Computerized decision support for mechanical ventilation of trauma induced ARDS: results of a randomized clinical trial.
BACKGROUND
Variability and logistic complexity of mechanical ventilatory support of acute respiratory distress syndrome, and need to standardize care among all clinicians and patients, led University of Utah/LDS Hospital physicians, nurses, and engineers to develop a comprehensive computerized protocol. This bedside decision support system was the basis of a multicenter clinical trial (1993-1998) that showed ability to export a computerized protocol to other sites and improved efficacy with computer- versus physician-directed ventilatory support. The Memorial Hermann Hospital Shock Trauma intensive care unit (ICU) (Houston, TX; a Level I trauma center and teaching affiliate of The University of Texas Houston Medical School) served as one of the 10 trial sites and recruited two thirds of the trauma patients. Results from the trauma patient subgroup at this site are reported to answer three questions: Can a computerized protocol be successfully exported to a trauma ICU? Was ventilator management different between study groups? Was patient outcome affected?


METHODS
Sixty-seven trauma patients were randomized at the Memorial Hermann Shock Trauma ICU site. "Protocol" assigned patients had ventilatory support directed by the bedside respiratory therapist using the computerized protocol. "Nonprotocol" patients were managed by physician orders.


RESULTS
Of the 67 trauma patients randomized, 33 were protocol (age 40 +/- 3; Injury Severity Score [ISS] 26 +/- 3; 73% blunt) and 34 were nonprotocol (age 38 +/- 2; ISS 25 +/- 2; 76% blunt). For the protocol group, the computerized protocol was used 96% of the time of ventilatory support and 95% of computer-generated instructions were followed by the bedside respiratory therapist. Outcome measures (i.e., survival, ICU length of stay, morbidity, and barotrauma) were not significantly different between groups. Fio2 > or = 0.6 and Pplateau > or = 35 cm H2O exposures were less for the protocol group.


CONCLUSIONS
A computerized protocol for bedside decision support was successfully exported to a trauma center, and effectively standardized mechanical ventilatory support of trauma-induced acute respiratory distress syndrome without adverse effect on patient outcome.
Department of Anesthesiology, University of Texas-Houston Medical School, Houston, Texas 77030, USA. Bruce.A.McKinley@uth.tmc.edu
B A
BA
McKinley
F A
FA
Moore
R M
RM
Sailors
C S
CS
Cocanour
A
A
Marquez
R K
RK
Wright
A S
AS
Tonnesen
C J
CJ
Wallace
A H
AH
Morris
T D
TD
East
D000328:Adult; D001784:Blood Gas Analysis; D002985:Clinical Protocols / Q000592:standards*; D003422:Critical Care / Q000592:standards*; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009017:Morbidity; D009104:Multiple Trauma / Q000145:classification / Q000150:complications* / Q000628:therapy; D017063:Outcome Assessment, Health Care; D019095:Point-of-Care Systems / Q000592:standards; D011175:Positive-Pressure Respiration / Q000009:adverse effects / Q000379:methods* / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards; D012128:Respiratory Distress Syndrome / Q000209:etiology* / Q000378:metabolism / Q000401:mortality / Q000628:therapy*; D016019:Survival Analysis; D014193:Trauma Centers