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Friederich A, Martin N, Swanson MB, Faine BA, Mohr NM. Normal Saline Solution and Lactated Ringer's Solution Have a Similar Effect on Quality of Recovery: A Randomized Controlled Trial. Ann Emerg Med 2018; 73:160-169. [PMID: 30146446 DOI: 10.1016/j.annemergmed.2018.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/20/2018] [Accepted: 07/09/2018] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE The purpose of this study is to test the hypothesis that balanced crystalloids improve quality of recovery more than normal saline solution (0.9% sodium chloride) in stable emergency department (ED) patients. Secondary outcomes measured differences in health care use. METHODS A single-site, participant- and evaluator-blinded, 2-arm parallel allocation (1:1), comparative effectiveness, randomized controlled trial allocated adults receiving intravenous fluids in the ED before discharge to receive 2 L of lactated Ringer's solution or normal saline solution. The primary outcome was symptom scores measured by the validated Quality of Recovery-40 instrument (scores 40 to 200) 24 hours after enrollment. Secondary outcomes included subsequent health care use and medication compliance. RESULTS Participants (N=157) were enrolled and follow-up was analyzed for 94 (follow-up rate of 60%) with intention-to-treat methodology. There was no difference in postenrollment Quality of Recovery-40 scores between normal saline solution and lactated Ringer's solution groups (mean difference 2.4; 95% confidence interval [CI] -6.8 to 11.6). Although preenrollment scores were higher in the lactated Ringer's solution group (mean difference 10.5; 95% CI 1.9 to 19.0), adjusting for presurvey imbalances did not change the primary outcome (adjusted difference -3.9; 95% CI -12.9 to 5.2). There were no differences in return to ED (mean difference 7.5%; 95% CI -8.7% to 23.8%), prescriptions filled (mean difference 22.2%; 95% CI -3.3% to 47.6%), or seeking care from another provider (mean difference -2.0%; 95% CI -19.9% to 15.9%) at 7 days. CONCLUSION Normal saline solution and lactated Ringer's solution were associated with similar 24-hour recovery scores and 7-day health care use in stable ED patients. These results supplement those of recent trials by informing fluid choice for stable ED patients.
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Mohr NM, Young T, Harland KK, Skow B, Wittrock A, Bell A, Ward MM. Emergency Department Telemedicine Shortens Rural Time-To-Provider and Emergency Department Transfer Times. Telemed J E Health 2018; 24:582-593. [DOI: 10.1089/tmj.2017.0262] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Bobb MR, Ahmed A, Van Heukelom P, Tranter R, Harland KK, Firth BM, Fry R, Schneider K, Dierks KK, Miller SL, Mohr NM. Key High-efficiency Practices of Emergency Department Providers: A Mixed-methods Study. Acad Emerg Med 2018; 25:795-803. [PMID: 29265539 DOI: 10.1111/acem.13361] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/21/2017] [Accepted: 12/07/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs). METHODS A mixed-methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety-nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000- to 55,000-visit) community EDs during two 4-hour periods and recorded in minute-by-minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site. RESULTS Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, "inefficiency practices," demonstrated significant negative correlations: non-work-related tasks and documentation on patients no longer in the ED. CONCLUSIONS Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.
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Mohr NM, Young T, Harland KK, Skow B, Wittrock A, Bell A, Ward MM. Telemedicine Is Associated with Faster Diagnostic Imaging in Stroke Patients: A Cohort Study. Telemed J E Health 2018; 25:93-100. [PMID: 29958087 DOI: 10.1089/tmj.2018.0013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Meeting time goals for patients with time-sensitive conditions can be challenging in rural emergency departments (EDs), and adopting policies is critical. ED-based telemedicine has been proposed to improve quality and timeliness of care in rural EDs. INTRODUCTION The objective of this study was to test the hypothesis that diagnostic testing in telemedicine-supplemented ED care for patients with myocardial infarction (MI) and stroke would be faster than nontelemedicine care in rural EDs. MATERIALS AND METHODS This observational cohort study included all ED patients with MI or stroke in 19 rural critical access hospitals served by a single real-time contract-based telemedicine provider in the upper Midwest (2007-2015). The primary outcome for the MI cohort was time-to-electrocardiogram (EKG) and for the stroke cohort was time-to-head computed tomography (CT) interpretation. To measure the relationship between telemedicine and timeliness parameters, generalized estimating equations models were used, clustering on presenting hospital. RESULTS Of participating ED visits, 756 were included in the MI cohort (29% used telemedicine) and 140 were included in the stroke cohort (30% used telemedicine). Time-to-EKG did not differ when telemedicine was used (1% faster, 95% confidence interval [CI] -4% to 7%), or after telemedicine was implemented (4% faster, 95% CI -3% to 10%). Head CT interpretation was faster for telemedicine cases (15% faster, 95% CI 4-26%). No differences were observed in time to reperfusion therapy. CONCLUSIONS Telemedicine implementation was associated with more timely head CT interpretation for rural patients with stroke, but no difference in early MI care. Future work will focus on the specific manner in which telemedicine changes ED care processes and ongoing professional education.
