Chest
Volume 123, Issue 6, June 2003, Pages 2062-2073
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Clinical Investigations in Critical Care
Evaluation of a Practice Guideline for Noninvasive Positive-Pressure Ventilation for Acute Respiratory Failurea

https://doi.org/10.1378/chest.123.6.2062Get rights and content

Objectives

Clinical practice guidelines have been devised to change practitioner performance and to improve the process and outcomes of care. The objective of this study was to determine whether adherence to a practice guideline on noninvasive positive-pressure ventilation (NPPV) for the treatment of patients with acute respiratory failure (ARF) would change clinician behavior and resource utilization, and improve NPPV utilization and patient outcomes.

Design

Using a multidisciplinary team, we developed, implemented, and evaluated an NPPV practice guideline for ARF. Before and after guideline implementation, we recorded the incidence of endotracheal intubation (ETI) and mortality. Secondary outcomes were technological settings (ie, NPPV settings and duration) and NPPV administration (ie, cardiopulmonary monitoring, transfer to and time spent in the ICU, and pulmonary consultation).

Participants

We enrolled 189 patients, 91 in the preguideline phase and 98 in the postguideline phase. Patients were similar in the both phases with respect to diagnoses at hospital admission and severity of illness.

Results

Of patients receiving NPPV for ARF, 67.3% fulfilled the guideline eligibility criteria in the postguideline phase compared to 62.6% in the preguideline phase (p = 0.543). Compared to the preguideline phase, more patients in the postguideline phase were transferred to the ICU (14.7% vs 33.7%, respectively; p = 0.003), spent more time in the ICU (30.9% vs 62.4%, respectively; p < 0.0001), and had consultation by a pulmonary physician (28.4% vs 49.0%, respectively; p = 0.004). There were no changes in technological settings. Guideline implementation was associated with improved cardiopulmonary monitoring. Nursing and respiratory therapist flow sheets were well-utilized during the guideline phase. There were no differences in ETI rates and mortality rates before and after guideline implementation.

Conclusion

In this before-after study, we found that a multidisciplinary guideline for the use of NPPV for the treatment of patients with ARF was associated with changes in the process of care, with greater NPPV utilization in the ICU, and with increased pulmonary consultation, without any significant changes in the outcomes of care (ie, ETI and mortality rates).

Section snippets

Setting

The study was conducted at St. Joseph’s Hospital, a tertiary care teaching hospital in Hamilton, ON, Canada. The hospital is a 386-bed hospital that consists of a 28-bed clinical teaching unit (CTU), 15-bed mixed medical-surgical ICU, an 8-bed coronary care unit (CCU), and a 10-bed respiratory care unit (RCU). The CTU has two teams each composed of an internist, three to five residents in internal medicine and family medicine, and three to five medical students. The ICU team consisted of an

Results

Every patient receiving NPPV for ARF in the preguideline and postguideline phases was included in this study. In the preguideline phase, 91 patients underwent 95 trials of NPPV. In the postguideline phase, 98 patients underwent 104 trials of NPPV. Patient characteristics (Table 1) were similar with respect to age, gender, most hospital admission diagnoses, neurologic status, and ABG levels (Table 2). There were significant differences at baseline with respect to hospital admission diagnoses of

Discussion

Following the introduction of a clinical practice guideline for the use of NPPV in the treatment of patients with ARF, we found significant changes in the processes of care, including more patients being managed in the ICU, improved cardiopulmonary monitoring, and increased consultation by the pulmonary service. Overall, we did not find any significant differences in ETI rates or ICU or hospital mortality. We did, however, find a trend toward less ETI in patients with CHF who had been treated

Acknowledgment

We thank the nurses, respiratory therapists, physicians, and residents at St. Joseph’s Hospital for their support of this study. We are grateful to Dr. S.P. Keenan for his critical review of the manuscript, Barbara Hill for her administrative support, Michelle Shilton for her help with the data collection, and the NPPV education committee (Barb Fiorino, Karl Weiss, Gail MacKenzie, and Darlene Saratsiotis).

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    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

    Dr. Cook is a Critical Care Chair of the Canadian Institute of Health Research. Dr. Sinuff was supported by a Canadian Institute of Health Research Fellowship Award.

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