Matthew E Prekker1, Crystal Donelan2, Sum Ambur3, Brian E Driver4, Alex O'Brien-Lambert5, Daniel G Hottinger6, Alexander B Adams7. 1. Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America. Electronic address: matthew.prekker@hcmed.org. 2. Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America. Electronic address: donel010@umn.edu. 3. Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America. Electronic address: sumanth.ambur@hcmed.org. 4. Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America. Electronic address: brian.driver@hcmed.org. 5. Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America. Electronic address: aol87@u.washington.edu. 6. Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America. Electronic address: daniel.hottinger@seattlechildrens.org. 7. Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America; Respiratory Therapy Department, Hennepin County Medical Center, Minneapolis, MN, United States of America.
Abstract
BACKGROUND: Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation. METHODS: In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists. RESULTS: Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ± 1.4 mL/kg to 7.2 ± 0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW). CONCLUSIONS: Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients.
BACKGROUND: Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation. METHODS: In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists. RESULTS: Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ± 1.4 mL/kg to 7.2 ± 0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW). CONCLUSIONS: Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients.
Authors: Crystal M Ives Tallman; Carrie E Harvey; Stephanie L Laurinec; Amanda C Melvin; Kimberly A Fecteau; James A Cranford; Nathan L Haas; Benjamin S Bassin Journal: West J Emerg Med Date: 2021-01-11
Authors: Carrie E Harvey; Nathan L Haas; Chiu-Mei Chen; James A Cranford; Joseph A Hamera; Renee A Havey; Ryan E Tsuchida; Benjamin S Bassin Journal: Crit Care Explor Date: 2022-02-08