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Mohr NM, Doerschug KC. In Replay: Fever Control and Sepsis Mortality. Chest 2018; 145:667. [PMID: 27845648 DOI: 10.1378/chest.13-2809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Vakkalanka JP, Harland KK, Swanson MB, Mohr NM. Clinical and epidemiological variability in severe sepsis: an ecological study. J Epidemiol Community Health 2018; 72:741-745. [PMID: 29636401 DOI: 10.1136/jech-2018-210501] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/01/2018] [Accepted: 03/24/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND To assess clinical and epidemiological trends of severe sepsis. METHODS Ecological study of patients presenting to the emergency department with severe sepsis or septic shock between 2005 and 2013. Patients were identified using the state-wide hospital administrative database. Key outcomes included incidence rates (IRs) and mortality rates (per 1000 population) by age and medically underserved areas (MUAs), sepsis case fatality rate (deaths per 100 sepsis cases), and proportions of transfer and comorbidities. RESULTS There were 154 019 sepsis cases identified. In 2005, 85+ yo in non-MUAs had a 44% increase in IR compared with those in MUAs, and this difference rose to 74% by 2013. Mortality rates were 1.6 (95% CI 1.3 to 1.8) times greater among 85+ yo in non-MUAs. Mortality rates increased by 1.8% annually, while the sepsis case fatality rate decreased by 7.7%. The proportion of transfer among sepsis cases decreased by 2.1% per year (3.8% in non-MUAs, 0.7% in MUAs). CONCLUSIONS Sepsis incidence varies geographically, and access to healthcare is one proposed mechanism that may explain heterogeneity. Over time, we may be capturing higher acuity sepsis cases with better recognition and management, as well as observing differential diagnostic coding documentation by location.
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Roberts BW, Mohr NM, Ablordeppey E, Drewry AM, Ferguson IT, Trzeciak S, Kollef MH, Fuller BM. Association Between Partial Pressure of Arterial Carbon Dioxide and Survival to Hospital Discharge Among Patients Diagnosed With Sepsis in the Emergency Department. Crit Care Med 2018; 46:e213-e220. [PMID: 29261567 PMCID: PMC5825256 DOI: 10.1097/ccm.0000000000002918] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of this study was to test the association between the partial pressure of arterial carbon dioxide and survival to hospital discharge among mechanically ventilated patients diagnosed with sepsis in the emergency department. DESIGN Retrospective cohort study of a single center trial registry. SETTING Academic medical center. PATIENTS Mechanically ventilated emergency department patients. INCLUSION CRITERIA age 18 years and older, diagnosed with sepsis in the emergency department, and mechanical ventilation initiated in the emergency department. INTERVENTIONS Arterial blood gases obtained after initiation of mechanical ventilation were analyzed. The primary outcome was survival to hospital discharge. We tested the association between partial pressure of arterial carbon dioxide and survival using multivariable logistic regression adjusting for potential confounders. Sensitivity analyses, including propensity score matching were also performed. MEASUREMENTS AND MAIN RESULTS Six hundred subjects were included, and 429 (72%) survived to hospital discharge. The median (interquartile range) partial pressure of arterial carbon dioxide was 42 (34-53) mm Hg for the entire cohort and 44 (35-57) and 39 (31-45) mm Hg among survivors and nonsurvivors, respectively (p < 0.0001 Wilcox rank-sum test). On multivariable analysis, a 1 mm Hg rise in partial pressure of arterial carbon dioxide was associated with a 3% increase in odds of survival (adjusted odds ratio, 1.03; 95% CI, 1.01-1.04) after adjusting for tidal volume and other potential confounders. These results remained significant on all sensitivity analyses. CONCLUSION In this sample of mechanically ventilated sepsis patients, we found an association between increasing levels of partial pressure of arterial carbon dioxide and survival to hospital discharge. These findings justify future studies to determine the optimal target partial pressure of arterial carbon dioxide range for mechanically ventilated sepsis patients.
