Impact of a national collaborative project to improve the care of mechanically ventilated patients
Authors: Arabi Yaseen M. , Al Aseri Zohair , Alsaawi Abdulmohsen , Al Khathaami Ali M. , Al Qasim Eman , Alzahrani Abdullah A. , Al Qarni Mohammed , Abdukahil Sheryl Ann I. , Al-Dorzi Hasan M. , Alattasi Abdulaleem , Mandourah Yasser , Alaama Tareef Y. , Alabdulaali Mohammed K. , Alqahtani Abdulrahman , Shuaibi Ahmad , Al Qarni Ali , Alkatheri Mufareh , Al Hazme Raed H. , Vishwakarma Ramesh Kumar , Aldibasi Omar , Alshahrani Mohammed Saeed , Attia Ashraf , Alharthy Abdulrahman , Mady Ahmed , Abdelrahman Basheer Abdullah , Mhawish Huda Ahmad , Abdallah Hassan Ahmad , Al-Hameed Fahad , Alghamdi Khalid , Alghamdi Adnan , Almekhlafi Ghaleb A. , Qasim Saleh Abdorabo Haider , Al Haji Hussain Ali , Al Mutairi Mohammed , Tashkandi Nabiha , Alabbasi Shatha Othman , Al Shehri Tariq , Moftah Emad , Kalantan Basim , Matroud Amal , Naidu Brintha , Al Zayer Salha , Burrows Victoria , Said Zayneb , Soomro Naseer Ahmed , Yousef Moawea Hesham , Fattouh Ayman Abdulmonem , Tahoon Manar Aboelkhair , Muhammad Majdi , Alruwili Afifah Muslim , Al Hanafi Hossam Ahmed , Dandekar Pramodini B. , Ibrahim Kamel , AlHomsi Mwafaq , Al Harbi Asma Rayan , Saleem Adel , Masih Ejaz , Al Rashidi Nowayer Monawer , Amanatullah Aslam Khan , Al Mubarak Jaffar , Al Radwan Amro Ali Abduljalil , Al Hassan Ali , Al Muoalad Sadiyah , Alzahrani Ammar Abdullah , Chalabi Jamal , Qureshi Ahmad , Al Ansari Maryam , Sallam Hend , Elhazmi Alyaa , Alkhaldi Fawziah , Malibary Abdulrauf , Ababtain Abdullah , Latif Asad , Berenholtz Sean M. ,   the Saudi Critical Care Trials Group
Published: January 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).