• Clark G Owyang, Jeremy L Kim, George Loo, Shamsuddoha Ranginwala, and Kusum S Mathews.
• Department of Medicine, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, United States; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States. Electronic address: owyang@stanford.edu.
• J Crit Care. 2019 Aug 1; 52: 40-47.

ObjectiveTo measure effects of ED crowding on lung-protective ventilation (LPV) utilization in critically ill ED patients.MethodsThis is a retrospective cohort study of adult mechanically ventilated ED patients admitted to the medical intensive care unit (MICU), over a 3.5-year period at a single academic tertiary care hospital. Clinical data, including reason for intubation, severity of illness (MPM0-III), acute respiratory distress syndrome (ARDS) risk score (EDLIPS), and ventilator settings were extracted via electronic query of electronic health record and standardized chart abstraction. Crowding metrics were obtained at 5-min intervals and averaged over the ED stay, stratified by acuity and disposition. Multivariate logistic regression was used to predict likelihood of LPV prior to ED departure.ResultsMechanical ventilation was used in 446 patients for a median ED duration of 3.7 h (interquartile ratio, IQR, 2.3, 5.6). Mean MPM0-III score was 32.5 ± 22.7, with high risk for ARDS (EDLIPS ≥5) seen in 373 (82%) patients. Initial and final ED ventilator settings differed in 134 (30.0%) patients, of which only 47 (35.1%) involved tidal volume changes. Higher percentages of active ED patients (workup in-progress) and those requiring eventual admission were associated with lower odds of LPV utilization by ED departure (OR 0.97, 95%CI 0.94-1.00; OR 0.97, 95%CI 0.94-1.00, respectively). In periods of high volume, ventilator adjustments to settings other than the tidal volume were associated with higher odds of LPV utilization. Reason for intubation, MPM0-III, and EDLIPS were not associated with LPV utilization, with no interactions detected in times of crowding.ConclusionsED patients remain on suboptimal tidal volume settings with infrequent ventilator adjustments during the ED stay. Hospitals should focus on both systemic factors and bedside physician and/or respiratory therapist interventions to increase LPV utilization in times of ED boarding and crowding for all patients.Copyright © 2019 Elsevier Inc. All rights reserved.

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