Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis

The effect of threshold inspiratory muscle training on the duration of weaning in intensive care unit-admitted patients: A randomized clinical trial

Background

The purpose of this study was to evaluate the effect of threshold inspiratory muscle training (IMT) on the duration of weaning in intensive care unit (ICU)-admitted patients.

Materials and Methods

This randomized clinical trial enrolled 79 ICU-admitted, mechanically ventilated patients in 2020-2021 in Imam Reza Hospital, Mashhad. Patients were randomly divided into intervention (n = 40) and control (n = 39) groups. The intervention group received threshold IMT and conventional chest physiotherapy, while the control group only received conventional chest physiotherapy once a day. Before and after the end of the intervention, the strength of inspiratory muscles and the duration of weaning were measured in both the groups.

Results

The duration of weaning was shorter in the intervention group (8.4 ± 1.1 days) versus the control group (11.2 ± 0.6 days) (P < 0.001). The rapid shallow breathing index decreased by 46.5% in the intervention group and by 27.3% in the control group after the intervention (both P < 0.001), and the between-group comparison showed a significantly higher reduction in the intervention group than control group (P < 0.001). The patients' compliance after the intervention compared to the 1^st day increased to 16.2 ± 6.6 in the intervention group and 9.6 ± 6.8 in the control group (both P < 0.001), and the between-group comparison showed a significantly higher increase in the intervention group than control group. The maximum inspiratory pressure increased by 13.7 ± 6.1 in the intervention group and by 9.1 ± 6.0 in the control group (P < 0.001). Furthermore, the weaning success was 54% more probable in the intervention group than control group (P < 0.05).

Conclusion

The results of this study showed the positive effect of IMT with threshold IMT trainer on increased strength of respiratory muscles and reduced weaning duration.

Effects of Mechanical Ventilator Weaning Education on ICU Nurses and Patient Outcomes: A Scoping Review

BACKGROUND

Assessment of mechanical ventilator (MV) weaning is a complex process that requires education for nurses. This scoping review aimed to clarify the effects of MV weaning education on intensive care unit nurses and patient outcomes.

METHOD

Four databases were searched. The inclusion criteria were studies on MV weaning education for nurses, outcome measures for patients or nurses, and quantitative research.

RESULTS

In total, 663 studies were identified. The criteria for a full review (n = 15) were educational protocols (n = 13) and the Burns Wean Assessment Program (n = 2). Patient outcomes determined the MV duration. The weaning protocol was convenient for nurses. Nevertheless, their clinical judgment skills must be improved, regardless of the availability of a protocol. Education is crucial for producing positive outcomes.

CONCLUSION

Education for nurses on MV weaning showed shortened MV duration. No significant effects were found for other outcomes. [J Contin Educ Nurs. 2023;54(4):185-192.].

Factors influencing the implementation of a ventilation weaning protocol in an adult intensive care unit: a qualitative multidisciplinary evaluation

PURPOSE

Development of protocolized care in the intensive care unit (ICU) improves patient outcomes, but presents multiple challenges. A mechanical ventilation weaning protocol (WP) was adopted in our institution but was underused. This study aimed to determine the factors that influenced the implementation of this protocol locally.

METHODS

We performed a qualitative descriptive study using semidirected interviews in small profession-specific focus groups. The interviews were based on a standardized guide covering the major domains found in the Consolidated Framework for Implementation Research. A total of 32 participants across four key professions were recruited. The interviews were transcribed and codified sequentially, followed by categorization and analysis.

RESULTS

Three broad factors emerged that negatively impacted the implementation of the WP. First, the goals of the WP differed between professional groups. This difference led to significant frustration and breaches in collaboration. Second, there was a lack of a continuous quality improvement process. Third, the WP was incompatible with the routine and procedures already in place at the time of implementation. Time-of-day of WP application and patient safety concerns were specifically identified issues.

CONCLUSIONS

Implementation of a continuous improvement process with regular and specific follow-up may help identify potential challenges and thus help ensure a more consistent use of the WP.

A Delphi Survey of Canadian Respiratory Therapists' Practice Statements on Pediatric Mechanical Ventilation

BACKGROUND

Pediatric mechanical ventilation practice guidelines are not well established; therefore, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) developed consensus recommendations on pediatric mechanical ventilation management in 2017. However, the guideline's applicability in different health care settings is unknown. This study aimed to determine the consensus on pediatric mechanical ventilation practices from Canadian respiratory therapists' (RTs) perspectives and consensually validate aspects of the ESPNIC guideline.

