Using protocols to improve the outcomes of mechanically ventilated patients. Focus on weaning and sedation

Protocol-Driven Ventilator Management in Children: Comparison to Nonprotocol Care

The purpose of this study was to compare ventilator weaning time, time to spontaneous breathing, and overall ventilator hours duration with use of a ventilator management protocol (VMP) versus standard nonprotocol-based care in a pediatric intensive care unit. A multidisciplinary task force developed a comprehensive protocol for ventilator management with four specific phases: initial ventilator set up and adjustment, weaning, minimal settings, and spontaneous mode prior to extubation. Medical records of ventilated patients both before and after protocol implementation were reviewed. A total of 187 patients were studied (89 nonprotocol and 98 VMP patients). No differences were seen between groups in PRISM scores, Murray scores, or oxygenation indices, but VMP patients were significantly younger (P= .03). Ventilator weaning times (P= .005) and time to spontaneous breathing modes (P= .006) were significantly decreased in VMP patients compared to nonprotocol patients, but overall ventilator duration was not significantly different. No significant differences were seen in extubation failure, use of corticosteroids, or use of racemic epinephrine between groups. Use of an institution-specific VMP developed by a multidisciplinary team was associated with significantly reduced ventilator weaning time and time to spontaneous breathing. Further studies are needed.

Emergency nurses practices in assessing and administering continuous intravenous sedation for critically ill adult patients: a retrospective record review'

AIM

To generate an initial profile of emergency nurses' practices in and factors influencing the assessment and administration of continuous intravenous sedation and analgesia for critically ill mechanically ventilated adult patients.

BACKGROUND

Emergency nurses are relied upon to assess and manage critically ill patients, some of whom require continuous intravenous sedation. Balancing sedation is a highly complex activity. There is however little evidence relating to how emergency nurses manage continuous intravenous analgesia and sedation for the critically ill intubated patients.

DESIGN

Descriptive study.

METHOD

A 12-month retrospective medical record review was undertaken from January to December 2009 of patients (>16 years) administered continuous intravenous sedation in ED.

RESULTS

Fifty-five patients received ongoing intravenous sedation within the ED during a median length of stay of 3.4 h. Assessment of patient depth/quality of sedation and pain-relief varied and were rarely documented. Adverse events were documented, majority (16%) drug administration related. Thematic analysis identified three themes: 'Maintaining sedation', 'Directionless-directions', and 'Navigating the balance'.

CONCLUSION

Emergency nurses provide continuity of patient care and optimisation of analgesia and sedation for critically ill sedated patients. The safety and effectiveness of continuous intravenous sedation for the critically ill adult patient in ED are dependent on the expertise and decision-making abilities of the nurse.

ABCDEs of ICU: Early mobility

The intensive care unit (ICU) provides a critical level of care to medically unstable patients. Patients need intensive monitoring and treatment that may require emergency interventions. The vulnerability and complexity of the ICU unintentionally creates an environment that limits and poorly defines the intervention of early mobility in the unstable critically ill patients. The short- and long-term effects of immobility and bed rest increase acute complications, the length of stay in the ICU and hospital, and mortality and morbidity rates. According to current research, instituting early mobility programs can improve patient outcomes. Current research has demonstrated the safety and feasibility of the initiation of early mobility programs in the critically ill. The benefits to patients enhance recovery of functional exercise capacity, weaning outcomes, self-perceived functional status, and muscle force and strength. Consequently, patient's length of stay in the ICU and in hospital decreases and improves health outcomes. The scope of practice for nurses and other health care providers should guide by evidenced-based research to reduce complications and enhance patient outcomes. Further research is necessary to establish and institute policies and protocols on early mobility programs in the ICU to direct patient care. The role of the clinical nurse specialist can contribute by conducting evidence-based research, educating health care providers and patients, and implementing protocols. The hope is to change the culture of the ICU for the better.

Proactive clinical pharmacist interventions in critical care: effect of unit speciality and other factors

BACKGROUND

Clinical pharmacists working in critical-care areas have a beneficial effect on a range of medication-related therapies including improving medication safety, patient outcomes and reducing medicines' expenditure. However, there remains a lack of data on specific factors that affect the reason for and type of interventions made by clinical pharmacists, such as unit speciality.

OBJECTIVE

To compare the type of proactive medicines-related interventions made by clinical pharmacists on different critical-care units within the same institution.

