Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.
Department of Emergency, Department of Intensive Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
PLoS One. 2023 Jan 30;18(1):e0280744. doi: 10.1371/journal.pone.0280744. eCollection 2023.
This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).
这项前瞻性准实验研究来自 NASAM（国家标准化和改善机械通气方法）合作组织，评估了包括声门下吸引、每日自主唤醒试验（SAT）评估、自主呼吸试验（SBT）、床头抬高和除非有禁忌否则避免使用神经肌肉阻滞剂等基于证据的实践的影响。研究结果包括 VAE（主要）和重症监护病房（ICU）死亡率。使用重复测量混合模型评估每日护理过程措施和结果的变化。结果以每个额外月的发病率比（IRR）报告，置信区间（CI）为 95%。在沙特阿拉伯 26 家医院的 42 个 ICU 中实施了一项综合计划，包括对机械通气患者进行最佳护理的基于证据的实践教育，并实时基准化每日护理过程措施，以提高护理质量，观察时间超过 27000 天。在项目实施期间，声门下吸引、SAT 和 SBT 的依从性每月分别增加 3.5%、2.1%和 1.9%（IRR 1.035，95%CI 1.007-1.064，p=0.0148；1.021，95%CI 1.010-1.032，p=0.0003；1.019，95%CI 1.009-1.029，p=0.0001）。神经肌肉阻滞剂的使用每月减少 2.5%（IRR 0.975，95%CI 0.953-0.998，p=0.0341）。床头抬高的依从性在基线时较高，并且随着时间的推移没有变化。基于 83153 个呼吸机日的数据，VAE 发生率为 15.2/1000 呼吸机日（95%CI 12.6-18.1），在项目期间没有变化（IRR 1.019，95%CI 0.985-1.053，p=0.2812）。基于 8523 名患者的数据；死亡率为 30.4%（95%CI 27.4-33.6），在项目期间每月下降 1.6%（IRR 0.984，95%CI 0.973-0.996，p=0.0067）。国家质量改进合作与日常护理过程的改善有关。这些变化与死亡率的降低有关，但与 VAE 无关。该研究在 clinicaltrials.gov 注册（NCT03790150）。