METHODS

A 3-round modified electronic Delphi survey was conducted; contents were guided by ESPNIC. Participants were RTs with at least 5 years of experience working in standalone pediatric ICUs or units with dedicated pediatric intensive care beds across Canada. Round 1 collected open-text feedback, and subsequent rounds gathered feedback using a 6-point Likert scale. Consensus was defined as ≥ 75% agreement; if consensus was unmet, statements were revised for re-ranking in the subsequent round.

RESULTS

Fifty-two RTs from 14 different pediatric facilities participated in at least one of the 3 rounds. Rounds 1, 2, and 3 had a response rate of 80%, 93%, and 96%, respectively. A total of 59 practice statements achieved consensus by the end of round 3, categorized into 10 sections: (1) noninvasive ventilation and high-flow oxygen therapy, (2) tidal volume and inspiratory pressures, (3) breathing frequency and inspiratory times, (4) PEEP and F_IO2 , (5) advanced modes of ventilation, (6) weaning, (7) physiological targets, (8) monitoring, (9) general, and (10) equipment adjuncts. Cumulative text feedback guided the formation of the clinical remarks to supplement these practice statements.

CONCLUSIONS

This was the first study to survey RTs for their perspectives on the general practice of pediatric mechanical ventilation management in Canada, generally aligning with the ESPNIC guideline. These practice statements considered information from health organizations and institutes, supplemented with clinical remarks. Future studies are necessary to verify and understand these practices' effectiveness.

Quantitative EEG may predict weaning failure in ventilated patients on the neurological intensive care unit

Neurocritical patients suffer from a substantial risk of extubation failure. The aim of this prospective study was to analyze if quantitative EEG (qEEG) monitoring is able to predict successful extubation in these patients. We analyzed EEG-monitoring for at least six hours before extubation in patients receiving mechanical ventilation (MV) on our neurological intensive care unit (NICU) between November 2017 and May 2019. Patients were divided in 2 groups: patients with successful extubation (SE) versus patients with complications after MV withdrawal (failed extubation; FE), including reintubation, need for non-invasive ventilation (NIV) or death. Bipolar six channel EEG was applied. Unselected raw EEG signal underwent automated artefact rejection and Short Time Fast Fourier Transformation. The following relative proportions of global EEG spectrum were analyzed: relative beta (RB), alpha (RA), theta (RT), delta (RD) as well as the alpha delta ratio (ADR). Coefficient of variation (CV) was calculated as a measure of fluctuations in the different power bands. Mann-Whitney U test and logistic regression were applied to analyze group differences. 52 patients were included (26 male, mean age 65 ± 17 years, diagnosis: 40% seizures/status epilepticus, 37% ischemia, 13% intracranial hemorrhage, 10% others). Successful extubation was possible in 40 patients (77%), reintubation was necessary in 6 patients (12%), 5 patients (10%) required NIV, one patient died. In contrast to FE patients, SE patients showed more stable EEG power values (lower CV) considering all EEG channels (RB: p < 0.0005; RA: p = 0.045; RT: p = 0.045) with RB as an independent predictor of weaning success in logistic regression (p = 0.004). The proportion of the EEG frequency bands (RB, RA RT, RD) of the entire EEG power spectrum was not significantly different between SE and FE patients. Higher fluctuations in qEEG frequency bands, reflecting greater fluctuation in alertness, during the hours before cessation of MV were associated with a higher rate of complications after extubation in this cohort. The stability of qEEG power values may represent a non-invasive, examiner-independent parameter to facilitate weaning assessment in neurocritical patients.

Co-ordinated multidisciplinary intervention to reduce time to successful extubation for children on mechanical ventilation: the SANDWICH cluster stepped-wedge RCT

BACKGROUND

Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population.

OBJECTIVES

To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective).

DESIGN

A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations.

SETTING

Paediatric intensive care units in the UK.

PARTICIPANTS

Invasively mechanically ventilated children (aged < 16 years).

INTERVENTIONS

The intervention incorporated co-ordinated multidisciplinary care, patient-relevant sedation plans linked to sedation assessment, assessment of ventilation parameters with a higher than usual trigger for undertaking an extubation readiness test and a spontaneous breathing trial on low levels of respiratory support to test extubation readiness. The comparator was usual care. Hospital sites were randomised sequentially to transition from control to intervention and were non-blinded.

MAIN OUTCOME MEASURES

The primary outcome measure was the duration of invasive mechanical ventilation until the first successful extubation. The secondary outcome measures were successful extubation, unplanned extubation and reintubation, post-extubation use of non-invasive ventilation, tracheostomy, post-extubation stridor, adverse events, length of intensive care and hospital stay, mortality and cost per respiratory complication avoided at 28 days.

