(413) Active Telemedicine Feedback Enhances Spontaneous Breathing Trial Utilization

Introduction: Daily spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) increase ventilator-free days, intensive care unit (ICU)-free days, and hospital-free days. However, use of daily SAT/SBT has historically varied widely. After efforts to address barriers, we introduced a standard SAT/SBT clinical protocol in all ICUs in our multi-hospital system in February 2023. To promote adherence, we added an active feedback intervention delivered by tele-critical care nurses, with phased rollout in summer 2023. Here, we examine the impact of these interventions on SBTs.

Methods: This retrospective cohort study included ventilator days with an endotracheal tube between 10/1/2022 and 12/17/2023, excluding the day of intubation, day of ICU admission, and days on comfort measures. The primary outcome was the proportion of eligible days on which any pressure support ventilation (PSV) was documented. The effects of both the standard protocol and telemedicine feedback on the outcome were quantified using a linear mixed effects model, with random effects for ICU and fixed effects for time, academic/community setting, and bedside intensivist staffing model (24-hour in-house, daytime, or none).

Results: The analysis included 22,638 ventilator days (7209 baseline, 9255 with the protocol but before telemedicine feedback, and 6174 with telemedicine feedback) for 4919 unique patients in 15 ICUs at 10 hospitals. Overall, PSV occurred on 47% of eligible ventilator days at baseline, 51% following protocol deployment, and 52% with the telemedicine feedback intervention. In the overall cohort, no step change in the proportion of ventilator days with PSV was observed following introduction of the standard protocol or telemedicine feedback.

In ICUs with no bedside intensivist, PSV occurred on 39% of eligible ventilator days at baseline, 38% following protocol deployment, and 51% with telemedicine feedback. The increase following the addition of telemedicine feedback was statistically significant (absolute increase of 12%, 95%CI 1%-23%).

Conclusions: A telemedicine feedback intervention enhanced SBT adherence selectively in ICUs that did not have a bedside intensivist. Future work will examine the impact on SATs as well as downstream outcomes such as duration of mechanical ventilation and ICU length of stay.