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Miller DG, Vakkalanka P, Moubarek ML, Lee S, Mohr NM. Reduced Computed Tomography Use in the Emergency Department Evaluation of Headache Was Not Followed by Increased Death or Missed Diagnosis. West J Emerg Med 2018; 19:319-326. [PMID: 29560060 PMCID: PMC5851505 DOI: 10.5811/westjem.2017.12.34886] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 12/15/2017] [Accepted: 12/15/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction This study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit. Methods We reviewed the electronic medical records of all patients sampled during a quality improvement effort in which the aforementioned decrease in HCT use had been observed. We reviewed notes from the ED, neurology, neurosurgery, and primary care services, as well as all brain imaging results to determine if death occurred or if an intracranial condition was discovered in the 22.5 months after each index ED visit. An independent, blinded reviewer reviewed each case where an intracranial condition was diagnosed after ED discharge to determine whether the condition was reasonably likely to have been related to the index ED visit’s presentation, thereby representing a missed diagnosis. Results Of the 582 separate index ED visits sampled, we observed a total of nine deaths and 10 missed intracranial diagnoses. There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use. Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively). Conclusion Our study adds to the compelling evidence that there is opportunity to safely decrease CT imaging for ED patients. To determine the cost effectiveness of such reductions further research is needed to measure what patients and their healthcare providers do after discharge from the ED when unnecessary testing is withheld.
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Page D, Ablordeppey E, Wessman BT, Mohr NM, Trzeciak S, Kollef MH, Roberts BW, Fuller BM. Emergency department hyperoxia is associated with increased mortality in mechanically ventilated patients: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:9. [PMID: 29347982 PMCID: PMC5774130 DOI: 10.1186/s13054-017-1926-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/15/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Providing supplemental oxygen is fundamental in the management of mechanically ventilated patients. Increasing amounts of data show worse clinical outcomes associated with hyperoxia. However, these previous data in the critically ill have not focused on outcomes associated with brief hyperoxia exposure immediately after endotracheal intubation. Therefore, the objectives of this study were to evaluate the impact of isolated early hyperoxia exposure in the emergency department (ED) on clinical outcomes among mechanically ventilated patients with subsequent normoxia in the intensive care unit (ICU). METHODS This was an observational cohort study conducted in the ED and ICUs of an academic center in the USA. Mechanically ventilated normoxic (partial pressure of arterial oxygen (PaO2) 60-120 mm Hg) ICU patients with mechanical ventilation initiated in the ED were studied. The cohort was categorized into three oxygen exposure groups based on PaO2 values obtained after ED intubation: hypoxia, normoxia, and hyperoxia (defined as PaO2 < 60 mmHg, PaO2 60-120 mm Hg, and PaO2 > 120 mm Hg, respectively, based on previous literature). RESULTS A total of 688 patients were included. ED normoxia occurred in 350 (50.9%) patients, and 300 (43.6%) had exposure to ED hyperoxia. The ED hyperoxia group had a median (IQR) ED PaO2 of 189 mm Hg (146-249), compared to an ED PaO2 of 88 mm Hg (76-101) in the normoxia group, P < 0.001. Patients with ED hyperoxia had greater hospital mortality (29.7%), when compared to those with normoxia (19.4%) and hypoxia (13.2%). After multivariable logistic regression analysis, ED hyperoxia was an independent predictor of hospital mortality (adjusted OR 1.95 (1.34-2.85)). CONCLUSIONS ED exposure to hyperoxia is common and associated with increased mortality in mechanically ventilated patients achieving normoxia after admission. This suggests that hyperoxia in the immediate post-intubation period could be particularly injurious, and targeting normoxia from initiation of mechanical ventilation may improve outcome.
