Implementation of an Evidence-based Extubation Readiness Bundle in 499 Brain-injured Patients: A Before―After Evaluation of a Quality Improvement Project

• Published in: American journal of respiratory and critical care medicine Vol. 188; no. 8; pp. 958 - 966
• Main Authors: ROQUILLY, Antoine, CINOTTI, Raphaël, PAULUS, Jérôme, ROZEC, Bertrand, BLANLOEIL, Yvonnick, VIBET, Marie-Anne, SEBILLE, Véronique, FEUILLET, Fanny, ASEHNOUNE, Karim, JABER, Samir, VOURC'H, Mickael, PENGAM, Florence, MAHE, Pierre Joachim, LAKHAL, Karim, DEMEURE DIT LATTE, Dominique, RONDEAU, Nelly, LOUTREL, Olivier
• Format: Journal Article
• Language: English
• Published: New York, NY American Thoracic Society 15.10.2013
• Subjects: Adult and adolescent clinical studies; Airway Extubation - adverse effects; Airway Extubation - methods; Airway Extubation - standards; Anesthesia; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Brain Injuries - therapy; Clinical Protocols; Enteral nutrition; Enteral Nutrition - methods; Extubation; Female; Hematoma; Human health and pathology; Humans; Hypertension; Injuries of the nervous system and the skull. Diseases due to physical agents; Intensive care; Intensive care medicine; Intervention; Intracranial pressure; Life Sciences; Male; Medical sciences; Middle Aged; Mortality; Nutrition; Organic mental disorders. Neuropsychology; Pathogens; Patients; Performance evaluation; Pneumology; Pneumonia; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Quality Improvement; Respiration, Artificial - methods; Respiration, Artificial - standards; Time Factors; Traumas. Diseases due to physical agents; Traumatic brain injury; Ventilator Weaning - methods; Ventilators; Weaning; France; Ventilator; Intensive care; Weaning; Artificial ventilation; Evidence-based medicine; Extubation; Implementation; Improvement; brain injury; Motivation; Quality; Resuscitation; Human; Evaluation; Lung disease; Nervous system diseases; Respiratory disease; Evidence-based practice; Patient; Cerebral disorder; Project; Central nervous system disease; Head trauma; ventilator-induced lung injury; Mechanical ventilation
• ISSN: 1073-449X; 1535-4970
• DOI: 10.1164/rccm.201301-0116oc

Mechanical ventilation is associated with morbidity in patients with brain injury. This study aims to assess the effectiveness of an extubation readiness bundle to decrease ventilator time in patients with brain injury. Before-after design in two intensive care units (ICUs) in one university hospital. Brain-injured patients ventilated more than 24 hours were evaluated during two phases (a 3-yr control phase followed by a 22-mo 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. A total of 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 positive end-expiratory pressure (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 for extubation was 1.28 (95% confidence interval [CI], 1.04-1.57; P = 0.02) in the intervention phase. Adjusted hazard ratio 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 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). The implementation of an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in patients with brain injury.