• Brian M Fuller, Ian T Ferguson, Nicholas M Mohr, Anne M Drewry, Christopher Palmer, Brian T Wessman, Enyo Ablordeppey, Jacob Keeperman, Robert J Stephens, Cristopher C Briscoe, Angelina A Kolomiets, Richard S Hotchkiss, and Marin H Kollef.
• 1Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO.2School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.3Division of Critical Care, Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA.4Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO.5Washington University School of Medicine, St. Louis, MO.6School of Public Health and Social Justice, Saint Louis University, St. Louis, MO.7Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO.
• Crit. Care Med. 2017 Apr 1; 45 (4): 645-652.

ObjectivesTo evaluate the impact of an emergency department mechanical ventilation protocol on clinical outcomes and adherence to lung-protective ventilation in patients with acute respiratory distress syndrome.DesignQuasi-experimental, before-after trial.SettingEmergency department and ICUs of an academic center.PatientsMechanically ventilated emergency department patients experiencing acute respiratory distress syndrome while in the emergency department or after admission to the ICU.InterventionsAn emergency department ventilator protocol which targeted variables in need of quality improvement, as identified by prior work: 1) lung-protective tidal volume, 2) appropriate setting of positive end-expiratory pressure, 3) oxygen weaning, and 4) head-of-bed elevation.Measurements And Main ResultsA total of 229 patients (186 preintervention group, 43 intervention group) were studied. In the emergency department, the intervention was associated with significant changes (p < 0.01 for all) in tidal volume, positive end-expiratory pressure, respiratory rate, oxygen administration, and head-of-bed elevation. There was a reduction in emergency department tidal volume from 8.1 mL/kg predicted body weight (7.0-9.1) to 6.4 mL/kg predicted body weight (6.1-6.7) and an increase in lung-protective ventilation from 11.1% to 61.5%, p value of less than 0.01. The intervention was associated with a reduction in mortality from 54.8% to 39.5% (odds ratio, 0.38; 95% CI, 0.17-0.83; p = 0.02) and a 3.9 day increase in ventilator-free days, p value equals to 0.01.ConclusionsThis before-after study of mechanically ventilated patients with acute respiratory distress syndrome demonstrates that implementing a mechanical ventilator protocol in the emergency department is feasible and associated with improved clinical outcomes.

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