RESULTS

The trial included 10,495 patient admissions from 18 paediatric intensive care units from 5 February 2018 to 14 October 2019. In children with anticipated prolonged ventilation (n = 8843 admissions: control, n = 4155; intervention, n = 4688), the intervention resulted in a significantly shorter time to successful extubation [cluster and time-adjusted median difference -6.1 hours (interquartile range -8.2 to -5.3 hours); adjusted hazard ratio 1.11, 95% confidence interval 1.02 to 1.20; p = 0.02] and a higher incidence of successful extubation (adjusted relative risk 1.01, 95% confidence interval 1.00 to 1.02; p = 0.03) and unplanned extubation (adjusted relative risk 1.62, 95% confidence interval 1.05 to 2.51; p = 0.03), but not reintubation (adjusted relative risk 1.10, 95% confidence interval 0.89 to 1.36; p = 0.38). In the intervention period, the use of post-extubation non-invasive ventilation was significantly higher (adjusted relative risk 1.22, 95% confidence interval 1.01 to 1.49; p = 0.04), with no evidence of a difference in intensive care length of stay or other harms, but hospital length of stay was longer (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.97; p = 0.01). Findings for all children were broadly similar. The control period was associated with lower, but not statistically significantly lower, total costs (cost difference, mean £929.05, 95% confidence interval -£516.54 to £2374.64) and significantly fewer respiratory complications avoided (mean difference -0.10, 95% confidence interval -0.16 to -0.03).

LIMITATIONS

The unblinded intervention assignment may have resulted in performance or detection bias. It was not possible to determine which components were primarily responsible for the observed effect. Treatment effect in a more homogeneous group remains to be determined.

CONCLUSIONS

The intervention resulted in a statistically significant small reduction in time to first successful extubation; thus, the clinical importance of the effect size is uncertain.

FUTURE WORK

Future work should explore intervention sustainability and effects of the intervention in other paediatric populations.

TRIAL REGISTRATION

This trial is registered as ISRCTN16998143.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 18. See the NIHR Journals Library website for further project information.

Evaluating the effects of maternal positions in childbirth: An overview of Cochrane Systematic Reviews

INTRODUCTION

The purpose of this study is to conduct an overview of Cochrane systematic reviews (SRs) evaluating the effects of maternal positions in childbirth in order to compile existing evidence for relevant research questions that have been addressed by more than one review, to provide a succinct summary of the up-to-date evidence and to identify areas for future research.

METHODS

An electronic search was conducted in the Cochrane database. Two primary outcomes were the duration of labor and birth, and operative birth. The quality of included reviews was assessed using the AMSTAR criteria, and the quality of the evidence was rated using the GRADE criteria.

RESULTS

We included 3 Cochrane SRs. There was a significant mean difference (MD) found in the duration of the first stage by 1 hour and 22 minutes (MD= -1.21; 95% CI: -2.35 – -0.07, I²=94%) and reduction in caesarean section rates (RR=0.71; 95% CI: 0.54–0.94, I²=0%) in the upright birth position group compared with the horizontal. Also, there was a statistically significant difference in the duration (minutes) of the second stage of labor (MD= -6.16; 95% CI: -9.74 – -2.59, I²=91%) and a reduction in assisted vaginal birth rates (RR=0.75, 95% CI: 0.66–0.86, I²=29%) in the upright group compared with the horizontal without epidural analgesia. The quality of evidence within the reviews was very low to moderate.

CONCLUSIONS

There is currently a limited body of evidence to clearly assess the benefits and risks of assuming upright positions during childbirth. The overview highlights the need for high-quality research studies, involving better definition and comprehensive assessment of the effects of squatting during childbirth.

Weaning critically ill patients from mechanical ventilation: a protocol from a multicenter retrospective cohort study

BACKGROUND

Mechanical ventilation (MV) is an important lifesaving method in intensive care unit (ICU). Prolonged MV is associated with ventilator associated pneumonia (VAP) and other complications. However, premature weaning from MV may lead to higher risk of reintubation or mortality. Therefore, timely and safe weaning from MV is important. In addition, identification of the right patient and performing a suitable weaning process is necessary. Although several guidelines about weaning have been reported, compliance with these guidelines is unknown. Therefore, the aim of this study is to explore the variation of weaning in China, associations between initial MV reason and clinical outcomes, and factors associated with weaning strategies using a multicenter cohort.

METHODS

This multicenter retrospective cohort study will be conducted at 17 adult ICUs in China, that included patients who were admitted in this 17 ICUs between October 2020 and February 2021. Patients under 18 years of age and patients without the possibility for weaning will be excluded. The questionnaire information will be registered by a specific clinician in each center who has been evaluated and qualified to carry out the study.

