Effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in critically ill patients: A before and after trial

H.J.F. Helmerhorst, M. Schultz, P.H.J. van der Voort, M. de Vries, Robert J. Bosman, Nicole P. Juffermans, Rob B. P. de Wilde, M. Elske van den Akker-van Marle, Leti van Bodegom-Vos, David J. van Westerloo, Evert de Jonge

Research output: Contribution to journalArticleScientificpeer-review

Abstract

Objectives: 
Conservative oxygen therapy is aimed at the prevention of harm by iatrogenic hyperoxia while preserving adequate tissue oxygenation. Our aim was to study the effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in the ICU.
Design: 
This was a before and after stepwise implementation study of conservative oxygenation targets, between July 2011 and July 2014. The primary endpoint was the proportion of PaO2 values within the target range. Secondary outcomes included ventilator-free days at day 28, length of stay, and mortality.
Setting: 
Three closed-format ICUs in the Netherlands.
Patients: 
We analyzed data on 15,045 eligible admissions.Interventions: The first implementation phase consisted of providing training and feedback on new guidelines instructing for explicit targets for arterial oxygen tension (PaO2, 55–86 mm Hg) and oxyhemoglobin saturation (SpO2, 92–95%). In the second phase, bedside clinicians were additionally assisted in guideline adherence by a computerized decision-support system.
Measurements and Main Results: 
The proportion of PaO2 in the target range increased from 47% at baseline to 63% in phase 1 and to 68% in phase 2 (p < 0.0001). Episodes of hyperoxia decreased (p < 0.0001), whereas hypoxic episodes remained unchanged (p = 0.06) during the study. Mechanical ventilation time was significantly lower (p < 0.01) during both study phases. After adjustment for potential confounders, ventilator-free days in phase 1 and phase 2 were higher than baseline: adjusted mean difference, 0.55 (95% CI, 0.25–0.84) and 0.48 (95% CI, 0.11–0.86), respectively. Adjusted ICU mortality and ICU-free days did not significantly differ between study phases. Hospital mortality decreased in reference to baseline: adjusted odds ratio, 0.84 (95% CI, 0.74–0.96) for phase 1 and 0.82 (95% CI, 0.69–0.96) for phase 2.
Conclusions: 
Stepwise implementation of conservative oxygenation targets was feasible, effective, and seemed safe in critically ill patients. The implementation was associated with several changes in clinical outcomes, but the causal impact of conservative oxygenation is still to be determined.
Original languageEnglish
Pages (from-to)554-563
JournalCritical Care Medicine
Volume44
Issue number3
DOIs
Publication statusPublished - 2016

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Hyperoxia
Critical Illness
Oxygen
Guideline Adherence
Oxyhemoglobins
Hospital Mortality
Netherlands
Length of Stay
Arterial Pressure
Odds Ratio
Conservative Treatment

