Efficacy of implementation strategies of an evidenced-based awakening and breathing protocol: An observational quality improvement study

Abstract

Breathing Protocol: an observational Quality Improvement study Osama Almuslim,MD; Mamdouh Rezk,MD; Naglaa Hassan,MD Critical Care, KFSH-Dammam ,Saudi Arabia Introduction: A protocol that paired spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) decreased the duration of mechanical ventilation, the ICU length of stay (LOS) and mortality. We studied the efficacy of multifaceted implementation strategies of an evidence-based protocol at a tertiary academic center. Methods: This was a retrospective observational cohort study with historical control (before and after, protocol implementation study design). The cohort consisted of consecutive adult patients who were extubated at least once during the ICU stay. The interventions were: multifaceted implementation strategies of an evidence-based protocol pairing SAT and SBT. These strategies included: preprinted daily order sheets, structured daily multidisciplinary rounds, daily monitoring of the ICU staff compliance with feedback, data collection and analysis followed by quality improvement (QI) action plans. The outcomes were: reintubation rate, duration of mechanical ventilation (MV), ICU LOS and hospital mortality. Statistical analysis: Fisher’s Exact test for categorical variables, Wilcoxon rank-sum test for continuous variables; Kaplan Meier method and covariate-adjusted Cox regression were used. Covariates were: age, APACHE II and maximum SOFA during ICU stay. Results: The total included patients were n=164 (2009 n=40;2010 n=124).The baseline characteristics were imbalance for age and APACHE II. The 2009 group was older and had higher APACHE II score. The 2010 group (after QI group) had less duration of mechanical ventilation, less ICU LOS and lower hospital mortality (table). The 2010 group had shorter time to successful extubation, adjusted hazard ratio = 2.0 (95 CI %: 1.4-2.9; p<0.01) and delayed time to death, adjusted hazard ra o = 0.37 ; (95 CI %: 0.20-0.68; ; p<0.01). Outcomes Group 2009, n=40 Group 2010, n=124 p-value Reintubation 32.5% (n=13) 14.5% (n=18) P = 0.02 MV duration in days 7 (IQR 3 15) 3 (IQR 1 7) P <0.01 ICU LOS in days 10 (IQR 6 16) 5 (IQR 3 10) P <0.01 Hospital mortality 60.0% (n=24) 16.9% (n=21) P <0.01