DISCUSSION

In a previous observational study of weaning in 17 ICUs in China, weaning practices varies nationally. Therefore, a multicenter retrospective cohort study is necessary to be conducted to explore the present weaning methods used in China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) (No. ChiCTR2100044634).

Effect of intracutaneous pyonex on analgesia and sedation in critically ill patients with mechanical ventilation

The purpose of this study was to evaluate the effect of intracutaneous pyonex on analgesia and sedation in critically ill patients who underwent mechanical ventilation. A total of 88 critically ill patients were divided into a control group and an intervention group. Critical Care Pain Observation Tool (CPOT) and Richmond Agitation and Sedation Scale (RASS) were used to evaluate pain and agitation. The dosage and treatment period of sedative and analgesic drugs in the intervention group were notably lower than the control group (p < 0.05). Analgesia compliance time in the intervention group was superior to control group (p < 0.05). The shallow sedation compliance rate in the intervention group was significantly higher than the control group (p < 0.01). There was significant difference in blood gas analysis before and after treatment between the two groups (p < 0.05). After 2 h of sedation and analgesia, heart rate in the intervention group was lower than control group, but respiratory rate was higher than the control group (p < 0.05). The traditional analgesia and sedation combined with intracutaneous pyonex reduced the total amount and treatment period of sedative and analgesic drugs in critically ill patients throughout the treatment process, and it also decreased the adverse reactions such as blood pressure drops and respiratory depression.

Automated Near Real-Time Ventilator Data Feedback Reduces Incidence of Ventilator-Associated Events: A Retrospective Observational Study

Objectives:

Critical care teams are encouraged to follow best practice protocols to help wean mechanically ventilated patients from the ventilator to reduce ventilator-associated events including ventilator-associated conditions, probable ventilator-associated pneumonias, and infection-related ventilator-associated conditions. Providers monitor for alerts suggestive of possible ventilator-associated events and advise when patients should undergo spontaneous breathing trials. Compliance with protocols in most units is suboptimal.

Design:

Retrospective review of clinical data over 24 months.

Setting:

St. Joseph Mercy Hospital Candler Hospital Medical-Surgical ICU.

Patients:

All mechanically ventilated patients.

Interventions:

The Respiratory Knowledge Portal was implemented in our ICU. For 13 months, Respiratory Knowledge Portal data were ported to ICU workstations (control). For the following 11 months, Respiratory Knowledge Portal data were also presented on tablet computers (intervention) for use during multidisciplinary rounds. We performed a retrospective review of Respiratory Knowledge Portal data from before and after the implementation of the tablet computers.

Measurements and Main Results:

Data were collected from 337 patients (187 control group, 150 intervention group). A decrease in the occurrence of ventilator-associated events was observed during the intervention group compared with the control group. Only 2.0% of patients in the intervention group experienced any category of ventilator-associated event, while 11.2% of patients in the control group experienced one event (p = 0.003). Intervention patients experienced less ventilator-associated conditions (p = 0.002), infection-related ventilator-associated conditions (p = 0.026), and probable ventilator-associated pneumonias (p = 0.036) than control patients. Twenty-one of the 24 patients with any ventilator-associated events were in the control group. There was no significant difference between the days spent on ventilation nor hospital length of stay in the control compared with intervention group patients.

Conclusions:

Fewer ventilator-associated events, ventilator-associated conditions, infection-related ventilator-associated conditions, and probable ventilator-associated pneumonias were seen during the period when Respiratory Knowledge Portal monitoring data was presented on tablet computers. There was no difference in time on ventilator nor overall length of stay.

Mechanical ventilation strategy for pulmonary rehabilitation based on patient-ventilator interaction

Mechanical ventilation is an effective medical means in the treatment of patients with critically ill, COVID-19 and other pulmonary diseases. During the mechanical ventilation and the weaning process, the conduct of pulmonary rehabilitation is essential for the patients to improve the spontaneous breathing ability and to avoid the weakness of respiratory muscles and other pulmonary functional trauma. However, inappropriate mechanical ventilation strategies for pulmonary rehabilitation often result in weaning difficulties and other ventilator complications. In this article, the mechanical ventilation strategies for pulmonary rehabilitation are studied based on the analysis of patient-ventilator interaction. A pneumatic model of the mechanical ventilation system is established to determine the mathematical relationship among the pressure, the volumetric flow, and the tidal volume. Each ventilation cycle is divided into four phases according to the different respiratory characteristics of patients, namely, the triggering phase, the inhalation phase, the switching phase, and the exhalation phase. The control parameters of the ventilator are adjusted by analyzing the interaction between the patient and the ventilator at different phases. A novel fuzzy control method of the ventilator support pressure is proposed in the pressure support ventilation mode. According to the fuzzy rules in this research, the plateau pressure can be obtained by the trigger sensitivity and the patient's inspiratory effort. An experiment prototype of the ventilator is established to verify the accuracy of the pneumatic model and the validity of the mechanical ventilation strategies proposed in this article. In addition, through the discussion of the patient-ventilator asynchrony, the strategies for mechanical ventilation can be adjusted accordingly. The results of this research are meaningful for the clinical operation of mechanical ventilation. Besides, these results provide a theoretical basis for the future research on the intelligent control of ventilator and the automation of weaning process.