METHODS

A retrospective evaluation of proactive clinical pharmacist recommendations, made in three separate critical-care areas. Intervention data were analysed over 18 months (general units) and 2 weeks for the cardiac and neurological units. Assessment of potential patient harm related to the medication interventions were made in the neurological and cardiac units.

KEY FINDINGS

Overall, 5623, 211 and 156 proactive recommendations were made; on average 2.2, 3.8 and 4.6 per patient from the general, neurological and cardiac units respectively. The recommendations acceptance rate by medical staff was approximately 90% for each unit. The median potential severity of patient harm averted by the interventions were 3.6 (3; 4.2) and 4 (3.2; 4.4) for the neurological and cardiac units (P = 0.059). The reasons for, types and drug classification of the medication recommendations demonstrated some significant differences between the units.

CONCLUSIONS

Clinical pharmacists with critical-care training make important medication recommendations across general and specialist critical-care units. The patient case mix and admitting speciality have some bearing on the types of medication interventions made. Moreover, severity of patient illness, scope of regular/routine specialist pharmacist service and support systems provided also probably affect the reason for these interventions.

Sedation in adults receiving mechanical ventilation: physiological and comfort outcomes

OBJECTIVE

To describe the relationships among sedation, stability in physiological status, and comfort during a 24-hour period in patients receiving mechanical ventilation.

METHODS

Data from 169 patients monitored continuously for 24 hours were recorded at least every 12 seconds, including sedation levels, physiological status (heart rate, respiratory rate, oxygen saturation by pulse oximetry), and comfort (movement of arms and legs as measured by actigraphy). Generalized linear mixed-effect models were used to estimate the distribution of time spent at various heart and respiratory rates and oxygen saturation and actigraphy intervals overall and as a function of level of sedation and to compare the percentage of time in these intervals between the sedation states.

RESULTS

Patients were from various intensive care units: medical respiratory (52%), surgical trauma (35%), and cardiac surgery (13%). They spent 42% of the time in deep sedation, 38% in mild/moderate sedation, and 20% awake/alert. Distributions of physiological measures did not differ during levels of sedation (deep, mild/moderate, or awake/alert: heart rate, P = .44; respirations, P = .32; oxygen saturation, P = .51). Actigraphy findings differed with level of sedation (arm, P < .001; leg, P = .01), with less movement associated with greater levels of sedation, even though patients spent the vast majority of time with no arm movement or leg movement.

CONCLUSIONS

Level of sedation most likely does not affect the stability of physiological status but does have an effect on comfort.

Pharmacist proactive medication recommendations using electronic documentation in a UK general critical care unit

BACKGROUND

Specific data on the actual clinical practice of United Kingdom pharmacists in Critical Care are limited. Within the general critical care units of Sheffield Teaching Hospitals, clinical pharmacists have the facility to electronically document, communicate and follow-up proactive recommendations using a Pharmacy Review Form via the Clinical Information System, MetaVision(®).

OBJECTIVE

The objective of the service evaluation was to describe the acceptance rate by medical staff of pharmacist proactive medication recommendations; including data on the types of recommendations and reasons thereof, for general intensive care patients of a UK teaching hospital trust.

SETTING

Sheffield Teaching Hospitals National Health Service Foundation Trust with 20 intensive care beds located on two hospital sites admitting Level 3 and 2 mixed general medical, surgical, trauma, burns and haematology/ oncology patients.

METHOD

Retrospective analysis of pharmacist proactive recommendations recorded electronically from January 2009 to July 2011 in general intensive care unit patients. Main outcome 5,623 electronic medication recommendations were documented, providing an average of 2.2 proactive recommendations per patient admitted to intensive care from January 2009 to July 2011. 5,101 (90.7%) of the recommendations were accepted and acted upon by medical staff.

RESULTS

The most common recommendations were Add Drug 1,862 (28.2%); Dose Review 1,707 (25.8%); Discontinue Drug 1,185 (17.9%); Alternative Drug 903 (13.7%); Alternative Route 770 (11.7%). The most common reasons for the proactive medication recommendations were related to changes in gastrointestinal absorption 951 (15.6%); compliance with medication guidelines 857 (14.1%); sedation/delirium/agitation management 764 (12.6%); dose adjustment for renal dysfunction or continuous renal replacement therapies 756 (12.4%); and medication reconciliation 612 (10.1%). The majority of medication recommendations involved drugs in Gastrointestinal, Central Nervous System, Cardiovascular, Infection, Nutrition and Blood classes (British National Formulary).