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Page DB, Drewry AM, Ablordeppey E, Mohr NM, Kollef MH, Fuller BM. Thirty-day hospital readmissions among mechanically ventilated emergency department patients. Emerg Med J 2018; 35:252-256. [PMID: 29305381 DOI: 10.1136/emermed-2017-206651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 10/15/2017] [Accepted: 11/30/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Unplanned 30-day readmissions have a negative impact on patients and healthcare systems. Mechanically ventilated ED patients are at high risk for complications, but factors associated with readmission are unknown. OBJECTIVE (1) Determine the rate of 30-day hospital readmission for ED patients receiving mechanical ventilation. (2) Identify associations between ED-based risk factors and readmission. DESIGN Retrospective cohort study. SETTING Tertiary-care, academic medical centre. PATIENTS Adult ED patients receiving mechanical ventilation. MEASUREMENTS Baseline demographics, comorbid conditions, illness severity and treatment variables were collected, as were clinical outcomes occurring during the index hospitalisation. The primary outcome was 30-day hospital readmission rate. Multivariable logistic regression was used to evaluate factors associated with the primary outcome. RESULTS A total of 1262 patients were studied. The primary outcome occurred in 287 (22.7%) patients. There was no association between care in the ED and readmission. During the index hospitalisation, readmitted patients had shorter ventilator, hospital and intensive care unit duration (P<0.05 for all). The primary outcome was associated with African-American race (adjusted OR 1.34 (95% CI 1.02 to 1.78)), chronic obstructive pulmonary disease (adjusted OR 1.52 (95% CI 1.12 to 2.06)), diabetes mellitus (adjusted OR 1.34 (95% CI 1.02 to 1.78)) and higher illness severity (adjusted OR 1.03 (95% CI 1.01 to 1.05)). CONCLUSIONS Almost one in four mechanically ventilated ED patients are readmitted within 30 days, and readmission is associated with patient-level and institutional-level factors. Strategies must be developed to identify, treat and coordinate care for the most at-risk patients.
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Solie CJ, Mohr NM, Runde DP. Can Multidetector Computed Tomography Rule Out Left Atrial Thrombus in Patients With Atrial Fibrillation? Ann Emerg Med 2017; 71:480-481. [PMID: 29033295 DOI: 10.1016/j.annemergmed.2017.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Indexed: 11/25/2022]
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Fuller BM, Mohr NM, Drewry AM, Ferguson IT, Trzeciak S, Kollef MH, Roberts BW. Partial pressure of arterial carbon dioxide and survival to hospital discharge among patients requiring acute mechanical ventilation: A cohort study. J Crit Care 2017; 41:29-35. [PMID: 28472700 PMCID: PMC5633513 DOI: 10.1016/j.jcrc.2017.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/18/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To describe the prevalence of hypocapnia and hypercapnia during the earliest period of mechanical ventilation, and determine the association between PaCO2 and mortality. MATERIALS AND METHODS A cohort study using an emergency department registry of mechanically ventilated patients. PaCO2 was categorized: hypocapnia (<35mmHg), normocapnia (35-45mmHg), and hypercapnia (>45mmHg). The primary outcome was survival to hospital discharge. RESULTS A total of 1,491 patients were included. Hypocapnia occurred in 375 (25%) patients and hypercapnia in 569 (38%). Hypercapnia (85%) had higher survival rate compared to normocapnia (74%) and hypocapnia (66%), P<0.001. PaCO2 was an independent predictor of survival to hospital discharge [hypocapnia (aOR 0.65 (95% confidence interval [CI] 0.48-0.89), normocapnia (reference category), hypercapnia (aOR 1.83 (95% CI 1.32-2.54)]. Over ascending ranges of PaCO2, there was a linear trend of increasing survival up to a PaCO2 range of 66-75mmHg, which had the strongest survival association, aOR 3.18 (95% CI 1.35-7.50). CONCLUSIONS Hypocapnia and hypercapnia occurred frequently after initiation of mechanical ventilation. Higher PaCO2 levels were associated with increased survival. These data provide rationale for a trial examining the optimal PaCO2 in the critically ill.
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Nelson LF, Harland KK, Shane DM, Ahmed A, Mohr NM. Safety of Back-Transfer to Local Hospitals During an Acute Care Hospitalization. J Rural Health 2017; 34:431-438. [PMID: 28921673 DOI: 10.1111/jrh.12267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/03/2017] [Accepted: 08/03/2017] [Indexed: 12/01/2022]
Abstract
PURPOSE This paper investigates patient outcomes including length of stay (LOS), cost of hospitalization, bounce-back rates, transition to hospice care, and mortality, following back-transfer. METHODS This study was an observational case-control study of adults hospitalized in Iowa between 2005 and 2013 to identify back-transferred patients. Back-transfer was defined as the transfer of rural patients near the end of their acute hospitalization in a comprehensive medical center back to a local community hospital for the completion of their medical care. Demographic, geographic, rurality, procedural, and disease information was compared between case and control groups, then propensity score (PS) matching was performed to create comparable groups to perform analyses. FINDINGS Over the 9-year period, 1,056,773 patients meeting inclusion criteria were admitted, of which 430 (0.04%) were back-transferred. After PS matching, LOS was 60% (95% CI: 0.50-0.71) higher and costs were 42% (95% CI: 0.33-0.50) higher in the back-transferred group. Back-transferred cases had 8.34 (95% CI: 3.66-19.0) times the odds of hospice transition and 2.17 (95% CI: 1.37-3.46) the odds of mortality compared to controls. Four percent of back-transfers "failed" with the patient being returned to the larger hospital before discharge. CONCLUSIONS Back-transfer is a rare occurrence, and it is associated with longer LOS, higher hospitalization cost, higher mortality, more hospice transfers, and occasional bounce-backs to comprehensive medical centers. Future work should focus more on prospective indications for transfer, the role of end-of-life care, financial impact, and identifying patient populations for whom back-transfer is safest.
