Implementing evidence-based practice in the neuroscience intensive care unit

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.

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

Before/after observational study.

Two ICUs in one university hospital in France.

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

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.

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.

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).

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.

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