ECONOMIC FEASIBILITY OF A NOVEL TOOL TO ASSIST EXTUBATION DECISION-MAKING: AN EARLY HEALTH ECONOMIC MODELLING

Liberation from mechanical ventilation using Extubation Advisor Decision Support (LEADS): protocol for a multicentre pilot trial

INTRODUCTION

Timely successful liberation from invasive ventilation has the potential to minimise critically ill patients' exposure to invasive ventilation, save costs and improve outcomes; yet no trials have evaluated strategies to better inform extubation decision-making. The Liberation from mechanical ventilation using Extubation Advisor (EA) Decision Support (LEADS) Pilot Trial will assess the feasibility of a trial of a novel extubation decision support tool on feasibility metrics. The primary feasibility outcome will reflect our ability to recruit the desired population. Secondary feasibility outcomes will assess rates of (1) consent, (2) randomisation, (3) intervention adherence, (4) bidirectional crossovers and the (5) completeness of clinical outcomes collected. We will also evaluate physicians' perceptions of the usefulness of the EA tool and measure costs related to EA implementation.

METHODS AND ANALYSIS

We will include critically ill adults who are invasively ventilated for ≥48 hours and who are ready to undergo a spontaneous breathing trial (SBT) with a view to extubation. Patients in the intervention arm will undergo an EA assessment that measures respiratory rate variability to derive an estimate of extubation readiness. Treating clinicians (respiratory therapists, attending physicians and intensive care unit fellows) will receive an EA report for each SBT conducted. The EA report will assist, rather than direct, extubation decision-making. Patients in the control arm will receive standard care. SBTs will be directed by clinicians, using current best evidence, without EA assessments or reports. We aim to recruit 1 to 2 patients/month in approximately 10 centres, and to achieve >75% consent rate, >95% randomisation among consented patients, >80% of EA reports generated and delivered (intervention arm), <10% crossovers (both arms) and >90% of patients with complete clinical outcomes. We will also report physician point-of-care perceptions of the usefulness of the EA tool.

ETHICS AND DISSEMINATION

The LEADS Pilot Trial is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (4008). We will disseminate the LEADS trial findings through conference presentations and publication.

TRIAL REGISTRATION NUMBER

NCT05506904.

PROTOCOL VERSION

24 April 2024.

Clinical practice, decision-making, and use of clinical decision support systems in invasive mechanical ventilation: a narrative review

Invasive mechanical ventilation is a key supportive therapy for patients on intensive care. There is increasing emphasis on personalised ventilation strategies. Clinical decision support systems (CDSS) have been developed to support this. We conducted a narrative review to assess evidence that could inform device implementation. A search was conducted in MEDLINE (Ovid) and EMBASE. Twenty-nine studies met the inclusion criteria. Role allocation is well described, with interprofessional collaboration dependent on culture, nurse:patient ratio, the use of protocols, and perception of responsibility. There were no descriptions of process measures, quality metrics, or clinical workflow. Nurse-led weaning is well-described, with factors grouped by patient, nurse, and system. Physician-led weaning is heterogenous, guided by subjective and objective information, and 'gestalt'. No studies explored decision-making with CDSS. Several explored facilitators and barriers to implementation, grouped by clinician (facilitators: confidence using CDSS, retaining decision-making ownership; barriers: undermining clinician's role, ambiguity moving off protocol), intervention (facilitators: user-friendly interface, ease of workflow integration, minimal training requirement; barriers: increased documentation time), and organisation (facilitators: system-level mandate; barriers: poor communication, inconsistent training, lack of technical support). One study described factors that support CDSS implementation. There are gaps in our understanding of ventilation practice. A coordinated approach grounded in implementation science is required to support CDSS implementation. Future research should describe factors that guide clinical decision-making throughout mechanical ventilation, with and without CDSS, map clinical workflow, and devise implementation toolkits. Novel research design analogous to a learning organisation, that considers the commercial aspects of device design, is required.