CONCLUSION

There was a high acceptance rate for proactive medication-related recommendations made by critical care pharmacists via the electronic review form. The majority of pharmacist recommendations were related to adding or refining currently prescribed medication. Ten percent of recommendations related to medication reconciliation of patients' pre-admission medication.

Multidisciplinary team developed and implemented protocols to assist mechanical ventilation weaning: a systematic review of literature

AIM

The aim of this review was to determine if ventilation-weaning protocols developed and implemented by multidisciplinary teams (MDTs) reduced the duration of mechanical ventilation in adult intensive care patients compared to usual care.

METHOD

A systematic review was conducted to review published research studies from January 1999 to June 2009 to identify and analyse the best available evidence on MDT-based weaning protocols in adult intensive care patients. All relevant studies based on electronic searches of MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Registry and the Cochrane Database of Systematic Reviews were included. Where possible data were pooled and a meta-analysis performed. A narrative synthesis of data was conducted to provide a critical appraisal of nonrandomised controlled trials included in the review.

RESULTS

Three pre- and postinterventional studies were identified for inclusion in this review. Results show equivocal support for weaning protocols developed and implemented by MDTs for reducing duration of mechanical ventilation.

CONCLUSION

Communication and organizational processes must be addressed for multidisciplinary protocols to be effective. Due to methodological limitations of included studies, large randomised controlled trials are required to provide high-level evidence of the effects of MDT-based protocols on duration of mechanical ventilation.

Physicians' perceptions of protocol-directed weaning in an intensive care unit in Norway

The aim of this paper is to identify physicians' perceptions of protocol-directed weaning from mechanical ventilation in an intensive care unit in Norway. Errors occur in the absence of procedures, plans, and a team culture. Standardized weaning protocols, or pathways, offer a systematic approach. The focus group method was used. Four themes emerged: (i) acceptance, where the participants perceived the protocol as having a positive influence on the weaning process, although some barriers were identified, such as its failure to facilitate the "difficult-to-wean" patient; (ii) indignant responses, which gave the impression that the protocol was prescribed for the benefit of the nurses; (iii) ambivalence was evident in the two different approaches to the weaning process when problems occurred, which were "directing" and "collaborating"; and (iv) continuity and professional competence were perceived as important aspects of the weaning process. An unclear pattern of responsibility and poor interprofessional collaboration and communication were reported.

Not-so-trivial pursuit: mechanical ventilation risk reduction

As many as half of critically ill patients require mechanical ventilation. In this article, a program of research focused on reduction of risk associated with mechanical ventilation is reviewed. Airway management practices can have profound effects on outcomes in these patients. How patients are suctioned, types of processes used, effects of suctioning in patients with lung injury, and open versus closed suctioning systems all have been examined to determine best practices. Pneumonia is a common complication of mechanical ventilation (ventilator-associated pneumonia), and use of higher backrest elevations reduces risk of pneumonia, although compliance with such recommendations varies. The studies reviewed here describe backrest elevation practices, factors that affect backrest elevation, and the effect of backrest elevation on ventilator-associated pneumonia. Oral care strategies also have been investigated to determine their effect on ventilator-associated pneumonia. Oral care practices are reported to hold a low care priority, vary widely across care providers, and differ in intubated versus nonintubated patients. However, in several studies, oral applications of chlorhexidine have reduced the occurrence of ventilator-associated pneumonia. Although ventilator patients require sedation, sedation is associated with significant risks. The overall goals of sedation are to provide physiological stability, to maintain ventilator synchrony, and to ensure patients' comfort-although methods to evaluate achievement of these goals are limited. Reducing risks associated with mechanical ventilation in critically ill patients is a complex and interdisciplinary process. Our understanding of the risks associated with mechanical ventilation is constantly changing, but care of these patients must be based on the best evidence.

Dissemination of research-based knowledge in an intensive care unit-a qualitative study

BACKGROUND

A gap exists between best evidence and best practice in intensive care units. The aim of this study was to investigate different aspects of intensive care nurses' and physicians' inter- and intraprofessional collaboration, with focus on factors associated with standardised weaning from mechanical ventilation.

METHODS

A qualitative design was used for implementing research-based knowledge into multistage focus group discussions. Data were analysed by means of qualitative content analysis.