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Nelson LF, Harland KK, Shane DM, Ahmed A, Mohr NM. Against the current: back-transfer as a mechanism for rural regionalization. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:e287-e294. [PMID: 29087168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES This paper investigates back-transfer: the transfer of patients near the end of their acute hospitalization to a local community hospital for the completion of their medical care. We seek to describe factors contributing to back-transfer, with the goal of elucidating the current use of back-transfer and barriers to its more widespread adoption for rural healthcare regionalization. STUDY DESIGN Observational unmatched case-control. METHODS This was a retrospective study of adults hospitalized in Iowa between 2005 and 2013 to identify back-transferred patients. Demographic, geographic, rurality, procedural, and disease information was compared among cases and control groups using univariate analysis and multivariable logistic regression. RESULTS Over the 9-year period, 172,544 back-transfer eligible patients were admitted to 1 of 5 large Iowa hospitals, of which 287 (0.2%) were back-transferred. Back-transferred patients were more likely than their non-back-transferred counterparts to be older, male, and white; to live in large rural areas; and to have public insurance. As inpatients, they had longer median lengths of stay (15 vs 5 days; P <.001), more medical comorbidities, and were more likely to have a cardiac catheterization procedure than the control group. CONCLUSIONS Back-transfer is a very rare event. While demographic and medical differences between back-transferred patients and controls may partially explain the infrequency, other systematic barriers must exist to limit back-transfer. These barriers likely include legal, financial, logistical, and patient care concerns. Despite the rarity with which it is employed, back-transfer is a promising strategy that could better utilize health resources, especially in rural America.
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Mohr NM, Vakkalanka JP, Harland KK, Bell A, Skow B, Shane DM, Ward MM. Telemedicine Use Decreases Rural Emergency Department Length of Stay for Transferred North Dakota Trauma Patients. Telemed J E Health 2017; 24:194-202. [PMID: 28731843 DOI: 10.1089/tmj.2017.0083] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Telemedicine has been proposed as one strategy to improve local trauma care and decrease disparities between rural and urban trauma outcomes. OBJECTIVES This study was conducted to describe the effect of telemedicine on management and clinical outcomes for trauma patients in North Dakota. METHODS Cohort study of adult (age ≥18 years) trauma patients treated in North Dakota Critical Access Hospital (CAH) Emergency Departments (EDs) from 2008 to 2014. Records were linked to a telemedicine network's call records, indicating whether telemedicine was available and/or used at the institution at the time of the care. Multivariable generalized estimating equations were developed to identify associations between telemedicine consultation and availability and outcomes such as transfer, timeliness of care, trauma imaging, and mortality. RESULTS Of the 7,500 North Dakota trauma patients seen in CAH, telemedicine was consulted for 11% of patients in telemedicine-capable EDs and 4% of total trauma patients. Telemedicine utilization was independently associated with decreased initial ED length of stay (LOS) (30 min, 95% confidence interval [CI] 14-45 min) for transferred patients. Telemedicine availability was associated with an increase in the probability of interhospital transfer (adjusted odds ratio [aOR] 1.2, 95% CI 1.1-1.4). Telemedicine availability was associated with increased total ED LOS (15 min, 95% CI 10-21 min), and computed tomography scans (aOR 1.6, 95% CI 1.3-1.9). CONCLUSIONS ED-based telemedicine consultation is requested for the most severely injured rural trauma patients. Telemedicine consultation was associated with more rapid interhospital transfer, and telemedicine availability is associated with increased radiography use and transfer. Future work should evaluate how telemedicine could target patients likely to benefit from telemedicine consultation.
