Critical Care |

Process of Care Elements Associated With the Failure to Provide Lung Protective Ventilation for Patients With ARDS FREE TO VIEW

Husam Ahmed, MD; Abdurrahman Husain, MD; Greg Martin, MD; Jonathan Sevransky, MD; David Murphy, MD
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Emory University School of Medicine Department of Medicine Division of Pulmonary, Allergy and Critical Care Medicine, Atlanta, GA

Chest. 2013;144(4_MeetingAbstracts):375A. doi:10.1378/chest.1704552
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SESSION TITLE: Critical Care Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Despite evidence that lung protective ventilation (LPV) strategy reduces mortality for ARDS patients, LPV adherence remains variable. Limited data exist regarding factors associated with initiating LPV. We examined the association between clinician documentation of the ARDS diagnosis and decision to prescribe LPV on the odds of delivering LPV.

METHODS: As part of a prospective cohort study, we enrolled mechanically ventilated patients who met AECC ARDS criteria in three academic medical ICUs over 2 years. We defined LPV adherence as providing a tidal volume (VT) ≤ 6.5ml/kg predicted body weight [PBW] with a plateau pressure ≤30cmH2O within 24 hours of ARDS onset. We extracted documentation of process of care elements (e.g. ARDS diagnosis, decision to provide LPV) from clinician progress notes. A multiple logistic regression model evaluated the independent association between process of care elements and the provision of LPV while accounting for potentially relevant covariates.

RESULTS: Of 189 enrolled patients, 19 were excluded since LPV adherence could not be assessed due to ventilator mode or no documented height. In the remaining 170 patients, the mean (SD) absolute VT, relative VT, and plateau pressure were 446(92) ml, 7.1(1.9) ml/kg PBW, and 26(7.8) cmH2O, respectively. Fifty-two patients (30.6%) received LPV. In adjusted analysis, explicitly documenting the ARDS diagnosis increased the odds of delivering LPV (odds ratio [OR]: 2.79, p=0.049), while documenting both the ARDS diagnosis and decision to provide LPV increased the odds of delivering LPV (OR=5.1, p=0.001).

CONCLUSIONS: Few ARDS patients receive LPV. Failure to deliver LPV may be due to errors within the process of care such as failing to diagnose ARDS or not deciding to prescribe LPV.

CLINICAL IMPLICATIONS: Patients commonly do not receive evidence-based practices such as LPV. An improved understanding of the process of care elements required to deliver LPV including diagnosing ARDS and deciding to prescribe LPV may help close the gap between evidence and practice.

DISCLOSURE: The following authors have nothing to disclose: Husam Ahmed, Abdurrahman Husain, Greg Martin, Jonathan Sevransky, David Murphy

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