Evaluation of the Perceived Barriers and Facilitators to Timely Extubation of Critically Ill Adults: An Interprofessional Survey

BACKGROUND

Spontaneous breathing trials (SBTs) are an evidence-based way of identifying patients ready for mechanical ventilation (MV) liberation. Despite their effectiveness, global SBT performance rates remain suboptimal, and many patients who demonstrate the ability to breathe on their own remain on MV. The factors that influence clinicians' decision to discontinue MV following a successful SBT remain unclear.

AIMS

The aim of this study was to explore the underlying causes of extubation delays in the intensive care unit (ICU) from an interprofessional perspective.

METHODS

An exploratory, descriptive, cross-sectional design was used. An online survey was administered in December 2019 to clinicians practicing in three ICUs at a single medical center in the U.S. Survey questions focused on clinicians' perceptions of current MV liberation practices and perceived barriers or facilitators to timely extubation after a successful SBT.

RESULTS

Of 425 eligible clinicians, 135 completed the survey (31.7% response rate). The majority of clinicians believed the current SBT and extubation process took too long (n = 108; 80.0%) and that this delay negatively affected patient outcomes. While professional groups differed in their rankings of importance, factors perceived to contribute to extubation delays most commonly included SBT timing, low provider confidence levels in making extubation decisions, and patient-specific factors. Potential strategies to overcome these barriers included developing an automated extubation protocol, performing SBTs when the provider responsible for final extubation decisions is physically present, and decreasing clinician perception of reprimand or condemnation for failed extubations.

LINKING EVIDENCE TO ACTION

The MV liberation process is complex and dependent on the decisions of various ICU professionals. Clinicians perceive a number of potentially modifiable provider- and organizational-level factors that cause extubation delays in everyday practice. Understanding and addressing these barriers is essential for improving ICU quality and patient outcomes. Future research should explore the effect of nurse and respiratory therapist-driven extubation protocols on MV liberation rates.

Extubation in the pediatric intensive care unit: predictive methods. An integrative literature review

For extubation in pediatric patients, the evaluation of readiness is strongly recommended. However, a device or practice that is superior to clinical judgment has not yet been accurately determined. Thus, it is important to conduct a review on the techniques of choice in clinical practice to predict extubation failure in pediatric patients. Based on a search in the PubMed®, Biblioteca Virtual em Saúde, Cochrane Library and Scopus databases, we conducted a survey of the predictive variables of extubation failure most commonly used in clinical practice in pediatric patients. Of the eight predictors described, the three most commonly used were the spontaneous breathing test, the rapid shallow breathing index and maximum inspiratory pressure. Although the disparity of the data presented in the studies prevented statistical treatment, it was still possible to describe and analyze the performance of these tests.

Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design

OBJECTIVE

To identify factors associated with the ABCDEF bundle (Assess, prevent, and manage pain, Both, spontaneous awakening and breathing trials, Choice of sedation/analgesia, Delirium assess, prevent and manage, Early mobility/exercise and Family engagement/empowerment) adherence, in critically ill patients during the first 96 hours of mechanical ventilation.

DESIGN

Observational study using electronic health record data.

SETTING

15 intensive care units located in seven community hospitals in a western United States health system.

PATIENTS

977 adult patients who were on mechanical ventilation for greater than 24 hours and admitted to an intensive care unit over six months.

MEASUREMENTS AND MAIN RESULTS

Multiple regression analysis was used to examine factors contributing to bundle adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed. ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = 0.01), who received continuous sedation for less than 24 hours (p < 0.001), admitted from skilled nursing facilities (p < 0.05), and over the course of the six-month study period (p < 0.01). Bundle adherence was significantly lower for Hispanic patients (p < 0.01).

CONCLUSIONS

Our study identified potentially modifiable factors that could improve the team's performance of the ABCDEF bundle in patients requiring mechanical ventilation.

