Protocol for a multicentre, prospective cohort study of practice patterns and clinical outcomes associated with emergency department sedation for mechanically ventilated patients: the ED-SED Study

Abstract

IntroductionIn mechanically ventilated patients, sedation strategies are a major determinant of outcome. The emergency department (ED) is the earliest exposure to mechanical ventilation for hundreds of thousands of patients annually in the USA. The one retrospective study that exists regarding ED sedation for mechanically ventilated patients showed a strong association between deep sedation in the ED and worse clinical outcomes. This finding suggests that the ED may be an optimal location to study the impact of early sedation on outcome, yet a lack of prospective studies represents a knowledge gap in this arena. This protocol describes a prospective observational study aimed at further characterising ED sedation practices and assessing the relationship between ED sedation and clinical outcomes. An association between ED sedation and clinical outcomes across multiple sites would suggest the need for changes in the current sedation strategies used in the ED, and provide evidence for future interventional studies in this field.Methods and analysisThis is a multicentre, prospective cohort study testing the hypothesis that deep sedation in the ED is associated with worse clinical outcomes. A cohort of over 300 mechanically ventilated ED patients will be included. The primary outcome is ventilator-free days, and secondary outcomes include hospital mortality, incidence of acute brain dysfunction and lengths of stay. Multivariable linear regression will test the hypothesis that deep sedation in the ED is associated with a decrease in ventilator-free days.Ethics and disseminationApproval of the study by the Institutional Review Board (IRB) at each participating site has been obtained prior to data collection on the first patient. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.

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

“…12 However, in this study only 58.4% of patients actually received lung-protective ventilation in the ED. In addition, therapeutic interventions started in the ED are often carried forward during the patient's stay in the intensive care unit (ICU), 13 further highlighting the importance of starting lung-protective ventilation early.…”

Variability in sedation assessment among intubated patients in the emergency department

“…There is little evidence to guide early sedation practices in the emergency department (ED), where mechanical ventilation is regularly initiated. Observational data suggest early deep sedation Richmond Agitation Sedation Scale Richmond Agitation Sedation Scale (RASS –3 to –5) after intubation is common and associated with increased delirium, coma, length of stay, and mortality 6‐9 . There may be opportunities to improve patient outcomes by targeting interventions in the early postintubation period, but there is limited understanding of current ED practices regarding sedation assessment.…”

“…Randomized trials comparing sedation strategies have generally enrolled patients 48 to 96 hours after initiation of mechanical ventilation, when patients have transferred to an ICU. Fuller et al 8 performed a multicenter observational cohort study of mechanically ventilated patients in the ED, but used the first ICU RASS assessment as a proxy in patients lacking documented sedation assessments in the ED. As such, this study represents the first multicenter investigation explicitly describing the proportion of patients receiving sedation assessments in the ED.…”

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

“…2 In the United States, annually hundreds of thousands of patients undergo mechanical ventilation in HE. 3 In Japan, 46.4% of patients under this type of ventilation were exclusively monitored outside the Intensive Care setting. 4 However, pneumonia associated with mechanical ventilation (PAMV) has been attributed to intubation in HE and length of stay in this sector.…”