Implementing evidence-based practice in the neuroscience intensive care unit.

Abstract

Background: Mechanical ventilation is associated with substantial morbidity in brain-injured patients. This study aimed to assess the effectiveness of an extubation readiness bundle to decrease duration of mechanical ventilation after brain injury.

Methods:

Objective: To evaluate whether the implementation of an evidence-based care bundle can accelerate extubation readiness in brain-injured patients.

Design: Before/after observational study.

Setting: Two ICUs in one university hospital in France.

Subjects: Brain-injured patients ventilated >24 hours with an initial Glasgow Coma Scale score ≤12 and an acutely abnormal brain computerized tomography.

Intervention: One year of targeted education focused on a four-element treatment bundle consisting of lung protective ventilation, early enteral nutrition, standardization of antibiotherapy for hospital-acquired pneumonia and a systematic approach to extubation.

Measurements: Observational data were recorded prospectively during the pre- and post-intervention periods. The primary endpoint was the duration of mechanical ventilation. Secondary endpoints included ventilator-free days at 28 and 90 days, ICU and 90 day mortality, development of hospital acquired pneumonia or acute respiratory distress syndrome and unplanned or failed extubation.

Results: The study included 499 patients, 299 in the control phase and 200 in the intervention phase. Admission during the intervention phase was associated with lower mean tidal volume (P < 0.01), higher mean positive end-expiratory pressure levels (P < 0.01), and higher enteral intake in the first 7 days (P = 0.01). The mean 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 to 1.57; P = 0.02) in the intervention phase. The adjusted HR was 1.40 (95% CI 1.12 to 1.76, P < 0.01) in multivariate analysis and 1.34 (95% CI 1.03 to 1.74, P = 0.02) in a propensity score-adjusted analysis. ICU-free days at day 90 increased from 50 ± 33 in the control phase to 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).

Limitations: The major limitations of this work are those inherent in a before-after observational study design. Additionally, the authors do not present a needs assessment to support the design of their quality improvement initiative.

Conclusions: Targeted education focused on an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in brain-injured patients.