Effect of the SAFE-CARE nursing bundle on artificial airway-related complications in adult ICU patients: a before-and-after interrupted time-series study

Objective: To evaluate the effectiveness and sustainability of the SAFE-CARE nursing bundle in reducing artificial airway related complications in adult ICU patients, and to assess whether it provides a practical model for low and middle income countries and under resourced ICUs. Methods: This single center retrospective before and after interrupted time series study included adult patients who received invasive mechanical ventilation with an artificial airway retained for at least 24 h. The control group was February to December 2023 and the intervention group was January to December 2024. Primary outcomes included pericuff microaspiration (PM), ventilator associated pneumonia (VAP), medical device related pressure injury (MDR-PI), and unplanned extubation (UE). Secondary outcomes included duration of mechanical ventilation, ICU length of stay, and nursing checklist compliance. Results: A total of 122 patients were included, with 61 patients in each group. PM decreased from 29.5 to 6.6%, VAP decreased from 26.2 to 4.9%, MDR-PI decreased from 19.7 to 4.9%, and UE decreased from 31.1 to 3.3%. Mechanical ventilation duration and ICU length of stay showed no significant differences between groups. Checklist compliance improved from 67.9 to 90.80%. Interrupted time series analysis showed an immediate reduction after implementation, with sustained post implementation declines for PM and VAP. Conclusion: SAFE-CARE was associated with rapid and clinically meaningful reductions in multiple airway related complications and demonstrated sustained improvement for key infection related outcomes, suggesting a scalable low cost strategy for general ICUs.