Cite this

Helmerhorst, H. J. F., Schultz, M., van der Voort, P. H. J., de Vries, M., Bosman, R. J., Juffermans, N. P., ... de Jonge, E. (2016). Effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in critically ill patients: A before and after trial. Critical Care Medicine, 44(3), 554-563. https://doi.org/10.1097/CCM.0000000000001461
Helmerhorst, H.J.F. ; Schultz, M. ; van der Voort, P.H.J. ; de Vries, M. ; Bosman, Robert J. ; Juffermans, Nicole P. ; de Wilde, Rob B. P. ; van den Akker-van Marle, M. Elske ; van Bodegom-Vos, Leti ; van Westerloo, David J. ; de Jonge, Evert. / Effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in critically ill patients : A before and after trial. In: Critical Care Medicine. 2016 ; Vol. 44, No. 3. pp. 554-563.
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title = "Effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in critically ill patients: A before and after trial",
abstract = "Objectives: Conservative oxygen therapy is aimed at the prevention of harm by iatrogenic hyperoxia while preserving adequate tissue oxygenation. Our aim was to study the effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in the ICU.Design: This was a before and after stepwise implementation study of conservative oxygenation targets, between July 2011 and July 2014. The primary endpoint was the proportion of PaO2 values within the target range. Secondary outcomes included ventilator-free days at day 28, length of stay, and mortality.Setting: Three closed-format ICUs in the Netherlands.Patients: We analyzed data on 15,045 eligible admissions.Interventions: The first implementation phase consisted of providing training and feedback on new guidelines instructing for explicit targets for arterial oxygen tension (PaO2, 55–86 mm Hg) and oxyhemoglobin saturation (SpO2, 92–95{\%}). In the second phase, bedside clinicians were additionally assisted in guideline adherence by a computerized decision-support system.Measurements and Main Results: The proportion of PaO2 in the target range increased from 47{\%} at baseline to 63{\%} in phase 1 and to 68{\%} in phase 2 (p < 0.0001). Episodes of hyperoxia decreased (p < 0.0001), whereas hypoxic episodes remained unchanged (p = 0.06) during the study. Mechanical ventilation time was significantly lower (p < 0.01) during both study phases. After adjustment for potential confounders, ventilator-free days in phase 1 and phase 2 were higher than baseline: adjusted mean difference, 0.55 (95{\%} CI, 0.25–0.84) and 0.48 (95{\%} CI, 0.11–0.86), respectively. Adjusted ICU mortality and ICU-free days did not significantly differ between study phases. Hospital mortality decreased in reference to baseline: adjusted odds ratio, 0.84 (95{\%} CI, 0.74–0.96) for phase 1 and 0.82 (95{\%} CI, 0.69–0.96) for phase 2.Conclusions: Stepwise implementation of conservative oxygenation targets was feasible, effective, and seemed safe in critically ill patients. The implementation was associated with several changes in clinical outcomes, but the causal impact of conservative oxygenation is still to be determined.",
author = "H.J.F. Helmerhorst and M. Schultz and {van der Voort}, P.H.J. and {de Vries}, M. and Bosman, {Robert J.} and Juffermans, {Nicole P.} and {de Wilde}, {Rob B. P.} and {van den Akker-van Marle}, {M. Elske} and {van Bodegom-Vos}, Leti and {van Westerloo}, {David J.} and {de Jonge}, Evert",
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Helmerhorst, HJF, Schultz, M, van der Voort, PHJ, de Vries, M, Bosman, RJ, Juffermans, NP, de Wilde, RBP, van den Akker-van Marle, ME, van Bodegom-Vos, L, van Westerloo, DJ & de Jonge, E 2016, 'Effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in critically ill patients: A before and after trial', Critical Care Medicine, vol. 44, no. 3, pp. 554-563. https://doi.org/10.1097/CCM.0000000000001461

Effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in critically ill patients : A before and after trial. / Helmerhorst, H.J.F.; Schultz, M.; van der Voort, P.H.J.; de Vries, M.; Bosman, Robert J.; Juffermans, Nicole P.; de Wilde, Rob B. P.; van den Akker-van Marle, M. Elske; van Bodegom-Vos, Leti; van Westerloo, David J.; de Jonge, Evert.

In: Critical Care Medicine, Vol. 44, No. 3, 2016, p. 554-563.

Research output: Contribution to journalArticleScientificpeer-review

TY - JOUR

T1 - Effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in critically ill patients

T2 - A before and after trial

AU - Helmerhorst, H.J.F.

AU - Schultz, M.

AU - van der Voort, P.H.J.

AU - de Vries, M.

AU - Bosman, Robert J.

AU - Juffermans, Nicole P.

AU - de Wilde, Rob B. P.

AU - van den Akker-van Marle, M. Elske

AU - van Bodegom-Vos, Leti

AU - van Westerloo, David J.

