The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

A RANDOMIZED CONTROLLED TRIAL OF PROTOCOL-DIRECTED VERSUS PHYSICIAN-DIRECTED WEANING FROM MECHANICAL VENTILATION.

Marin H. Kollef, MD; Steven D. Shaplro, M.D.; Patricia Silver, MEd; Robert E. St.John MSN; Donna Prentice MSN; Sharon Sauer BSN; Tom S. Ahrens, DNS; William Shannon, PhD; Dametta Baker-Clinkscale, MBA; Department of Internal Medicine, Pulmonary and Critical Care Division, Division of General Medical Sciences, Washington University School of Medicine, Departments of Nursing and Respiratory Therapy, Barnes and Jewish Hospitals of the BJC Health System; St. Louis, MO 631.10

Background: To compare a practice of protocol-directed weaning from mechanical ventilation Implemented by nurses and respiratory therapists to physician-directed weaning. Method: Randomized controlled trial of 357 patients in the medical and surgical intensive care units of two university-affillated teaching hospitals. Patients were randomly assigned to receive either protocol-directed (n=179) or physician-directed (n=178) weaning from mechanical ventilation. The primary outcome measure was the duration of mechanical ventilation. Other outcome measures included need for reintubation, length of hospital stay, hospital mortallty, and hospital charges. Result: The median duration of mechanical ventilation was 35 hours for the protocol-directed group (first quartile, 15 hours; third quartile, 114 hours) compared to 44 hours for the physician-directed group (first quartile, 21 hours; third quartile, 209 hours). Kaplan-Meler analysis demonstrated that patients randomized to protocol-directed weaning had significantly shorter durations of mechanical ventilation compared to patients randomized to physician-directed weaning(X^{2}= 3.62, P = 0.057, Log-Rank test; X^{2} = 5.12, P = 0.024, Wilcoxon test). Cox proportional-hazards regression analysis, adjusting for other co-variates, showed that the rate of successful weaning was significantly greater for patients receiving protocol-directed weaning compared to patients receiving physician-directed weaning (risk ratio, 1.31; 95 percent confidence interval, 1.15 to 1.50; P=0.039). The hospital mortality rates for the two treatment groups were similar (protocol-directed, 22.3% versus physician-directed, 23.6%; P=0.779). Hospital charges for patients in the protocol-directed group averaged $3866 less than hospital charges for patients in the physician-directed group. Conclusions: Protocol-guided weaning of mechanical ventilation, as performed by nurses and respiratory therapists, is safe and led to extubation more rapidly than physician-directed weaning.

Reference: OF-96-008

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