RESULTS

One main theme emerged: The need for strategies aimed at improving quality control of care, and three sub-themes: 'Interprofessional learning', 'Quality control of care', and 'Teamwork and communication'. The multistage focus groups were perceived as an important interprofessional arena for improving quality of care. Improvement projects and research dissemination must be regarded as vital parts of the organisation's ongoing development work. Management was perceived as crucial for success.

CONCLUSION

Interprofessional research dissemination was perceived as important both in the creation of a common understanding and in knowledge development. Managers should make use of the valuable knowledge possessed by bedside professionals in their strategic planning. There is a need to allocate time for learning and reflection to provide a safe practice environment.

Mechanical ventilation in the ICU--is there a gap between the time available and time used for nurse-led weaning?

BACKGROUND

Mechanical ventilation (MV) is a key component in the care of critically ill and injured patients. Weaning from MV constitutes a major challenge in intensive care units (ICUs). Any delay in weaning may increase the number of complications and leads to greater expense. Nurse-led, protocol-directed weaning has become popular, but it remains underused. The aim of this study was to identify and quantify discrepancies between the time available for weaning and time actually used for weaning. Further, we also wished to analyse patient and systemic factors associated with weaning activity.

METHODS

This retrospective study was performed in a 12-bed general ICU at a university hospital. Weaning data were collected from 68 adult patients on MV and recorded in terms of ventilator-shifts. One ventilator-shift was defined as an 8-hour nursing shift for one MV patient.

RESULTS

Of the 2000 ventilator-shifts analysed, 572 ventilator-shifts were available for weaning. We found that only 46% of the ventilator shifts available for weaning were actually used for weaning. While physician prescription of weaning was associated with increased weaning activity (p < 0.001), a large amount (22%) of weaning took place without physician prescription. Both increased nursing workload and night shifts were associated with reduced weaning activity. During the study period there was a significant increase in performed weaning, both when prescribed or not (p < 0.001).

CONCLUSION

Our study identified a significant gap between the time available and time actually used for weaning. While various patient and systemic factors were linked to weaning activity, the most important factor in our study was whether the intensive care nurses made use of the time available for weaning.

Effect of acute kidney injury on weaning from mechanical ventilation in critically ill patients*

OBJECTIVES

Acute kidney injury (AKI) worsens outcome in various scenarios. We sought to investigate whether the occurrence of AKI has any effect on weaning from mechanical ventilation.

DESIGN AND SETTING

Observational, retrospective study in a 23-bed medical/surgical intensive care unit (ICU) in a cancer hospital from January to December 2003.

PATIENTS

The inclusion criterion was invasive mechanical ventilation for > or =48 hrs. AKI was defined as at least one measurement of serum creatinine of > or =1.5 mg/dL during the ICU stay. Patients were then separated into AKI and non-AKI patients (control group). The criterion for weaning was the combination of positive end-expiratory pressure of < or =8 cm H2O, pressure support of < or =10 cm H2O, and Fio2 of < or =0.4, with spontaneous breathing. The primary end point was duration of weaning and the secondary end points were rate of weaning failure, total length of mechanical ventilation, length of stay in the ICU, and ICU mortality.

RESULTS

A total of 140 patients were studied: 93 with AKI and 47 controls. The groups were similar in regard to age, sex, and type of tumor. Diagnosis of acute lung injury/acute respiratory distress syndrome as cause of respiratory failure and Simplified Acute Physiology Score II at admission did not differ between groups. During ICU stay, AKI patients had markers of more severe disease: increased occurrence of severe sepsis or septic shock, higher number of antibiotics, and longer use of vasoactive drugs. The median (interquartile range) duration of mechanical ventilation (10 [6-17] vs. 7 [2-12] days, p = .017) and duration of weaning from mechanical ventilation (41 [16-97] vs. 21 [7-33.5] hrs, p = .018) were longer in AKI patients compared with control patients. Cox regression analysis demonstrated that a > or =85% increase in baseline serum creatinine (hazard rate, 2.30; 95% confidence interval, 1.30-4.08), oliguria (hazard rate, 2.51; 95% confidence interval, 1.24-5.08), and the number of antibiotics (hazard rate, 2.64; 95% confidence interval, 1.51-4.63) predicted longer duration of weaning. The length of ICU stay and ICU mortality rate were significantly greater in the AKI patients. After adjusting for Simplified Acute Physiology Score II, oliguria (odds ratio, 30.8; 95% confidence interval, 7.7-123.0) remained as a strong risk factor for mortality.

