title: Implementing evidence-based practice in the neuroscience intensive care unit.
abstract: BACKGROUND
  Mechanical ventilation is associated with substantial morbidity in brain-injured patients. This study aimed to assess the effectiveness of an extubation readiness bundle to decrease duration of mechanical ventilation after brain injury.
  
  
  METHODS
  
  
  
  OBJECTIVE
  To evaluate whether the implementation of an evidence-based care bundle can accelerate extubation readiness in brain-injured patients.
  
  
  METHODS
  Before/after observational study.
  
  
  METHODS
  Two ICUs in one university hospital in France.
  
  
  METHODS
  Brain-injured patients ventilated >24 hours with an initial Glasgow Coma Scale score ≤12 and an acutely abnormal brain computerized tomography.
  
  
  METHODS
  One year of targeted education focused on a four-element treatment bundle consisting of lung protective ventilation, early enteral nutrition, standardization of antibiotherapy for hospital-acquired pneumonia and a systematic approach to extubation.
  
  
  METHODS
  Observational data were recorded prospectively during the pre- and post-intervention periods. The primary endpoint was the duration of mechanical ventilation. Secondary endpoints included ventilator-free days at 28 and 90 days, ICU and 90 day mortality, development of hospital acquired pneumonia or acute respiratory distress syndrome and unplanned or failed extubation.
  
  
  RESULTS
  The study included 499 patients, 299 in the control phase and 200 in the intervention phase. Admission during the intervention phase was associated with lower mean tidal volume (P < 0.01), higher mean positive end-expiratory pressure levels (P < 0.01), and higher enteral intake in the first 7 days (P = 0.01). The mean duration of mechanical ventilation was 14.9 ± 11.7 days in the control phase and 12.6 ± 10.3 days in the intervention phase (P = 0.02). The hazard ratio (HR) for extubation was 1.28 (95% confidence interval (95% CI) 1.04 to 1.57; P = 0.02) in the intervention phase. The adjusted HR was 1.40 (95% CI 1.12 to 1.76, P < 0.01) in multivariate analysis and 1.34 (95% CI 1.03 to 1.74, P = 0.02) in a propensity score-adjusted analysis. ICU-free days at day 90 increased from 50 ± 33 in the control phase to 57 ± 29 in the intervention phase (P < 0.01). Mortality at day 90 was 28.4% in the control phase and 23.5% in the intervention phase (P = 0.22).
  
  
  CONCLUSIONS
  The major limitations of this work are those inherent in a before-after observational study design. Additionally, the authors do not present a needs assessment to support the design of their quality improvement initiative.
  
  
  CONCLUSIONS
  Targeted education focused on an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in brain-injured patients.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Elmer
authors.forename: Jeremy
authors.initials: J
authors.lastname: Kahn
mesh_terms: D001930:Brain Injuries / Q000175:diagnosis / Q000628:therapy*; D055317:Evidence-Based Practice / Q000379:methods* / Q000639:trends; D006801:Humans; D007362:Intensive Care Units / Q000639:trends; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods* / Q000639:trends