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Stephens RJ, Ablordeppey E, Drewry AM, Palmer C, Wessman BT, Mohr NM, Roberts BW, Liang SY, Kollef MH, Fuller BM. Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study. Chest 2017. [PMID: 28645462 DOI: 10.1016/j.chest.2017.05.041] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Analgesia and sedation are cornerstone therapies for mechanically ventilated patients. Despite data showing that early deep sedation in the ICU influences outcome, this has not been investigated in the ED. Therefore, ED-based sedation practices, and their influence on outcome, remain incompletely defined. This study's objectives were to describe ED sedation practices in mechanically ventilated patients and to test the hypothesis that ED sedation depth is associated with worse outcomes. METHODS This was a cohort study of a prospectively compiled ED registry of adult mechanically ventilated patients at a single academic medical center. Hospital mortality was the primary outcome and hospital-, ICU-, and ventilator-free days were secondary outcomes. A backward stepwise multivariable logistic regression model evaluated the primary outcome as a function of ED sedation depth. Sedation depth was assessed with the Richmond Agitation-Sedation Scale (RASS). RESULTS Four hundred fourteen patients were studied. In the ED, 354 patients (85.5%) received fentanyl, 254 (61.3%) received midazolam, and 194 (46.9%) received propofol. Deep sedation was observed in 244 patients (64.0%). After adjusting for confounders, a deeper ED RASS was associated with mortality (adjusted OR, 0.77; 95% CI, 0.63-0.94). CONCLUSIONS Early deep sedation is common in mechanically ventilated ED patients and is associated with worse mortality. These data suggest that ED-based sedation is a modifiable variable that could be targeted to improve outcome.
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Fuller BM, Ferguson IT, Mohr NM, Drewry AM, Palmer C, Wessman BT, Ablordeppey E, Keeperman J, Stephens RJ, Briscoe CC, Kolomiets AA, Hotchkiss RS, Kollef MH. A Quasi-Experimental, Before-After Trial Examining the Impact of an Emergency Department Mechanical Ventilator Protocol on Clinical Outcomes and Lung-Protective Ventilation in Acute Respiratory Distress Syndrome. Crit Care Med 2017; 45:645-652. [PMID: 28157140 PMCID: PMC5350028 DOI: 10.1097/ccm.0000000000002268] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To 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. DESIGN Quasi-experimental, before-after trial. SETTING Emergency department and ICUs of an academic center. PATIENTS Mechanically ventilated emergency department patients experiencing acute respiratory distress syndrome while in the emergency department or after admission to the ICU. INTERVENTIONS An 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 RESULTS A 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. CONCLUSIONS This 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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Fuller BM, Ferguson IT, Mohr NM, Drewry AM, Palmer C, Wessman BT, Ablordeppey E, Keeperman J, Stephens RJ, Briscoe CC, Kolomiets AA, Hotchkiss RS, Kollef MH. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017; 70:406-418.e4. [PMID: 28259481 DOI: 10.1016/j.annemergmed.2017.01.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications. METHODS This was a quasi-experimental, before-after study that consisted of a preintervention period, a run-in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure, rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions. RESULTS A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63). CONCLUSION Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.
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Mohr NM, Harland KK, Chrischilles EA, Bell A, Shane DM, Ward MM. Emergency Department Telemedicine Is Used for More Severely Injured Rural Trauma Patients, but Does Not Decrease Transfer: A Cohort Study. Acad Emerg Med 2017; 24:177-185. [PMID: 28187248 DOI: 10.1111/acem.13120] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/29/2016] [Accepted: 10/11/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Traumatic injury is a leading cause of death in the United States, and rural populations are at increased risk of injury and death. Rural residents have limited access to trauma care, and telemedicine has been proposed as one strategy to improve the provision of trauma care locally. The objective of this study was to describe patient-level factors associated with telemedicine consultation in North Dakota critical-access hospital (CAH) emergency departments (EDs) and to measure the association between telemedicine consultation and interhospital transfer. METHODS Observational cohort study of all adult (age ≥ 18 years) trauma patients treated in North Dakota CAH EDs with an active telemedicine subscription between 2008 and 2014. Trauma cases were identified from the North Dakota Trauma Registry, and telemedicine-enabled care was determined using a probabilistic linking algorithm with the call records of the predominant telemedicine network in North Dakota. Multivariable generalized estimating equations were used to identify factors associated with telemedicine consultation and to measure the association between telemedicine consultation and interhospital transfer, adjusting for patient, injury, and hospital factors. RESULTS Of the 9,281 North Dakota trauma patients seen in CAHs, 2,837 were treated in an ED with an active telemedicine subscription. Telemedicine was consulted for 11% of all trauma patients in telemedicine-capable EDs. Factors associated with telemedicine consultation included higher Injury Severity Score, penetrating injuries, burns, hypotension, tachycardia, and ambulance transport. Adjusting for severity of illness, injury mechanism, and type of injury, telemedicine use was not associated with interhospital transfer (adjusted odds ratio = 1.28, 95% confidence interval = 0.94 to 1.75). CONCLUSION Emergency department-based telemedicine consultation is requested for the most severely injured rural trauma patients, especially with those with penetrating trauma, burns, and abnormal presenting vital signs. Telemedicine consultation was not independently associated with increased probability of transfer. Future work should evaluate how telemedicine impacts the timeliness of care and specific care interventions.
