Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database

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Abstract

Background

Survival benefit from low tidal volume ( V _T) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV.

Methods

Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a V _T ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV.

Results

The study included 5719 patients; 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61–14.24%]; p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55–9.81%]; p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85–33.60%]; p = 0.045) were the only three factors that had an independent association with adherence to LTVV.

Conclusions

Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients.

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Most cited references 26

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Nurse-staffing levels and the quality of care in hospitals.

Jack Needleman, Peter Buerhaus, Soeren Mattke … (2002)

It is uncertain whether lower levels of staffing by nurses at hospitals are associated with an increased risk that patients will have complications or die. We used administrative data from 1997 for 799 hospitals in 11 states (covering 5,075,969 discharges of medical patients and 1,104,659 discharges of surgical patients) to examine the relation between the amount of care provided by nurses at the hospital and patients' outcomes. We conducted regression analyses in which we controlled for patients' risk of adverse outcomes, differences in the nursing care needed for each hospital's patients, and other variables. The mean number of hours of nursing care per patient-day was 11.4, of which 7.8 hours were provided by registered nurses, 1.2 hours by licensed practical nurses, and 2.4 hours by nurses' aides. Among medical patients, a higher proportion of hours of care per day provided by registered nurses and a greater absolute number of hours of care per day provided by registered nurses were associated with a shorter length of stay (P=0.01 and P<0.001, respectively) and lower rates of both urinary tract infections (P<0.001 and P=0.003, respectively) and upper gastrointestinal bleeding (P=0.03 and P=0.007, respectively). A higher proportion of hours of care provided by registered nurses was also associated with lower rates of pneumonia (P=0.001), shock or cardiac arrest (P=0.007), and "failure to rescue," which was defined as death from pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis, or deep venous thrombosis (P=0.05). Among surgical patients, a higher proportion of care provided by registered nurses was associated with lower rates of urinary tract infections (P=0.04), and a greater number of hours of care per day provided by registered nurses was associated with lower rates of "failure to rescue" (P=0.008). We found no associations between increased levels of staffing by registered nurses and the rate of in-hospital death or between increased staffing by licensed practical nurses or nurses' aides and the rate of adverse outcomes. A higher proportion of hours of nursing care provided by registered nurses and a greater number of hours of care by registered nurses per day are associated with better care for hospitalized patients.

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Evolution of mortality over time in patients receiving mechanical ventilation.

Andrés Esteban, Fernando Frutos-Vivar, Alfonso Muriel … (2013)

Baseline characteristics and management have changed over time in patients requiring mechanical ventilation; however, the impact of these changes on patient outcomes is unclear. To estimate whether mortality in mechanically ventilated patients has changed over time. Prospective cohort studies conducted in 1998, 2004, and 2010, including patients receiving mechanical ventilation for more than 12 hours in a 1-month period, from 927 units in 40 countries. To examine effects over time on mortality in intensive care units, we performed generalized estimating equation models. We included 18,302 patients. The reasons for initiating mechanical ventilation varied significantly among cohorts. Ventilatory management changed over time (P < 0.001), with increased use of noninvasive positive-pressure ventilation (5% in 1998 to 14% in 2010), a decrease in tidal volume (mean 8.8 ml/kg actual body weight [SD = 2.1] in 1998 to 6.9 ml/kg [SD = 1.9] in 2010), and an increase in applied positive end-expiratory pressure (mean 4.2 cm H2O [SD = 3.8] in 1998 to 7.0 cm of H2O [SD = 3.0] in 2010). Crude mortality in the intensive care unit decreased in 2010 compared with 1998 (28 versus 31%; odds ratio, 0.87; 95% confidence interval, 0.80-0.94), despite a similar complication rate. Hospital mortality decreased similarly. After adjusting for baseline and management variables, this difference remained significant (odds ratio, 0.78; 95% confidence interval, 0.67-0.92). Patient characteristics and ventilation practices have changed over time, and outcomes of mechanically ventilated patients have improved. Clinical trials registered with www.clinicaltrials.gov (NCT01093482).

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Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis.

Ary Serpa Neto, Sérgio Cardoso, José Manetta … (2012)

