A Quality Assurance Study Assessing Mechanical Ventilation Practices in the Emergency Department
CCCF ePoster library. Sharif S. Nov 8, 2018; 233369; 64
Dr. Sameer Sharif
Dr. Sameer Sharif
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Introduction Mechanical ventilation (MV) is lifesaving for patients with respiratory failure and is frequently initiated in the emergency department (ED). Despite the benefits, MV can be associated with complications. Ventilator settings affects the risk of developing ventilator-associated complications and subsequent outcomes. Specifically, both low tidal volume (TV) ventilation and avoidance of excess oxygen delivery have been associated with improved outcomes for patients receiving MV. Recent research indicates that these benefits extend to ED patients. Specifically, a before-after study examined the impact of an ED bundle that focused on low TV ventilation, levels of PEEP, and oxygen weaning. The bundle was associated with numerous benefits including lower rates of ARDS, shorter durations of MV, and a reduction in mortality. This result warrants replication to determine if an ED MV bundle can improve outcomes.

Objectives 1) To document current ventilation practices through a retrospective chart review of patients intubated in the ED and transferred to the ICU; 2) To analyze the association between ED ventilation settings and subsequent ICU outcomes

Methods We identified consecutive ventilated ED patients at the study centre over a 1-year period. Demographics, ED length of stay, diagnosis, mode of arrival, and indication for intubation were abstracted. ED ventilation settings including delivered TV, PEEP, percentage inspired oxygen (FiO2), and oxygen saturations were also collected. Lung protective ventilation (LPV) was defined as a TV of less than or equal to 8ml/kg of predicted body weight given this is the upper limit prescribed in ARDSnet. In line with previous research, hyperoxia was defined as the provision of an FiO2 greater than 40% with saturations greater than 95%. Analysis were conducted examining the association between ED ventilation practices and ICU outcomes. The primary outcome was mortality during the index hospitalization. Secondary outcomes included the duration of MV among survivors and the mean arterial oxygen to inspired oxygen ratio (PaO2/FiO2) during the initial 48 hours of admission.

Results 126 patients were included in the study. The mean time from ED arrival to intubation was 3.1 hours (SD = 6.8 hours) and from intubation to ICU transfer was 3.5 hours (SD - 2.1 hours). The majority (99%) of patients received a PEEP of least 5cm of water in the ED. Only 20% of patients had an ideal body weight recorded in the ED and 40% of patients were ventilated with volumes greater than 8ml/kg. Forty-eight percent of patients met criteria for hyperoxia while ventilated in the ED. Thirty-one percent of patients who received LPV died durng the index hospitalization as compared to 42% percent of patients who did not receive LPV which was not a statistically significant difference. Patients who met criteria for hyperoxia in the ED were more likely to die (45% mortality) compared with patients who did not receive hyperoxia in the ED (26% mortality; RR = 1.74, 95% CI 1.04 - 2.92).

Conclusions The current study indicates that many patients are ventilated in the ED using tidal volumes and levels of FiO2 greater than what is recommended based upon research and guidelines. These unadjusted results suggest that the delivery of excessive oxygen in the ED may negatively impact patient outcomes. A quality improvement initiative focused on optimizing ED ventilation has the potential to change practice and improve outcomes.

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