CONCLUSION

This study shows that renal dysfunction has serious consequences in the duration of mechanical ventilation, weaning from mechanical ventilation, and mortality in critically ill cancer patients.

Nursing care of the mechanically ventilated patient: what does the evidence say? Part two

The care of the mechanically ventilated patient is a fundamental component of a nurse's clinical practice in the intensive care unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly, yet is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient was explored with specific focus on patient safety: particularly patient and equipment assessment. This article, part two, examines the evidence related to the mechanically ventilated patient's comfort: patient position, hygiene, management of stressors (such as communication, sleep disturbance and isolation), pain management and sedation.

Investigating nurses' perceptions of their role in managing sedation in intensive care: an exploratory study

Most patients who are admitted to intensive care in need of ventilator support may also require sedation. It is a part of the nurses' role to manage sedation therapy according to patients' needs, avoiding complications of over and under sedation. The purpose of the study was to explore nurses' perceptions of their role in sedation management. A convenience sample of 107 registered nurses in the intensive care unit of a large teaching hospital was accessed and a response rate of 86% (n=92) obtained. Results showed that the nurse has a major role in sedation management in the critically ill patient. Sedation scoring is used in the assessment of the patient's sedation level and sedation is then titrated by the nurse in collaboration with medical staff to an agreed target level. However, the impact of this role depends on the experience and confidence of the nurse as knowledge and skills are required in order to provide effective sedation for patients. Recommendations from this study are to incorporate a team approach within a locally devised sedation protocol. This should be supported by an education programme aiming to improve decision-making about sedation management at the bedside.

Prospective Evaluation of an Extubation Protocol in a Trauma Intensive Care Unit Population

Little data exists regarding extubation protocols in critically injured trauma patients. The objective of the current study was to prospectively examine the impact of implementing an extubation protocol on the outcomes of ventilated trauma patients in a surgical intensive care unit (STICU). Trauma patients admitted to the STICU over a 15-month period at a Level 1 trauma center were prospectively evaluated. The total period was divided into an education and institution period (April 2002–November 2003) and an evaluation period (December 2003–July 2003). Patient demographics, hospital course, complications, and outcomes from period I were compared with those obtained during period II. From April 8, 2002 through July 5, 2003, 69 patients intubated for greater than 24 hours were included in our analysis. Thirty-three were treated during period I and 36 were treated during period II. Both groups were well matched in terms of age, sex, Injury Severity Score, and chest Abbreviated Injury Score. Ventilation days significantly decreased from a mean of 16.3 to 8.2 days (P = 0.04). ICU length of stay also decreased, nearly meeting significance. A rigorously enforced extubation protocol significantly decreased ventilator days in STICU patients. Continued education of health care providers is key to the success of the protocol.

Protocol-driven vs. physician-driven electrolyte replacement in adult critically ill patients

BACKGROUND

The intensive care unit is a dynamic environment, where high numbers of patients cared for by health care workers of different experiences and backgrounds might result in great variability in patient care. Protocol-driven interventions may facilitate timely and uniform care of common problems, like electrolyte disturbances. We prospectively compared protocol-driven (PRD) vs. physician-driven (PHD) electrolyte replacement in adult critically ill patients.

PATIENTS AND METHODS

In the first month of the two-month study, potassium, magnesium, and phosphate levels were checked by a physician before ordering replacement (PHD replacement period). Over the second month, ICU nurses proceeded with replacement according to the protocol (PRD replacement period). We collected demographic data, admission diagnosis, number of potassium, magnesium, and phosphate levels done per day, number of low levels per day, number of replacements per day, time between availability of results to ordering replacement, time to starting replacement, post-replacement levels, serum creatinine, replacement dose, arrhythmias and replacement route.

RESULTS

During the PHD replacement period, 43 patients meeting the inclusion criteria were admitted to the ICU, while 44 were admitted during the PRD month. The mean time (minutes) from identifying results to replacement of potassium, phosphate and magnesium was significantly longer with PHD replacement compared with PRD replacement (161, 187, and 189 minutes vs. 19, 26, and 19 minutes) (P<0.0001). The number of replacements needed and not given was also significantly lower in the PRD replacement period compared with the PHD replacement period (2, 4, and 0 compared with 9, 6 and 0) (P<0.05). No patients had high post-replacement serum concentrations of potassium, phosphate or magnesium.