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Van Oeveren L, Donner J, Fantegrossi A, Mohr NM, Brown CA. Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry Study. Telemed J E Health 2016; 23:290-297. [PMID: 27673565 DOI: 10.1089/tmj.2016.0140] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intubation in rural emergency departments (EDs) is a high-risk procedure, often with little or no specialty support. Rural EDs are utilizing real-time telemedicine links, connecting providers to an ED physician who may provide clinical guidance. INTRODUCTION We endeavored to describe telemedicine-assisted intubation in rural EDs that are served by an ED telemedicine network. MATERIALS AND METHODS Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May 1, 2014 to April 30, 2015. We report demographic information, indication, methods, number of attempts, operator characteristics, telemedicine involvement/intervention, adverse events, and clinical outcome by using descriptive statistics. RESULTS Included were 206 intubations. The most common indication for intubation was respiratory failure. First-pass success rate (postactivation) was 71%, and 96% were eventually intubated. Most attempts (66%) used rapid-sequence intubation. Fifty-four percent of first attempts used video laryngoscopy (VL). Telemedicine providers intervened in 24%, 43%, and 55% of first-third attempts, respectively. First-pass success with VL and direct laryngoscopy was equivalent (70% vs. 71%, p = 0.802). Adverse events were reported in 49 cases (24%), which were most frequently hypoxemia. DISCUSSION The impact of telemedicine during emergency intubation is not defined. We showed a 71% first-pass rate post-telemedicine linkage (70% of cases had a previous attempt). Our ultimate success rate was 96%, similar to that in large-center studies. Telemedicine support may contribute to success. CONCLUSIONS Telemedicine-supported endotracheal intubation performed in rural hospitals is feasible, with good success rates. Future research is required to better define the impact of telemedicine providers on emergency airway management.
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Mohr NM, Harland KK, Shane DM, Miller SL, Torner JC. Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study. Acad Emerg Med 2016; 23:885-94. [PMID: 27018337 DOI: 10.1111/acem.12972] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/14/2016] [Accepted: 03/24/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Interhospital transfer is a common strategy to provide high-quality regionalized care in rural emergency departments (EDs), but several reports have highlighted problems with selection of children for transfer. The purpose of this study is to characterize the burden of potentially avoidable transfer (PAT) and to estimate the medical and family-oriented costs associated with PAT. METHODS This study was a cohort study of all children treated in Iowa EDs between 2004 and 2013. PAT was defined as a child who was transferred and then either discharged from the receiving ED or admitted for ≤ 1 day, without having any separately billed procedures performed. Costs of care were estimated from 1) medical costs, 2) ambulance transfer, and 3) family costs (travel and lodging). RESULTS Over 10 years, 2,117,317 children were included (1% transferred to another hospital). Only 63% were transferred to a designated children's hospital, and PATs were identified in 39% of all transfers. PAT was associated with $909 in additional cost. The conditions most strongly associated with PAT were seizure (additional cost $1,138), fracture ($814), isolated traumatic brain injury without extra-axial bleeding ($1,455), respiratory infection ($556), and wheezing ($804). Few of these charges are attributable to nonmedical family costs ($21). CONCLUSIONS Potentially avoidable pediatric interhospital transfer is common and is responsible for significant healthcare-related costs. Future work should focus on improving selection of children who benefit from interhospital transfer for high-yield conditions, to reduce the costly and distressing burden that PAT places on rural patients and their families.
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Mohr NM, Harland KK, Shane DM, Ahmed A, Fuller BM, Torner JC. Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach. J Crit Care 2016; 36:187-194. [PMID: 27546770 DOI: 10.1016/j.jcrc.2016.07.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/12/2016] [Accepted: 07/19/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state. MATERIALS AND METHODS Observational case-control study using statewide administrative claims data from 2005 to 2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations models and with instrumental variables models. RESULTS A total of 18 246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable generalized estimating equations (GEE) model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95% CI 1.5-1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of $6897 (95% CI $5769-8024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with $5167 (95% CI $3696-6638) in additional cost. CONCLUSIONS The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.