Lung-protective mechanical ventilation with the use of lower tidal volumes has been found to improve outcomes of patients with acute respiratory distress syndrome (ARDS). It has been suggested that use of lower tidal volumes also benefits patients who do not have ARDS. To determine whether use of lower tidal volumes is associated with improved outcomes of patients receiving ventilation who do not have ARDS. MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials up to August 2012. Eligible studies evaluated use of lower vs higher tidal volumes in patients without ARDS at onset of mechanical ventilation and reported lung injury development, overall mortality, pulmonary infection, atelectasis, and biochemical alterations. Three reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus. Twenty articles (2822 participants) were included. Meta-analysis using a fixed-effects model showed a decrease in lung injury development (risk ratio [RR], 0.33; 95% CI, 0.23 to 0.47; I2, 0%; number needed to treat [NNT], 11), and mortality (RR, 0.64; 95% CI, 0.46 to 0.89; I2, 0%; NNT, 23) in patients receiving ventilation with lower tidal volumes. The results of lung injury development were similar when stratified by the type of study (randomized vs nonrandomized) and were significant only in randomized trials for pulmonary infection and only in nonrandomized trials for mortality. Meta-analysis using a random-effects model showed, in protective ventilation groups, a lower incidence of pulmonary infection (RR, 0.45; 95% CI, 0.22 to 0.92; I2, 32%; NNT, 26), lower mean (SD) hospital length of stay (6.91 [2.36] vs 8.87 [2.93] days, respectively; standardized mean difference [SMD], 0.51; 95% CI, 0.20 to 0.82; I2, 75%), higher mean (SD) PaCO2 levels (41.05 [3.79] vs 37.90 [4.19] mm Hg, respectively; SMD, -0.51; 95% CI, -0.70 to -0.32; I2, 54%), and lower mean (SD) pH values (7.37 [0.03] vs 7.40 [0.04], respectively; SMD, 1.16; 95% CI, 0.31 to 2.02; I2, 96%) but similar mean (SD) ratios of PaO2 to fraction of inspired oxygen (304.40 [65.7] vs 312.97 [68.13], respectively; SMD, 0.11; 95% CI, -0.06 to 0.27; I2, 60%). Tidal volume gradients between the 2 groups did not influence significantly the final results. Among patients without ARDS, protective ventilation with lower tidal volumes was associated with better clinical outcomes. Some of the limitations of the meta-analysis were the mixed setting of mechanical ventilation (intensive care unit or operating room) and the duration of mechanical ventilation.

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Author and article information

Contributors

Ary Serpa Neto:

ORCID: http://orcid.org/0000-0003-1520-9387

ary.neto2@einstein.br

Journal

Journal ID (nlm-ta): Ann Intensive Care

Journal ID (iso-abbrev): Ann Intensive Care

Title: Annals of Intensive Care

Publisher: Springer International Publishing (Cham )

ISSN (Electronic): 2110-5820

Publication date (Electronic): 1 June 2020

Publication date PMC-release: 1 June 2020

Publication date Collection: 2020

Volume: 10

Electronic Location Identifier: 68

Affiliations

[1 ]GRID grid.413562.7, ISNI 0000 0001 0385 1941, Department of Critical Care Medicine, , Hospital Israelita Albert Einstein, ; Albert Einstein Avenue, 700, São Paulo, Brazil

[2 ]GRID grid.472984.4, Research Institute, , Instituto D’Or de Pesquisa e Ensino (IDOR), ; Rio de Janeiro, Brazil

[3 ]GRID grid.418068.3, ISNI 0000 0001 0723 0931, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), ; Rio de Janeiro, Brazil

[4 ]GRID grid.411249.b, ISNI 0000 0001 0514 7202, Anesthesiology, Pain and Intensive Care Department, , Federal University of São Paulo, ; São Paulo, Brazil

[5 ]GRID grid.413562.7, ISNI 0000 0001 0385 1941, Academic Research Organization, , Hospital Israelita Albert Einstein, ; São Paulo, Brazil

[6 ]GRID grid.472984.4, Graduate Program in Translational Medicine and Department of Critical Care, , Instituto D’Or de Pesquisa e Ensino (IDOR), ; Rio de Janeiro, Brazil

[7 ]GRID grid.8536.8, ISNI 0000 0001 2294 473X, Post Graduate Program in Internal Medicine, , Universidade Federal do Rio de Janeiro, ; Rio de Janeiro, Brazil

[8 ]GRID grid.413320.7, ISNI 0000 0004 0437 1183, Intensive Care Unit and Postgraduate Program, , A.C. Camargo Cancer Center, ; São Paulo, Brazil

[9 ]GRID grid.477370.0, ISNI 0000 0004 0454 243X, Research Institute, HCor-Hospital do Coração, ; São Paulo, Brazil

[10 ]GRID grid.5650.6, ISNI 0000000404654431, Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), , Academic Medical Center, ; Amsterdam, The Netherlands

[11 ]GRID grid.10223.32, ISNI 0000 0004 1937 0490, Mahidol–Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, , Mahidol University, ; Bangkok, Thailand

Author information

Ary Serpa Neto http://orcid.org/0000-0003-1520-9387

Article

Publisher ID: 687

DOI: 10.1186/s13613-020-00687-3

PMC ID: 7266115

PubMed ID: 32488524

SO-VID: 4d933234-19d3-4eff-bb0b-9f72575db494

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 6 February 2020

Date accepted : 25 May 2020

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intensive care unit,invasive ventilation, lung protection,tidal volume, low tidal volume ventilation,organizational factors

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intensive care unit, invasive ventilation, lung protection, tidal volume, low tidal volume ventilation, organizational factors

Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database

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Abstract

Background

Methods

Results

Conclusions

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Pediatric Pulse: Advancing Neonatal and Child Health

Most cited references 26

Nurse-staffing levels and the quality of care in hospitals.

Evolution of mortality over time in patients receiving mechanical ventilation.

Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis.

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