A Quasi-Experimental, Before-After Trial Examining the Impact of an Emergency Department Mechanical Ventilator Protocol on Clinical Outcomes and Lung-Protective Ventilation in Acute Respiratory Distress Syndrome.
OBJECTIVE
To evaluate the impact of an emergency department mechanical ventilation protocol on clinical outcomes and adherence to lung-protective ventilation in patients with acute respiratory distress syndrome.


METHODS
Quasi-experimental, before-after trial.


METHODS
Emergency department and ICUs of an academic center.


METHODS
Mechanically ventilated emergency department patients experiencing acute respiratory distress syndrome while in the emergency department or after admission to the ICU.


METHODS
An emergency department ventilator protocol which targeted variables in need of quality improvement, as identified by prior work: 1) lung-protective tidal volume, 2) appropriate setting of positive end-expiratory pressure, 3) oxygen weaning, and 4) head-of-bed elevation.


RESULTS
A total of 229 patients (186 preintervention group, 43 intervention group) were studied. In the emergency department, the intervention was associated with significant changes (p < 0.01 for all) in tidal volume, positive end-expiratory pressure, respiratory rate, oxygen administration, and head-of-bed elevation. There was a reduction in emergency department tidal volume from 8.1 mL/kg predicted body weight (7.0-9.1) to 6.4 mL/kg predicted body weight (6.1-6.7) and an increase in lung-protective ventilation from 11.1% to 61.5%, p value of less than 0.01. The intervention was associated with a reduction in mortality from 54.8% to 39.5% (odds ratio, 0.38; 95% CI, 0.17-0.83; p = 0.02) and a 3.9 day increase in ventilator-free days, p value equals to 0.01.


CONCLUSIONS
This before-after study of mechanically ventilated patients with acute respiratory distress syndrome demonstrates that implementing a mechanical ventilator protocol in the emergency department is feasible and associated with improved clinical outcomes.
1Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO.2School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.3Division of Critical Care, Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA.4Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO.5Washington University School of Medicine, St. Louis, MO.6School of Public Health and Social Justice, Saint Louis University, St. Louis, MO.7Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO.
Brian M
BM
Fuller
Ian T
IT
Ferguson
Nicholas M
NM
Mohr
Anne M
AM
Drewry
Christopher
C
Palmer
Brian T
BT
Wessman
Enyo
E
Ablordeppey
Jacob
J
Keeperman
Robert J
RJ
Stephens
Cristopher C
CC
Briscoe
Angelina A
AA
Kolomiets
Richard S
RS
Hotchkiss
Marin H
MH
Kollef
D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D065187:Controlled Before-After Studies; D004636:Emergency Service, Hospital; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010102:Oxygen Inhalation Therapy; D056888:Patient Positioning; D011175:Positive-Pressure Respiration / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000503:physiopathology* / Q000628:therapy*; D056152:Respiratory Rate; D013990:Tidal Volume