Background: Spontaneous awakening and breathing trials, early mobilization, and interventions to reduce ventilator-associated events may improve outcomes such as delirium, duration of mechanical ventilation, length of stay,... [ view full abstract ]
Background: Spontaneous awakening and breathing trials, early mobilization, and interventions to reduce ventilator-associated events may improve outcomes such as delirium, duration of mechanical ventilation, length of stay, or mortality among intensive care unit (ICU) patients. This study assesses the effectiveness of a bundled initiative in changing these practices for mechanically ventilated patients in the ICU.
Methods: Prospective cohort quality improvement project in two adult medical-surgical ICUs. In May 2015, an interdisciplinary team of physicians, nurses, respiratory and physical therapists began rolling out an initiative aimed at increasing six daily process measures for mechanically ventilated patients: spontaneous awakening trials (SATs), spontaneous breathing trials (SBTs), delirium screening, early mobilization, elevated head of bed, and use of endotracheal tubes (ETTs) with subglottic suction ports. Rates of each activity were compared pre- (1/1/15-3/31/15) and 14-15 months into (6/1/16-7/30/16) the initiative using chi-squared (or Fisher exact) tests.
Results: A total of 147 pre- and 155 post-intervention patient-days were included in the analysis. There was a significant increase in the rates of daily spontaneous breathing trials (82.8% vs 52.5%, P=0.001), delirium screenings (95.4% vs 29.0%, p<0.001), percent of days patients mobilized out of bed (22.0% vs 7.8%, p<0.001), elevated head of bed (96.0% vs 82.3%, P=0.003), and use of subglottic ETTs (57.9% vs 3.9%, P<0.001). Rates of spontaneous awakening trials (53.2% vs 45.7%, p=0.43) remained unchanged. Similarly, rates of documented contraindications to SBTs decreased significantly (46.3% vs 66.5%, p=0.001) while those for SATs remained unchanged (42.0% vs 43.1%, p=0.88).
Conclusions: Through education of care providers, updated protocols and electronic documentation, dedicated staff and equipment, and routine project assessment, a multidisciplinary team succeeded in effecting several changes in our ICUs. However, failure to alter spontaneous awakening trials or documented contraindications to them may represent more ingrained practices and/or highlight an area for additional education. Further work is planned to address these barriers and to assess the impact of these practice changes on patient outcomes.
