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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

Fuller, Brian M. MD, MSCI1; Ferguson, Ian T. MPH2; Mohr, Nicholas M. MD, MS3; Drewry, Anne M. MD, MSCI4; Palmer, Christopher MD1; Wessman, Brian T. MD1; Ablordeppey, Enyo MD, MPH1; Keeperman, Jacob MD1; Stephens, Robert J. BS5; Briscoe, Cristopher C. BA5; Kolomiets, Angelina A. BS6; Hotchkiss, Richard S. MD4; Kollef, Marin H. MD7

doi: 10.1097/CCM.0000000000002268
Clinical Investigations

Objectives: 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.

Design: Quasi-experimental, before-after trial.

Setting: Emergency department and ICUs of an academic center.

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

Interventions: 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.

Measurements and Main 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.

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This work was performed at Washington University School of Medicine in St. Louis.

Supported, in part, by the Washington University Institute of Clinical and Translational Sciences (Grants UL1 TR000448 and KL2 TR000450) from the National Center for Advancing Translational Sciences.

Drs. Fuller, Drewry, Stephens, and Briscoe received support for article research from the National Institutes of Health (NIH). Dr. Fuller’s institution received funding from KL2 Career Development Award KL2 TR000450 and from Foundation for Barnes-Jewish Hospital Clinical and Translational Sciences Research Program (Grant 8041–88). Dr. Drewry’s institution received funding from Foundation for Anesthesia Education and Research and from the NIH. Dr. Mohr disclosed other support from Emergency Medicine Foundation, Iowa Health Care Collaborative, NIH, National Institute on Minority Health, and Health Disparities Children’s Miracle Network. He received funding from Illinois College of Emergency Physicians, Annals of Emergency Medicine Editorial Board, and from the University of Nebraska. Dr. Ablordeppey’s institution received funding from Washington University School of Medicine, and from Barnes Jewish Hospital Foundation. Dr. Keeperman received funding from Teleflex (provided clinical education on vascular access devices). Dr. Stephens disclosed other support from the Clinical and Translational Science Award program of the National Center for Advancing Translational Sciences of the NIH under Award Numbers UL1 TR000448 and TL1 TR000449. He also received funding from NIH. Dr. Briscoe received funding from NIH T35 National Heart, Lung and Blood Institute Training Grant Grant Title: Short-Term Training in Health Professional Schools, Grant Number: 5 T35 HL007815, and Grant principal investigator: Dr. Koong-Nah Chung. Dr. Hotchkiss was supported by NIH grants R01 GM44118-22 and R01 GM09839 and has research grants with GlaxoSmithKline and Bristol-Myers Squibb for studies testing immunotherapeutics in mice and in patient blood. Dr. Kollef was supported by the Barnes-Jewish Hospital Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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