The Maximizing Extubation outcomes Through Educational and Organizational Research (METEOR) Trial

PROJECT SUMMARY Nearly one million patients require invasive mechanical ventilation for acute respiratory failure in the United States each year. Most of these patients will recover to the point of extubation, yet even those who are extubated remain vulnerable to complications and poor outcomes. Multiple high-profile randomized controlled trials have shown that two preventive post-extubation respiratory therapies— noninvasive ventilation (NIV) and high-flow nasal cannula oxygen (HFNC)—can prevent recurrent respiratory failure, reintubation, and death in this population. Despite this evidence, however, these therapies remain severely underutilized, leading to preventable morbidity and mortality. To address this implementation gap, we propose to conduct the Maximizing Extubation outcomes Through Educational and Organizational Research (METEOR) Trial, a cluster-randomized, stepped-wedge, type 2 hybrid effectiveness-implementation trial of interprofessional education about preventive post-extubation NIV and HFNC with and without clinical protocols. We designed the METEOR Trial based on extensive preliminary studies, during which we identified barriers to adoption of preventive post-extubation respiratory care and pilot tested interprofessional education as an implementation strategy in the ICU. These studies revealed that a major barrier to implementation is the lack of a shared understanding about the value of these therapies within the interprofessional ICU team; a theory-based interprofessional education intervention designed to create a shared understanding and support “transactive memory” among team members is both feasible and acceptable; and interprofessional education can be strengthened by linking it with a clinical protocol. During the METEOR Trial, we will randomize ICUs to one of four implementation strategies: an active control, protocol-directed care, interprofessional education, or a combination of protocol-directed care and interprofessional education. In parallel, we will randomize ICUs to one of two clinical strategies, one emphasizing either post- extubation NIV or HFNC based on patient risk vs. one emphasizing post-extubation HFNC for all patients. The specific aims of the trial are to (1) test the effectiveness of interprofessional education on the implementation of preventive, post-extubation therapies, (2) compare the effectiveness of two preventive, post-extubation therapies (NIV and HFNC) on patient-centered clinical outcomes, and (3) perform a comprehensive qualitative evaluation of the trial processes and outcomes in order to better understand mechanism, identify what worked and what didn’t, and set the stage for broader dissemination of the study findings. Together these aims will provide critical insight into the role of interprofessional education as an implementation strategy in hospital settings, leading to improved outcomes for hundreds of thousands of patients with acute respiratory failure.