Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA 02115, USA.
J Intensive Care Med. 2013 May-Jun;28(3):189-97. doi: 10.1177/0885066612444255. Epub 2012 May 17.
While one controlled trial found that a daily awakening and spontaneous breathing trial (DA-SBT) decreases time on mechanical ventilation (MV), there is a paucity of real-world data surrounding the development, implementation, and impact of DA-SBT protocols. We describe a multidisciplinary process improvement effort in 2, 10-bed medical intensive care units (MICUs) at a 330-bed academic medical center that focused on the development, implementation, and evaluation of a new DA-SBT protocol.
A DA-SBT protocol, developed using results from a nursing survey literature and available institutional resources, was implemented after extensive clinician education and institution of quality reminders to boost use. Postprotocol compliance was evaluated. Use of sedation, DA and SBT practices, and clinical outcomes were retrospectively compared between the before and after DA-SBT protocol groups (ie, consecutive MICU patients requiring a continuously infused sedative [CIS] ≥24 hours).
In the after group (n = 32), the DA and SBT compliances were 44% and 84%, respectively. Compared with the before group (n = 33), after group patients received CIS on fewer days of MV (100% vs 67%, P = .003) and had their CIS down-titrated by ≥25% on more days of CIS (40% vs 71%, P = .006). Neither total CIS dose (P = .49), total MV days (P = .75), days of MV where a SBT occurred (P = .38), nor episodes of self-extubation (15% vs 6%, P = .43) differed between the 2 groups.
Despite the implementation of a DA-SBT protocol that was individualized to clinician preferences and institutional resources and accompanied by substantial education and reminders for use, compliance to the DA component of this protocol was low and duration of MV remained unchanged. Additional quality improvement strategies are needed to overcome barriers to DA-SBT protocol use that may not exist in controlled clinical trials.
虽然一项对照试验发现每日唤醒和自主呼吸试验（DA-SBT）可减少机械通气（MV）时间，但围绕 DA-SBT 方案的制定、实施和影响，实际数据仍十分匮乏。我们描述了一项在一家拥有 330 张床位的学术医疗中心的 2 个 10 床重症监护病房（MICU）进行的多学科流程改进工作，重点是开发、实施和评估新的 DA-SBT 方案。
使用护理调查文献和现有机构资源的结果制定了 DA-SBT 方案，在广泛的临床医生教育和实施质量提醒以提高使用量之后实施。评估方案实施后的依从性。回顾性比较 DA-SBT 方案实施前后（即需要持续输注镇静剂 [CIS] 超过 24 小时的连续 MICU 患者）两组的镇静、DA 和 SBT 实践以及临床结局。
在后组（n = 32），DA 和 SBT 的依从率分别为 44%和 84%。与前一组（n = 33）相比，后一组患者接受 MV 的 CIS 天数更少（100%对 67%，P =.003），CIS 滴定量减少≥25%的天数更多（40%对 71%，P =.006）。两组患者的 CIS 总剂量（P =.49）、MV 总天数（P =.75）、发生 SBT 的 MV 天数（P =.38）或自行拔管的发作次数（15%对 6%，P =.43）均无差异。
尽管实施了针对临床医生偏好和机构资源制定的个体化 DA-SBT 方案，并进行了大量的教育和提醒，但该方案的 DA 部分的依从性仍然很低，MV 持续时间没有改变。需要采取其他质量改进策略来克服可能在对照临床试验中不存在的 DA-SBT 方案使用障碍。
