Duration of Mechanical Ventilation in the Emergency Department

Abstract

IntroductionDue to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS).MethodsThis was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort.ResultsWe enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator.ConclusionIn a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.

Boarding of critically Ill patients in the emergency department

“…Several studies defined a time threshold a priori as greater than 2, 4, or 6 hours 16,29‐31 . Two studies assessed boarding based only on the total number of hours an intubated patient spent in the ED 19,32 . The DELAY‐ED study group identified 6 hours in the ED (from time of arrival at triage) as the definition of ED boarding, based primarily on their observations that adverse outcomes among admitted critically ill patients are more common with an ED stay greater than 6 hours 31 .…”

“…Both retrospective and prospective observational studies demonstrate worse outcomes for critically ill patients after ED boarding (Supplemental Table 2, Supplemental Digital Content 1, http://links.lww.com/CCM/F477), including increased duration of mechanical ventilation, longer ICU length of stay, and higher mortality 16,18,19,31,32,38,39 . Increased ED boarding times are associated with worsening organ dysfunction and a four‐fold increase in the probability of poor neurologic recovery in patients presenting with stroke 38 .…”

“…ED boarding also contributes to low‐quality process‐related care of the critically ill waiting for ICU admission. Mechanically ventilated patients rarely have six postintubation care elements performed while boarding in the ED 19 and boarding for more than 7 hours increases duration of mechanical ventilation and hospital mortality 32 . Boarding patients have delays in home medication initiation, fluid, and antibiotic administration, disease‐specific protocolized care, and those boarding in the ED have more medication‐related adverse events than admitted inpatients 41‐43 .…”

Boas práticas de enfermagem a pacientes em ventilação mecânica invasiva na emergência hospitalara

“…Related care to bronchial aspiration prevention Keep the headboard elevated between 30 and 45°1 [7][8][9][10][11][12][13][14][15][16][17][18][19] IIb, VI…”

“…6 Although these patients may benefit from immediate transfer to an ICU, this option is limited by overcrowding and scarce resources, which justifies the implementation of patient-directed care on mechanical ventilation in HE. 7 Mechanical ventilation totally or partially replaces spontaneous ventilation and is indicated in acute respiratory failure (ARF) or acute-on-chronic. When used invasively, endotracheal tube or tracheostomy tube is used.…”