Gaps between current clinical practice and evidence-based guidelines for treatment and care of older patients with Community Acquired Pneumonia: a descriptive cross-sectional study

Background

Community acquired pneumonia (CAP) remains a significant cause of morbidity and in-hospital mortality, and readmission rates are rising for older persons (> 65 years). Optimized treatment and nursing care will benefit patients and the health economy. Hence, there is a need to describe gaps between current clinical practice and recommendations in evidence-based guidelines for diagnostic procedures, medical treatment and nursing interventions for older patients with CAP.

Methods

Structured observations, individual ad hoc interviews and audits of patient records were carried out in an emergency department and three medical units. Data were analysed by manifest content analysis and descriptive statistics.

Results

Thirty patients (median age 74 years) admitted with CAP and 86 physicians, nurses, physiotherapists were included. The median length of stay (LOS) was 6.5 days, in-hospital mortality was10 and 40.7% were readmitted within one month. The severity assessment tool (CURB-65) was used in 16.7% of the patients, correct antibiotic treatment prescribed for 13.3% and chest radiography (≤6 weeks post-discharge) prescribed for 22.2%. Fluid therapy, nutrition support and mobilisation plans were found to be developed sporadically, and interventions to be performed unsystematically and sparingly. Positive Expiratory Pressure therapy and oral care were the nursing interventions with lowest adherence, ranging from 18.2 to 55.6%.

Conclusions

Adherence to recommendations was low for several central treatment and nursing care interventions for patients with CAP with possible consequences for patients and the use of resources. Thus, there is an urgent need to identify and remove barriers to adherence to recommendations in the neglected areas in view of the potential to improve patient outcomes.

Effects of an extubation readiness test protocol at a tertiary care fully outborn neonatal intensive care unit

Background and objectives

Extubation readiness testing (ERT) in the Neonatal Intensive Care Unit (NICU) is highly variable and lacking standardized criteria. To address this gap, an evidence-based, inter-professionally developed ERT protocol was implemented to assess effectiveness on extubation failure within 72 h and on duration of intubation (DOI).

Methods

A longitudinal retrospective chart review in a level III, fully outborn NICU, of intubated infants admitted 1-year prior (Group 1), and 1 year after implementation (Group 2). Patients were extubated if they passed a 2-stage ERT protocol (3 min continuous positive airway pressure (CPAP) followed by 7 min CPAP + pressure support). Descriptive, comparative statistics, and univariate and multiple logistic regression were completed on all patients and a ≤32 6/7 weeks subgroup (intubated at day-of-life 1); p < 0.05 is considered significant.

Results

All patients (n = 589 (n = 294 Group 1, n = 295 Group 2)) were included (preterm, intubated day of life one subgroup: n = 42 Group 1, n = 38 Group 2). For all patients, extubation failure decreased significantly from 9.9% to 4.1% (p = 0.006); Group 1 patients were 2.42 times more likely to experience extubation failure compared with Group 2. Extubation failure in the preterm subgroup decreased from 21.7% to 2.6% (p = 0.01); Group 1 patients were 10.71 times more likely to experience extubation failure. Median DOI was similar in both groups for all patients and in the preterm subgroup.

Conclusions

A unique two-stage ERT protocol was effective at reducing extubation failure rate, without increasing DOI, largely in preterm infants. The evidence-based, interprofessionally developed ERT protocol and its integration into the NICU culture largely contributed to its success.

Critical Care Organizations: Building and Integrating Academic Programs

OBJECTIVE

Academic medical centers in North America are expanding their missions from the traditional triad of patient care, research, and education to include the broader issue of healthcare delivery improvement. In recent years, integrated Critical Care Organizations have developed within academic centers to better meet the challenges of this broadening mission. The goal of this article was to provide interested administrators and intensivists with the proper resources, lines of communication, and organizational approach to accomplish integration and Critical Care Organization formation effectively.

DESIGN

The Academic Critical Care Organization Building section workgroup of the taskforce established regular monthly conference calls to reach consensus on the development of a toolkit utilizing methods proven to advance the development of their own academic Critical Care Organizations. Relevant medical literature was reviewed by literature search. Materials from federal agencies and other national organizations were accessed through the Internet.

SETTING

The Society of Critical Care Medicine convened a taskforce entitled "Academic Leaders in Critical Care Medicine" on February 22, 2016 at the 45th Critical Care Congress using the expertise of successful leaders of advanced governance Critical Care Organizations in North America to develop a toolkit for advancing Critical Care Organizations.

MEASUREMENTS AND MAIN RESULTS

Key elements of an academic Critical Care Organization are outlined. The vital missions of multidisciplinary patient care, safety, and quality are linked to the research, education, and professional development missions that enhance the value of such organizations. Core features, benefits, barriers, and recommendations for integration of academic programs within Critical Care Organizations are described. Selected readings and resources to successfully implement the recommendations are provided. Communication with medical school and hospital leadership is discussed.

