence on the optimal strategy for liberating infants and children from invasive mechanical ventilation in the pediatric intensive care unit.ObjectiveTo determine if a sedation and ventilator liberation protocol intervention reduces the duration of invasive mechanical ventilation in infants and children anticipated to require prolonged mechanical ventilation.Design, setting, and participantsA pragmatic multicenter, stepped-wedge, cluster randomized clinical trial was conducted that included 17 hospital sites (18 pediatric intensive care units) in the UK sequentially randomized from usual care to the protocol intervention. From February 2018 to October 2019, 8843 critically ill infants and children anticipated to require prolonged mechanical ventilation were recruited. The last date of follow-up was November 11, 2019.InterventionsPediatric intensive care units provided usual care (n = 4155 infants and children) or a sedation and ventilator liberation protocol intervention (n = 4688 infants and children) that consisted of assessment of sedation level, daily screening for readiness to undertake a spontaneous breathing trial, a spontaneous breathing trial to test ventilator liberation potential, and daily rounds to review sedation and readiness screening and set patient-relevant targets.Main outcomes and measuresThe primary outcome was the duration of invasive mechanical ventilation from initiation of ventilation until the first successful extubation. The primary estimate of the treatment effect was a hazard ratio (with a 95% CI) adjusted for calendar time and cluster (hospital site) for infants and children anticipated to require prolonged mechanical ventilation.ResultsThere were a total of 8843 infants and children (median age, 8 months [interquartile range, 1 to 46 months]; 42% were female) who completed the trial. There was a significantly shorter median time to successful extubation for the protocol intervention compared with usual care (64.8 hours vs 66.2 hours, respectively; adjusted median difference, -6.1 hours [interquartile range, -8.2 to -5.3 hours]; adjusted hazard ratio, 1.11 [95% CI, 1.02 to 1.20], P = .02). The serious adverse event of hypoxia occurred in 9 (0.2%) infants and children for the protocol intervention vs 11 (0.3%) for usual care; nonvascular device dislodgement occurred in 2 (0.04%) vs 7 (0.1%), respectively.Conclusions and relevanceAmong infants and children anticipated to require prolonged mechanical ventilation, a sedation and ventilator liberation protocol intervention compared with usual care resulted in a statistically significant reduction in time to first successful extubation. However, the clinical importance of the effect size is uncertain.Trial registrationisrctn.org Identifier: ISRCTN16998143.

Project description:BackgroundMechanical ventilation (MV) via tracheostomy is performed commonly for patients who are in long-term acute care hospitals (LTACHs) after respiratory failure. However, the outcome of MV in COVID-19-associated respiratory failure in LTACHs is not known.Research questionWhat is the ventilator liberation rate of patients who have received tracheostomy with COVID-19-associated respiratory failure compared with those with respiratory failure unrelated to COVID-19 in LTACHs?Study design and methodsIn this retrospective cohort study, we examined mechanically ventilated patients discharged between June 2020 and March 2021. Of 242 discharges, 165 patients who had undergone tracheostomy arrived and were considered for ventilator liberation. One hundred twenty-eight patients did not have COVID-19 and 37 patients were admitted for COVID-19.ResultsThe primary outcome of the study was ventilator liberation; secondary outcomes were functional recovery, length of stay (LOS) at the LTACH, and discharge disposition. After controlling for demographics, the number of comorbidities, hemodialysis, vasopressor need, thrombocytopenia, and the LOS at the short-term acute care hospital, our results indicated that patients with COVID-19 showed a higher adjusted ventilator liberation rate of 91.4% vs 56.0% in those without COVID-19. Functional ability was assessed with the change of Functional Status Score for the Intensive Care Unit (FSS-ICU) between admission and discharge. The adjusted mean change in FSS-ICU was significantly higher in the COVID-19 group than in the non-COVID-19 group: 9.49 (95% CI, 7.38-11.6) vs 2.08 (95% CI, 1.05-3.11), respectively (P < .001). Patients with COVID-19 experienced a shorter adjusted LOS at the LTACH with an adjusted hazard ratio of 1.57 (95% CI, 1.0-2.46; P = .05) compared with patients without COVID-19. We did not observe significant differences between the two groups regarding discharge location, but a trend toward need for lower level of care was found in patients with COVID-19.InterpretationOur study suggests that patients with COVID-19 requiring MV and tracheostomy have a higher chance for recovery than those without COVID-19.

Project description:OBJECTIVE:Ventilator dyssynchrony is potentially harmful to patients with or at risk for the acute respiratory distress syndrome. Automated detection of ventilator dyssynchrony from ventilator waveforms has been difficult. It is unclear if certain types of ventilator dyssynchrony deliver large tidal volumes and whether levels of sedation alter the frequency of ventilator dyssynchrony. DESIGN:A prospective observational study. SETTING:A university medical ICU. PATIENTS:Patients with or at risk for acute respiratory distress syndrome. INTERVENTIONS:Continuous pressure-time, flow-time, and volume-time data were directly obtained from the ventilator. The level of sedation and the use of neuromuscular blockade was extracted from the medical record. Machine learning algorithms that incorporate clinical insight were developed and trained to detect four previously described and clinically relevant forms of ventilator dyssynchrony. The association between normalized tidal volume and ventilator dyssynchrony and the association between sedation and the frequency of ventilator dyssynchrony were determined. MEASUREMENTS AND MAIN RESULTS:A total of 4.26 million breaths were recorded from 62 ventilated patients. Our algorithm detected three types of ventilator dyssynchrony with an area under the receiver operator curve of greater than 0.89. Ventilator dyssynchrony occurred in 34.4% (95% CI, 34.41-34.49%) of breaths. When compared with synchronous breaths, double-triggered and flow-limited breaths were more likely to deliver tidal volumes greater than 10?mL/kg (40% and 11% compared with 0.2%; p < 0.001 for both comparisons). Deep sedation reduced but did not eliminate the frequency of all ventilator dyssynchrony breaths (p < 0.05). Ventilator dyssynchrony was eliminated with neuromuscular blockade (p < 0.001). CONCLUSION:We developed a computerized algorithm that accurately detects three types of ventilator dyssynchrony. Double-triggered and flow-limited breaths are associated with the frequent delivery of tidal volumes of greater than 10?mL/kg. Although ventilator dyssynchrony is reduced by deep sedation, potentially deleterious tidal volumes may still be delivered. However, neuromuscular blockade effectively eliminates ventilator dyssynchrony.

Dataset Information

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study.

Design

Setting

Patients

Interventions

Measurements and main results

Conclusions

Publications

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study.

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