Prevention of Severe Acute Respiratory Failure in Patients With PROOFCheck

Severe acute respiratory failure (ARF) requiring prolonged mechanical ventilation is the most
common form of acute organ dysfunction in the hospital, and is often associated with multiple
organ failure (MOF), high mortality, and functional impairment. Most studies on ARF have
focused on patients in the intensive care unit (ICU) after they have been on mechanical
ventilation for days and end organ damage is already established. The overall goal of this
proposed project is to improve the outcomes of patients at high risk for developing severe
ARF and prolonged mechanical ventilation in and outside of the ICU. The project aims to
intervene early in high risk patients with an electronic medical records (EMR)-based,
patient-centered checklist of common critical care practices aimed at preventing lung injury
and hospital acquired adverse events that commonly lead to organ failure (Prevention of Organ
Failure checklist -PROOFcheck). This application proposes a stepped-wedge, clustered
randomized control trial to determine the utility of PROOFcheck to improve survival and
reduce the duration of mechanical ventilation and multiple organ failure in patients
identified as high risk for progressing to severe ARF and prolonged mechanical ventilation.
The aims in the UH2 phase are: 1) to refine a previously validated Lung Injury Prediction
Score into a pragmatic, EMR-based early prediction model to Accurately Predict Prolonged
Ventilation (APPROVE), which will automatically identify patients anywhere in the hospital
who are at high risk for developing severe ARF requiring mechanical ventilation >48 hours; 2)
to incorporate PROOFcheck into the EMR to prompt clinicians on care practices to limit lung
injury, prevent adverse events, and avoid additional organ failure; and 3) to establish the
infrastructure for the proposed trial. The proposed pragmatic trial will harness the
hospital-wide EMR to identify patients at high risk for prolonged mechanical ventilation with
APPROVE for intervention with PROOFcheck. As such, the proposed trial aims to break out of
the clinical silos by which care is currently organized in the hospital and bring
patient-centered, context appropriate care to the acutely ill patient wherever and whenever
the patient's condition requires it.