CONCLUSIONS

We present the rationale for critical care programs to transition to integrated Critical Care Organizations within academic medical centers and provide recommendations and resources to facilitate this transition and foster Critical Care Organization effectiveness and future success.

Patient and family-initiated escalation of care: a qualitative systematic review protocol

BACKGROUND

Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. This systematic review will address this gap. The aim of this review is to explore patients', relatives' and healthcare professionals' experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We will search Medline, CINAHL, Embase and PsycINFO databases using free-text and MESH terms relating to deterioration, family-initiated rapid response, families, patients, healthcare staff, hospital and experiences. We will search grey literature and reference lists of included studies for further published and unpublished literature. All studies with a qualitative design or method will be included. Two reviewers will independently assess studies for eligibility, extract data and appraise the quality of included studies. Data will be synthesised using a thematic synthesis approach, and findings will be presented narratively.

DISCUSSION

Patient- and family-initiated escalation of care schemes have been developed and implemented in several countries including the United States, the United Kingdom and Australia, but there is limited evidence regarding patients' or families' perceptions of deterioration or the barriers and facilitators to using these schemes in practice, particularly in acute adult areas. This systematic review will provide evidence for the development of a patient and family escalation of care scheme that can be tested in a feasibility study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018106952.

Global Critical Care: Moving Forward in Resource-Limited Settings

Caring for critically ill patients is challenging in resource-limited settings, where the burden of disease and mortality from potentially treatable illnesses is higher than in resource-rich areas. Barriers to delivering quality critical care in these settings include lack of epidemiologic data and context-specific evidence for medical decision-making, deficiencies in health systems organization and resources, and institutional obstacles to implementation of life-saving interventions. Potential solutions include the development of common definitions for intensive care unit (ICU), intensivist, and intensive care to create a universal ICU organization framework; development of educational programs for capacity building of health care professionals working in resource-limited settings; global prioritization of epidemiologic and clinical research in resource-limited settings to conduct timely and ethical studies in response to emerging threats; adaptation of international guidelines to promote implementation of evidence-based care; and strengthening of health systems that integrates these interventions. This manuscript reviews the field of global critical care, barriers to safe high-quality care, and potential solutions to existing challenges. We also suggest a roadmap for improving the treatment of critically ill patients in resource-limited settings.

Why do we fail to deliver evidence-based practice in critical care medicine?

PURPOSE OF REVIEW

The use of evidence-based practices in clinical practice is frequently inadequate. Recent research has uncovered many barriers to the implementation of evidence-based practices in critical care medicine. Using a comprehensive conceptual framework, this review identifies and classifies the barriers to implementation of several major critical care evidence-based practices.

RECENT FINDINGS

The many barriers that have been recently identified can be classified into domains of the consolidated framework for implementation research (CFIR). Barriers to the management of patients with acute respiratory distress syndrome (ARDS) include ARDS under-recognition. Barriers to the use of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle for mechanically ventilated patients and the sepsis bundle include patient-related, clinician-related, protocol-related, contextual-related, and intervention-related factors. Although these many barriers can be classified into all five CFIR domains (intervention, outer setting, inner setting, individuals, and process), most barriers fall within the individuals and inner setting domains.

SUMMARY

There are many barriers to the implementation of evidence-based practice in critical care medicine. Systematically classifying these barriers allows implementation researchers and clinicians to design targeted implementation strategies, giving them the greatest chance of success in improving the use of evidence-based practice.

What are the experiences of seeking, receiving and providing FGM-related healthcare? Perspectives of health professionals and women/girls who have undergone FGM: protocol for a systematic review of qualitative evidence

INTRODUCTION

Female genital mutilation (FGM) is an issue of global concern. High levels of migration mean that healthcare systems in higher-income western countries are increasingly being challenged to respond to the care needs of affected communities. Research has identified significant challenges in the provision of, and access to, FGM-related healthcare. There is a lack of confidence and competence among health professionals in providing appropriate care, suggesting an urgent need for evidence-based service development in this area. This study will involve two systematic reviews of qualitative evidence to explore the experiences, needs, barriers and facilitators to seeking and providing FGM-related healthcare in high-income (Organisation for Economic Cooperation and Development) countries, from the perspectives of: (1) women and girls who have undergone FGM and (2) health professionals.

REVIEW METHODS

Twelve databases including MEDLINE, EMBASE, PsycINFO, ASSIA, Web of Science, ERIC, CINAHL, and POPLINE will be searched with no limits on publication year. Relevant grey literature will be identified from digital sources and professional networks.Two reviewers will independently screen, select and critically appraise the studies. Study quality will be assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument appraisal tool. Findings will be extracted into NVivo software. Synthesis will involve inductive thematic analysis, including in-depth reading, line by line coding of the findings, development of descriptive themes and re-coding to higher level analytical themes. Confidence in the review findings will be assessed using the CERQual approach. Findings will be integrated into a comprehensive set of recommendations for research, policy and practice.