AU - de Jonge, Evert

PY - 2016

Y1 - 2016

N2 - Objectives: Conservative oxygen therapy is aimed at the prevention of harm by iatrogenic hyperoxia while preserving adequate tissue oxygenation. Our aim was to study the effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in the ICU.Design: This was a before and after stepwise implementation study of conservative oxygenation targets, between July 2011 and July 2014. The primary endpoint was the proportion of PaO2 values within the target range. Secondary outcomes included ventilator-free days at day 28, length of stay, and mortality.Setting: Three closed-format ICUs in the Netherlands.Patients: We analyzed data on 15,045 eligible admissions.Interventions: The first implementation phase consisted of providing training and feedback on new guidelines instructing for explicit targets for arterial oxygen tension (PaO2, 55–86 mm Hg) and oxyhemoglobin saturation (SpO2, 92–95%). In the second phase, bedside clinicians were additionally assisted in guideline adherence by a computerized decision-support system.Measurements and Main Results: The proportion of PaO2 in the target range increased from 47% at baseline to 63% in phase 1 and to 68% in phase 2 (p < 0.0001). Episodes of hyperoxia decreased (p < 0.0001), whereas hypoxic episodes remained unchanged (p = 0.06) during the study. Mechanical ventilation time was significantly lower (p < 0.01) during both study phases. After adjustment for potential confounders, ventilator-free days in phase 1 and phase 2 were higher than baseline: adjusted mean difference, 0.55 (95% CI, 0.25–0.84) and 0.48 (95% CI, 0.11–0.86), respectively. Adjusted ICU mortality and ICU-free days did not significantly differ between study phases. Hospital mortality decreased in reference to baseline: adjusted odds ratio, 0.84 (95% CI, 0.74–0.96) for phase 1 and 0.82 (95% CI, 0.69–0.96) for phase 2.Conclusions: Stepwise implementation of conservative oxygenation targets was feasible, effective, and seemed safe in critically ill patients. The implementation was associated with several changes in clinical outcomes, but the causal impact of conservative oxygenation is still to be determined.

AB - Objectives: Conservative oxygen therapy is aimed at the prevention of harm by iatrogenic hyperoxia while preserving adequate tissue oxygenation. Our aim was to study the effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in the ICU.Design: This was a before and after stepwise implementation study of conservative oxygenation targets, between July 2011 and July 2014. The primary endpoint was the proportion of PaO2 values within the target range. Secondary outcomes included ventilator-free days at day 28, length of stay, and mortality.Setting: Three closed-format ICUs in the Netherlands.Patients: We analyzed data on 15,045 eligible admissions.Interventions: The first implementation phase consisted of providing training and feedback on new guidelines instructing for explicit targets for arterial oxygen tension (PaO2, 55–86 mm Hg) and oxyhemoglobin saturation (SpO2, 92–95%). In the second phase, bedside clinicians were additionally assisted in guideline adherence by a computerized decision-support system.Measurements and Main Results: The proportion of PaO2 in the target range increased from 47% at baseline to 63% in phase 1 and to 68% in phase 2 (p < 0.0001). Episodes of hyperoxia decreased (p < 0.0001), whereas hypoxic episodes remained unchanged (p = 0.06) during the study. Mechanical ventilation time was significantly lower (p < 0.01) during both study phases. After adjustment for potential confounders, ventilator-free days in phase 1 and phase 2 were higher than baseline: adjusted mean difference, 0.55 (95% CI, 0.25–0.84) and 0.48 (95% CI, 0.11–0.86), respectively. Adjusted ICU mortality and ICU-free days did not significantly differ between study phases. Hospital mortality decreased in reference to baseline: adjusted odds ratio, 0.84 (95% CI, 0.74–0.96) for phase 1 and 0.82 (95% CI, 0.69–0.96) for phase 2.Conclusions: Stepwise implementation of conservative oxygenation targets was feasible, effective, and seemed safe in critically ill patients. The implementation was associated with several changes in clinical outcomes, but the causal impact of conservative oxygenation is still to be determined.

U2 - 10.1097/CCM.0000000000001461

DO - 10.1097/CCM.0000000000001461

M3 - Article

VL - 44

SP - 554

EP - 563

JO - Critical Care Medicine

JF - Critical Care Medicine

SN - 0090-3493

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