Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation

Tallman, Crystal M Ives; Harvey, Colleen K; Laurinec, Stephanie; Melvin, Amanda C.; Fecteau, Kimberly; Cranford, James A.; Haas, Nathan L.; Bassin, Benjamin S.

doi:10.5811/westjem.2020.10.49104

Cited by 3 publications

(6 citation statements)

References 18 publications

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“…In the final analysis, 21 studies were included. Eleven studies provided outcome data and were meta-analyzed (6, 11, 28, 35–42); 10 studies provided descriptive tidal volume data (16–18, 43–49). Supplemental Digital Content 5 (http://links.lww.com/CCM/H45) displays the study flow diagram at each stage of the review.…”

Section: Resultsmentioning

confidence: 99%

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Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact*

Monnin

Terian

Yaegar

et al. 2022

Critical Care Medicine

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Data suggest that low tidal volume ventilation (LTVV) initiated in the emergency department (ED) has a positive impact on outcome. This systematic review and meta-analysis quantify the impact of ED-based LTVV on outcomes and ventilator settings in the ED and ICU. DATA SOURCES:We systematically reviewed MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, references, conferences, and ClinicalTrials.gov. STUDY SELECTION:Randomized and nonrandomized studies of mechanically ventilated ED adults were eligible.DATA EXTRACTION: Two reviewers independently screened abstracts. The primary outcome was mortality. Secondary outcomes included ventilation duration, lengths of stay, and occurrence rate of acute respiratory distress syndrome (ARDS). We assessed impact of ED LTVV interventions on ED and ICU tidal volumes. DATA SYNTHESIS:The search identified 1,023 studies. Eleven studies (n = 12,912) provided outcome data and were meta-analyzed; 10 additional studies (n = 1,863) provided descriptive ED tidal volume data. Overall quality of evidence was low. Random effect meta-analytic models revealed that ED LTVV was associated with lower mortality (26.5%) versus non-LTVV (31.1%) (odds ratio, 0.80 [0.72-0.88]). ED LTVV was associated with shorter ICU (mean difference, −1.0; 95% CI, −1.7 to −0.3) and hospital (mean difference, −1.2; 95% CI, −2.3 to −0.1) lengths of stay, more ventilator-free days (mean difference, 1.4; 95% CI, 0.4-2.4), and lower occurrence rate (4.5% vs 8.3%) of ARDS (odds ratio, 0.57 [0.44-0.75]). ED LTVV interventions were associated with reductions in ED (−1.5-mL/kg predicted body weight [PBW] [−1.9 to −1.0]; p < 0.001) and ICU (−1.0-mL/kg PBW [−1.8 to −0.2]; p = 0.01) tidal volume. CONCLUSIONS:The use of LTVV in the ED is associated with improved clinical outcomes and increased use of lung protection, recognizing low quality of evidence in this domain. Interventions aimed at implementing and sustaining LTVV in the ED should be explored.

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Section: Resultsmentioning

confidence: 99%

“…In the final analysis, 21 studies were included. Eleven studies provided outcome data and were meta-analyzed (6,11,28,(35)(36)(37)(38)(39)(40)(41)(42); 10 studies provided descriptive tidal volume data (16)(17)(18)(43)(44)(45)(46)(47)(48)(49). Supplemental Digital Content 5 (http://links.lww.…”

Section: Search and Selectionmentioning

confidence: 99%

Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact*

Monnin

Terian

Yaegar

et al. 2022

Critical Care Medicine

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“…At our institution, the observed rates of LPV at the time of departure from the ED leave room for additional improvement. A recent quality assurance effort resulted in improved rates of accurate height measurements to provide ideal body weight and resultant low V t ventilation (conducted after this study period, thus unlikely to confound the observed results) (15). Future efforts can focus on improving rates of measuring and documenting Pplat, implementing standardized optimal PEEP strategies, and titrating oxygen to target normoxia.…”

Section: Discussionmentioning

confidence: 99%

“…Consequently, protocols have been developed to standardize processes of care in mechanically ventilated patients, with improved LPV adherence through the use of ventilator care bundles in the ED (3,7,(13)(14)(15)(16)(17). Implementation of these bundles is feasible, improves downstream LPV adherence in the ICU, and is associated with decreased mortality, development of ARDS, and cost (3,4,7,13,17).…”

mentioning

confidence: 99%

“…To combat this and to optimize early delivery of high-quality critical care, ED-based ICUs (also known as Resuscitative Care Units) have been implemented at a small number of institutions across the United States (25). In other disease processes, an ED-ICU has been associated with improved outcomes, including decreased mortality, inpatient ICU admission, and resource utilization (15,(26)(27)(28)(29)(30)(31). There are no prior investigations on the impact of an ED-ICU on adherence to LPV for ED patients receiving mechanical ventilation.…”

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confidence: 99%

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Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

Harvey

Haas²,

Chen

et al. 2022

Critical Care Explorations

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BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

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Disparities Exist in the Application of Low Tidal-volume Ventilation in the Emergency Department

Self¹,

Kennis²,

Lafree³

et al. 2023

WestJEM

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Introduction Low tidal-volume ventilation (LTVV), defined as a maximum tidal volume of 8 milliliters per kilogram (mL/kg) of ideal body weight, is a key component of lung protective ventilation. Although emergency department (ED) initiation of LTVV has been associated with improved outcomes, disparities in LTVV application exist. In this study our aim was to evaluate whether rates of LTVV are associated with demographic and physical characteristics in the ED. Methods We conducted a retrospective observational cohort study using a dataset of patients who underwent mechanical ventilation at three EDs in two health systems from January 2016–June 2019. Demographic, mechanical ventilation, and outcome data including mortality and hospital-free days were abstracted by automatic query. A LTVV approach was defined as a tidal volume ≤8 mL/kg ideal body weight. We performed descriptive statistics and univariate analysis as indicated, and created a multivariate logistic regression model. Results Of 1,029 patients included in the study, 79.5% received LTVV. Tidal volumes of 400–500 mL were used in 81.9% of patients. Approximately 18% of patients had tidal volumes changed in the ED. Female gender (adjusted odds ratio [aOR] 4.17, P < 0.001), obesity (aOR 2.27, P < 0.001), and first-quartile height (aOR 12.2, P < 0.001) were associated with receiving non-LTVV in multivariate regression analysis. Hispanic ethnicity and female gender were associated with first quartile height (68.5%, 43.7%, P < 0.001 for all). Hispanic ethnicity was associated with receiving non-LTVV in univariate analysis (40.8% vs 23.0%, P < 0.001). This relationship did not persist in sensitivity analysis controlling for height, weight, gender, and body mass index. Patients who received LTVV in the ED had 2.1 more hospital-free days compared to those who did not ( P = 0.040). No difference in mortality was observed. Conclusion Emergency physicians use a narrow range of initial tidal volumes that may not meet lung-protective ventilation goals, with few corrections. Female gender, obesity, and first-quartile height are independently associated with receiving non-LTVV in the ED. Using LTVV in the ED was associated with 2.1 fewer hospital-free days. If confirmed in future studies, these findings have important implications for achieving quality improvement and health equality.

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Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation

Abstract: BACKGROUND Approximately 240,000 patients receive mechanical ventilation in US emergency departments (ED) every

Cited by 3 publications

References 18 publications

Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact*

Low Tidal Volume Ventilation for Emergency Department Patients: A Systematic Review and Meta-Analysis on Practice Patterns and Clinical Impact*

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

Disparities Exist in the Application of Low Tidal-volume Ventilation in the Emergency Department

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