Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study

Abstract

Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation.

Design: Multi-ICU proof-of-concept study and a single ICU before-after study.

Setting: University hospital ICUs.

Patients: Adult patients receiving mechanical ventilation.

Interventions: An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers.

Measurements and main results: We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01-1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03-1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09-4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13-5.16 d; p = 0.040) shorter, compared with the expected durations without the application.

Conclusions: Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

Keywords: ABCDEF bundle; electronic dashboard; sedation minimization; spontaneous awakening trial; spontaneous breathing trial.

Figure 1.

Awakening and Breathing Coordination (ABC) application dashboard and text alerts. A, Representative screenshot of the electronic dashboard that provides real-time data on each patient’s spontaneous breathing trial (SBT)-readiness, depth of sedation as defined by the Richmond Agitation-Sedation Scale (RASS), and the patient’s current continuous analgesic and sedative infusion doses. For patients that are not SBT eligible, the dashboard provides the eligibility criteria that are not met as well as nudges to wean oxygen, positive end-expiratory pressure (PEEP), and vasoactive medications according to the prespecified algorithms. The dashboard also provides a nudge to wean sedation in patients with a RASS less than –1 who are receiving continuous analgesic or sedative infusions. B, Examples of the real-time HIPAA-compliant SBT and spontaneous awakening trial text-message alerts that are sent to bedside providers (respiratory therapist and nurse, respectively) as soon as a patient newly meets SBT eligibility, such as the patient who is listed as SBT ready and highlighted green in A. CAM = Confusion Assessment Method, MAP = mean arterial pressure, MICU = medical ICU, MV = minute ventilation, PS = pressure support, TV = tidal volume, UTA = unable to assess.

Figure 2.

Duration of mechanical ventilation in the before-after study. A, Cumulative incidence function describing the proportion of patients successfully extubated in the postintervention (blue line) and preintervention (red line) groups, adjusted for illness severity and vasopressor-dependent shock. Time to extubation was significantly shorter in the postintervention group, adjusted hazard ratio (HR) 1.28 (95% CI, 1.01–1.63; p = 0.043). B, Interrupted time series analysis using a level and slope change model with data aggregated on a weekly basis demonstrating the median duration of mechanical ventilation in the preintervention period (white background) and postintervention period (gray background). The solid line represents the median duration of mechanical ventilation in the preintervention and postintervention groups from the regression model, and the dotted line represents the counterfactual scenario, which is the expected trend in the absence of the intervention given the preexisting trend. The model shows a significant reduction in the median duration of mechanical ventilation in the postintervention group. For example, midway through the postintervention period (week 30), the median duration of mechanical ventilation was 2.20 d shorter (95% CI, 0.09–4.31, p = 0.042) compared with the counterfactual scenario.

Figure 3.

ICU length of stay in the before-after study. A, Cumulative incidence function describing the proportion of patients discharged from the ICU alive in the postintervention (blue line) and preintervention (red line) groups, adjusted for severity of illness and vasopressor-dependent shock. Time to ICU discharge was significantly shorter in the postintervention group, adjusted hazard ratio (HR) 1.31 (95% CI, 1.03–1.67; p = 0.027). B, Interrupted time series analysis using a level and slope change model with data aggregated on a weekly basis demonstrating the median ICU length of stay in the preintervention period (white background) and postintervention period (gray background). The solid line represents the median ICU length of stay in the preintervention and postintervention groups from the regression model, and the dotted line represents the counterfactual scenario, which is the expected trend in the absence of the intervention given the preexisting trend. The model shows a significant reduction in the median ICU length of stay in the postintervention group. For example, midway through the postintervention period (week 30), the median ICU length of stay was 2.65 d shorter (95% CI, 0.13–5.16; p = 0.040).

Figure 4.

Time to cessation of continuous sedatives and time from spontaneous breathing trial (SBT) ready to extubation in the before-after study. A, Cumulative incidence function describing the proportion of patients off continuous sedative infusions in the postintervention (blue line) and preintervention (red line) groups, adjusted for severity of illness and vasopressor-dependent shock. The time to cessation of continuous sedative infusions was shorter in the postintervention period, but the difference was not statistically significant, adjusted hazard ratio (HR) 1.27 (95% CI, 0.99–1.65; p = 0.065). B, Cumulative incidence function describing the proportion of patients who were extubated after being identified as SBT ready by the Awakening and Breathing Coordination application. The time from meeting SBT criteria to extubation was shorter in the postintervention period, but the difference was not statistically significant, adjusted HR 1.29 (95% CI, 0.98–1.70; p = 0.070).