CONCLUSIONS

This study shows that a protocol-driven replacement strategy for potassium, magnesium and phosphate is more efficient and as safe as a physician-driven replacement strategy.

The treatment of ventilator-associated pneumonia

OBJECTIVE

This manuscript attempts to provide insight into current concepts of prevention, diagnosis, and management of ventilator-associated pneumonia (VAP).

DATA SOURCES

A Medline search from 1996 to May 2004 was performed. Search terms included: ventilator-associated pneumonia with prevention, diagnosis, management, duration, resistance, and outcome.

DATA SELECTION

Emphasis was placed on the recent peer-reviewed literature. Human data were preferentially included.

DATA EXTRACTION

Where possible, recent publications (within the last year) were used in preference to older data. The references were chosen to present key citations.

DATA SYNTHESIS

Data selection was prioritized to address specific subtopics.

CONCLUSIONS

The treatment and prevention of VAP is evolving rapidly based on improved diagnostic skills and a better understanding of optimal antimicrobial therapy. An overview of new and key data guiding clinicians in the management of this important disease is presented.

The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infection in a Medical ICU

OBJECTIVE

To determine whether an education initiative could decrease the rate of catheter-associated bloodstream infection.

DESIGN

Preintervention and postintervention observational study.

SETTING

The 19-bed medical ICU in a 1,400-bed university-affiliated urban teaching hospital.

PATIENTS

Between January 2000 and December 2003, all patients admitted to the medical ICU were surveyed prospectively for the development of catheter-associated bloodstream infection.

INTERVENTION

A mandatory education program directed toward ICU nurses and physicians was developed by a multidisciplinary task force to highlight correct practices for the prevention of catheter-associated bloodstream infection. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related bloodstream infections and in-services at scheduled staff meetings. Each participant was required to complete a pretest before reviewing the study module and an identical test after completion of the study module. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU.

MEASUREMENTS AND MAIN RESULTS

Seventy-four episodes of catheter-associated bloodstream infection occurred in 7,879 catheter-days (9.4 per 1,000 catheter-days) in the 24 months before the introduction of the education program. Following implementation of the intervention, the rate of catheter-associated bloodstream infection decreased to 41 episodes in 7,455 catheter days (5.5 per 1,000 catheter-days) [p = 0.019]. The estimated cost savings secondary to the decreased rate of catheter-associated bloodstream infection for the 24 months following introduction of the education program was between $103,600 and $1,573,000.

CONCLUSIONS

An intervention focused on the education of health-care providers on the prevention of catheter-associated bloodstream infections may lead to a dramatic decrease in the incidence of primary bloodstream infections. Education programs may lead to a substantial decrease in medical-care costs and patient morbidity attributed to central venous catheterization when implemented as part of mandatory training.

Sedation, analgesia, and neuromuscular blockade in sepsis: An evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for sedation, analgesia, and neuromuscular blockade in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

There is no preferred sedative or analgesic agent for use in the critically ill septic patient during mechanical ventilation. Protocols should be utilized for administration of sedation with predefined sedation scale targets. Either intermittent bolus sedation or continuous infusion sedation to predetermined end points with daily interruption/lightening of continuous infusion sedation with awakening and re-titration, if necessary, are recommended. Neuromuscular blockade should be avoided if possible and, if used continuously, requires twitch monitoring.

Reporting of medical errors: An intensive care unit experience

OBJECTIVE

To determine the occurrence and type of medical errors in an intensive care setting using a voluntary reporting method.

DESIGN

Prospective, single-center, observational study.

SETTING

The medical intensive care unit (19 beds) at an urban teaching hospital.

PATIENTS

Adult patients requiring at least 48 hrs of intensive care.

INTERVENTIONS

Prospective reporting of medical errors.

MEASUREMENTS AND MAIN RESULTS

During a 6-month period, 232 medical events were reported involving 147 patients. A total of 2598 patient days were surveyed yielding 89.3 medical events reported per 1000 intensive care unit days. The source of the reports included nurses, who reported most of the medical events (59.1%), followed by physicians-in-training (27.2%) and intensive care unit attending physicians (2.6%). One hundred thirty (56.2%) medical events occurred within the intensive care unit and were judged to involve patient careproviders who were working directly in the intensive care unit area. One hundred and two (43.8%) medical events were commissions or omissions that occurred outside of the intensive care unit during patient transports or in the emergency department and hospital floors. Twenty-three (9.9%) medical events leading to a medical error resulted in the need for additional life-sustaining treatment, and seven (3.0%) medical errors may have contributed to patient deaths.