DISSEMINATION

The syntheses will be reported as per the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. Two reviews will be published in peer-reviewed journals and an integrated report disseminated at stakeholder engagement events.

PROSPEROREGISTRATION NUMBER

CRD42015030001: 2015 and CRD42015030004: 2015.

Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review

BACKGROUND

Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation.

METHODS

We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved.

RESULTS

Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination).

CONCLUSIONS

We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative evidence-synthesis

BACKGROUND

Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions.

OBJECTIVES

1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used.

SEARCH METHODS

We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.We reran the search on 3rd July 2016 and found three studies, which are awaiting classification.

SELECTION CRITERIA

We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation.

DATA COLLECTION AND ANALYSIS

At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews.

MAIN RESULTS

We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as 'low', 13 as 'moderate' and five as 'high' confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents.

AUTHORS' CONCLUSIONS

There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of 'ownership'. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.

Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients

BACKGROUND

This is an update of a review last published in Issue 5, 2010, of The Cochrane Library. Reducing weaning time is desirable in minimizing potential complications from mechanical ventilation. Standardized weaning protocols are purported to reduce time spent on mechanical ventilation. However, evidence supporting their use in clinical practice is inconsistent.

OBJECTIVES

The first objective of this review was to compare the total duration of mechanical ventilation of critically ill adults who were weaned using protocols versus usual (non-protocolized) practice.The second objective was to ascertain differences between protocolized and non-protocolized weaning in outcomes measuring weaning duration, harm (adverse events) and resource use (intensive care unit (ICU) and hospital length of stay, cost).The third objective was to explore, using subgroup analyses, variations in outcomes by type of ICU, type of protocol and approach to delivering the protocol (professional-led or computer-driven).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2014), MEDLINE (1950 to January 2014), EMBASE (1988 to January 2014), CINAHL (1937 to January 2014), LILACS (1982 to January 2014),  ISI Web of Science and ISI Conference Proceedings (1970 to February 2014), and reference lists of articles. We did not apply language restrictions. The original search was performed in January 2010 and updated in January 2014.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs of protocolized weaning versus non-protocolized weaning from mechanical ventilation in critically ill adults.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We performed a priori subgroup and sensitivity analyses. We contacted study authors for additional information.

MAIN RESULTS

We included 17 trials (with 2434 patients) in this updated review. The original review included 11 trials. The total geometric mean duration of mechanical ventilation in the protocolized weaning group was on average reduced by 26% compared with the usual care group (N = 14 trials, 95% confidence interval (CI) 13% to 37%, P = 0.0002). Reductions were most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. Weaning duration was reduced by 70% (N = 8 trials, 95% CI 27% to 88%, P = 0.009); and ICU length of stay by 11% (N = 9 trials, 95% CI 3% to 19%, P = 0.01). There was significant heterogeneity among studies for total duration of mechanical ventilation (I(2) = 67%, P < 0.0001) and weaning duration (I(2) = 97%, P < 0.00001), which could not be explained by subgroup analyses based on type of unit or type of approach.

AUTHORS' CONCLUSIONS

There is evidence of reduced duration of mechanical ventilation, weaning duration and ICU length of stay with use of standardized weaning protocols. Reductions are most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. However, significant heterogeneity among studies indicates caution in generalizing results. Some study authors suggest that organizational context may influence outcomes, however these factors were not considered in all included studies and could not be evaluated. Future trials should consider an evaluation of the process of intervention delivery to distinguish between intervention and implementation effects. There is an important need for further development and research in the neurosurgical population.

Celebrating methodological challenges and changes: reflecting on the emergence and importance of the role of qualitative evidence in Cochrane reviews

Cochrane systematic reviews have proven to be beneficial for decision making processes, both on a practitioner and a policy level, and there are current initiatives to extend the types of evidence used by them, including qualitative research. In this article we outline the major achievements of the Cochrane Qualitative and Implementation Methods Group. Although the Group has encountered numerous challenges in dealing with the evolution of qualitative evidence synthesis, both outside and within the Cochrane Collaboration, it has successfully responded to the challenges posed in terms of incorporating qualitative evidence in systematic reviews. The Methods Group will continue to advocate for more flexible and inclusive approaches to evidence synthesis in order to meet the exciting challenges and opportunities presented by mixed methods systematic reviews and reviews of complex interventions.