Implementation of an evidence-based extubation readiness bundle in 499 brain-injured patients – a before-after evaluation of a quality Improvement project. (Fortenberry)

Am J Respir Crit Care Med. 2013 Aug 8. [Epub ahead of print] PMID: 23927561

Rationale: Mechanical ventilation is associated with morbidity in brain-injured patients. This study aims to assess the effectiveness of an extubation readiness bundle to decrease ventilator time in brain-injured patients. Methods: Before/after design in two intensive care units (ICUs) in one university hospital. Brain-injured patients ventilated > 24 hours were evaluated during two phases (a 3-year control phase followed by a 22-month intervention phase). Bundle components were: protective ventilation, early enteral nutrition, standardization of antibiotherapy for hospital-acquired pneumonia and systematic approach to extubation. The primary endpoint was the duration of mechanical ventilation. Results: 299 and 200 patients respectively were analyzed in the control and the intervention phases of this before/after study. The intervention phase was associated with lower tidal volume (P<0.01), higher PEEP (P<0.01), and higher enteral intake in the first 7 days (P=0.01). The 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) 1.04-1.57; P=0.02) in the intervention phase. Adjusted HR was 1.40 (95%CI, 1.12-1.76, P<0.01) in multivariate analysis and 1.34 (95%CI, 1.03-1.74; P=0.02) in propensity score-adjusted analysis. ICU-free days at day-90 increased from 50±33 in the control phase versus 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). Conclusion: The implementation of an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in brain-injured patients.

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