CONCLUSION

Medical errors appear to be common among patients requiring intensive care. Medical events resulting in an error can result in the need for additional life-sustaining treatments and, in some circumstances, can contribute to patient death. Patient healthcare providers appear to be in a unique position to identify medical errors. Institutions should develop formalized methods for the reporting and analysis of medical errors to improve patient care.

Guidelines in the intensive care unit

The recent movement toward standardization of critical care practice is associated with a growth in the use of guidelines and protocols. Although complex, the process of guideline development, implementation, evaluation, and maintenance can be systematic. Guideline implementation can improve the processes and outcomes of care; however, guideline adherence represents a major challenge to their success. The quality of the growing number of practice guidelines in critical care is important to assess and several useful instruments are available for this purpose.

Collaborative Practice: Development, Implementation, and Evaluation of a Weaning Protocol for Patients Receiving Mechanical Ventilation

• Background Use of protocols to reduce weaning time for patients receiving mechanical ventilation helps reduce cost and length of stay. However, implementation of this type of protocol is not easy and requires a consistent collaborative effort.

• Objective To provide a systematic approach to the weaning process by developing, implementing, and evaluating a protocol for weaning patients from mechanical ventilation in a medical respiratory intensive care unit.

• Methods The weaning protocol used was a modification of a protocol developed by Ely et al. Modifications included a more aggressive approach in proceeding to the spontaneous breathing trial, inclusion of the Richmond Agitation-Sedation Scale, and documentation of the production of secretions.

• Results Implementation of the protocol significantly reduced the duration of mechanical ventilation as measured by 8-hour shifts and ventilator days. Although length of stay in the intensive care unit was not significantly reduced (P = .29), a continuing downward trend occurred, from a mean of 8.6 days before the protocol was implemented to 7.9 days during the last 6 months of data collection (P = .07).

• Conclusions The need to provide efficient care requires the collaboration of all disciplines involved in providing patients’ care. The weaning protocol introduced in this study demonstrates the benefits of using a collaborative team to identify best practices and implement them in a practice setting.

Health technology assessment in the ICU: noninvasive positive pressure ventilation for acute respiratory failure

Critical care practitioners have a number of health-related technologies at our disposal to provide the best possible care for our critically ill patients. Although certain technologies may improve outcomes in the intensive care unit (ICU), many technologies are disseminated without rigorous evaluation. Health technology assessment (HTA) in critical care is a complex and dynamic process, which is a powerful tool to assess a health technology for its initial use or continued application in the ICU. This article applies an HTA framework to the use of noninvasive positive pressure ventilation (NPPV) for patients with acute respiratory failure (ARF). The strongest evidence to date supports the use of NPPV in patients with ARF caused by exacerbations of chronic obstructive pulmonary disease (COPD); the benefit for patients with acute nonhypercarbic, hypoxemic respiratory failure is less clear. The success of NPPV technology depends on operator education and experience. The cost effectiveness of NPPV has been evaluated in patients with ARF caused by COPD, and cost reduction is attributed to the prevention of ventilator-associated pneumonia by avoiding endotracheal intubation. An HTA framework can help health care practitioners make important decisions regarding the acquisition of new technologies and the evaluation of current technologies. Careful evaluation of health technologies in the ICU should be an ongoing priority.

Proactive error prevention in the intensive care unit

Care provided in the ICU accounts for nearly 30% of acute care hospital costs and, with the aging of Americans, there is an increased demand for critical care services [1]. Critical illness reduces an individual's physical resilience. Minute-to-minute care decisions and interventions mean life or death during this acute disease phase. Critically ill patients have limited ability to defend themselves from the consequences of health care error. This patient population has the least ability to communicate symptoms to health care providers. The risk of adverse events caused by medications or equipment malfunction is higher because patients in the ICU receive twice as many medications as patients in general care units [2] and often require mechanical support of normal body functions, such as breathing, eating, and eliminating body waste. Consequently, the patient in the ICU has a higher exposure to medical error than patients in other areas of the hospital.