Moinhos de Vento Hospital, Brazil.
Moinhos de Vento Hospital, Brazil.
J Crit Care. 2017 Oct;41:296-302. doi: 10.1016/j.jcrc.2017.07.014. Epub 2017 Jul 12.
Implementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol.
We investigated all consecutive MV-dependent subjects admitted to a medical-surgical intensive care unit (ICU) for >24h over 7years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases.
We enrolled 2469 subjects over 7years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p<0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p<0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p<0.001). When the weaning protocol was evaluated step-by-step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p<0.001).
A multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation.
实施撤机方案与患者预后改善相关。然而，新方法可能需要数年时间才能成为日常实践中的标准治疗方法。我们进行了一项前瞻性队列研究，旨在调查实施机械通气（MV）撤机方案的多方面策略的有效性，并评估撤机成功率以及医生对方案的依从性。
我们调查了 7 年来在综合外科重症监护病房（ICU）接受>24 小时 MV 支持的所有连续 MV 依赖患者。多方面策略包括对主治医生和 ICU 工作人员进行继续教育以及定期反馈患者结局。该研究分三个阶段进行：方案制定、方案和多方面策略实施以及方案监测。在所有阶段均收集撤机结局和医生对撤机方案的依从性数据。
我们在 7 年内共纳入 2469 例患者，其中 1943 例（78.7%）成功撤机。在方案和多方面策略实施期间，医生对方案的依从性增加（从 38%增加到 86%，p<0.01），而在方案监测阶段下降（从 73.9%下降到 50.0%，p<0.01）。然而，在研究期间，所有患者的撤机成功率增加（从 73.1%增加到 85.4%，p<0.001）。逐步评估撤机方案时，我们发现无创通气使用（95%）和撤机预测指标测量（91%）的依从性较高，而液体平衡控制（57%）和每日镇静中断（24%）的依从性较低。与根据临床实践进行撤机的患者相比，接受撤机方案的患者撤机成功率更高（85.6% vs. 67.7%，p<0.001）。
由继续教育和定期反馈组成的多方面策略可以提高医生对机械通气撤机方案的依从性。