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Bobb MR, Van Heukelom PG, Faine BA, Ahmed A, Messerly JT, Bell G, Harland KK, Simon C, Mohr NM. Telemedicine Provides Noninferior Research Informed Consent for Remote Study Enrollment: A Randomized Controlled Trial. Acad Emerg Med 2016; 23:759-65. [PMID: 26990899 DOI: 10.1111/acem.12966] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 02/09/2016] [Accepted: 03/10/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Telemedicine networks are beginning to provide an avenue for conducting emergency medicine research, but using telemedicine to recruit participants for clinical trials has not been validated. The goal of this consent study was to determine whether patient comprehension of telemedicine-enabled research informed consent is noninferior to standard face-to-face (F2F) research informed consent. METHODS A prospective, open-label randomized controlled trial was performed in a 60,000-visit Midwestern academic emergency department (ED) to test whether telemedicine-enabled research informed consent provided noninferior comprehension compared with standard consent. This study was conducted as part of a parent clinical trial evaluating the effectiveness of 0.12% oral chlorhexidine gluconate in preventing hospital-acquired pneumonia among adult ED patients with expected hospital admission. Prior to being recruited into the study, potential participants were randomized in a 1:1 allocation ratio to consent by telemedicine versus standard F2F consent. Telemedicine connectivity was provided using a commercially available interface (REACH platform, Vidyo Inc.) to an emergency physician located in another part of the ED. Comprehension of research consent (primary outcome) was measured using the modified quality of informed consent (QuIC) instrument, a validated tool for measuring research informed consent comprehension. Parent trial accrual rate and qualitative survey data were secondary outcomes. RESULTS A total of 131 patients were randomized (n = 64, telemedicine), and 101 QuIC surveys were completed. Comprehension of research informed consent using telemedicine was not inferior to F2F consent (QuIC scores 74.4 ± 8.1 vs. 74.4 ± 6.9 on a 100-point scale, p = 0.999). Subjective understanding of consent (p = 0.194) and parent trial study accrual rates (56% vs. 69%, p = 0.142) were similar. CONCLUSION Telemedicine is noninferior to F2F consent for delivering research informed consent, with no detected differences in comprehension and patient-reported understanding. This consent study will inform design of future telemedicine-enabled clinical trials.
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Fuller BM, Ferguson I, Mohr NM, Stephens RJ, Briscoe CC, Kolomiets AA, Hotchkiss RS, Kollef MH. Lung-protective ventilation initiated in the emergency department (LOV-ED): a study protocol for a quasi-experimental, before-after trial aimed at reducing pulmonary complications. BMJ Open 2016; 6:e010991. [PMID: 27067896 PMCID: PMC4838728 DOI: 10.1136/bmjopen-2015-010991] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In critically ill patients, acute respiratory distress syndrome (ARDS) and ventilator-associated conditions (VACs) are associated with increased mortality, survivor morbidity and healthcare resource utilisation. Studies conclusively demonstrate that initial ventilator settings in patients with ARDS, and at risk for it, impact outcome. No studies have been conducted in the emergency department (ED) to determine if lung-protective ventilation in patients at risk for ARDS can reduce its incidence. Since the ED is the entry point to the intensive care unit for hundreds of thousands of mechanically ventilated patients annually in the USA, this represents a knowledge gap in this arena. A lung-protective ventilation strategy was instituted in our ED in 2014. It aims to address the parameters in need of quality improvement, as demonstrated by our previous research: (1) prevention of volutrauma; (2) appropriate positive end-expiratory pressure setting; (3) prevention of hyperoxia; and (4) aspiration precautions. METHODS AND ANALYSIS The lung-protective ventilation initiated in the emergency department (LOV-ED) trial is a single-centre, quasi-experimental before-after study testing the hypothesis that lung-protective ventilation, initiated in the ED, is associated with reduced pulmonary complications. An intervention cohort of 513 mechanically ventilated adult ED patients will be compared with over 1000 preintervention control patients. The primary outcome is a composite outcome of pulmonary complications after admission (ARDS and VACs). Multivariable logistic regression with propensity score adjustment will test the hypothesis that ED lung-protective ventilation decreases the incidence of pulmonary complications. ETHICS AND DISSEMINATION Approval of the study was obtained prior to data collection on the first patient. As the study is a before-after observational study, examining the effect of treatment changes over time, it is being conducted with waiver of informed consent. This work will be disseminated by publication of full-length manuscripts, presentation in abstract form at major scientific meetings and data sharing with other investigators through academically established means. TRIAL REGISTRATION NUMBER NCT02543554.
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