Improving Adherence to a Mechanical Ventilation Weaning Protocol for Critically Ill Adults: Outcomes After an Implementation Program

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.].

Effects of Donepezil and Medroxyprogesterone Versus Placebo on Weaning in Adult Patients With Non-Pulmonary Etiologies Receiving Invasive Mechanical Ventilation: A triple-blind Randomized Clinical Trial

Background: Medroxyprogesterone and donepezil could be used as respiratory stimulants in ventilated patients. However, no randomized placebo-controlled trial is available to confirm this approach and compare these drugs. The aim of the current study was to evaluate the effects of donepezil or medroxyprogesterone compared to the placebo in improvement in respiratory status and weaning facilitation in critically ill adult patients receiving mechanical ventilation.

Material and Methods: This randomized, triple-blind trial was conducted on 78 ventilated patients in intensive care units (ICU). Patients who were intubated due to pulmonary disorders were ruled out. Patients were randomized in a 1:1:1 ratio to receive 5 mg donepezil (n = 23) or 5 mg medroxyprogesterone (n = 26), or placebo (n = 24) twice a day until weaning (maximum 10 days). The primary endpoints were weaning duration, and duration of invasive mechanical ventilation. Secondary endpoints included rate of successful weaning, changes in arterial blood gas (ABG) parameters, GCS and sequential organ failure assessment (SOFA) score, hemoglobin (Hgb), ICU-mortality, and duration of ICU stay, were measured before and after the intervention and if successful weaning was recorded.

Results: Of 78 studied patients who were randomized, 59 weaned successfully. 87% patients in donepezil and 88.5% patients in medroxyprogesterone groups were successfully weaned compared to 66.7% patients in the placebo group. However, this difference was not statistically significant (p-Value = 0.111). Changes in pH, mean duration of intubation, and weaning duration were statistically different in donepezil compared with the control group (p-Value < 0.05). No significant difference in ABG, Hgb, GCS and SOFA score, and duration of intubation were seen in the medroxyprogesterone group, but weaning duration was significantly reduced to 1.429 days compared with the control group (p-Value = 0.038).

Conclusion: The results of this clinical trial have demonstrated that the administered dose of medroxyprogesterone and donepezil can expedite the weaning process by reducing the weaning duration compared to placebo. Furthermore, the total duration of invasive ventilation was significantly lower in the donepezil group compared to the control group. Future clinical trials with a larger sample size will determine the exact role of medroxyprogesterone and donepezil in mechanically ventilated patients.

Clinical Trial Registration:https://irct.ir/IRCT20190810044500N2 (April 1, 2020).

Investigating the Effect of Expiratory Time Constant on Outcome in Intubated Patients with Acute Respiratory Failure Caused by COVID-19 in Critical Care Unit: A Research Study

Background

The coronavirus disease 2019 (COVID-19) has a high prevalence and mortality worldwide. Thousands of patients with acute respiratory failure caused by COVID-19 are daily hospitalized in intensive care units (ICUs) around the world. Many of these patients require full mechanical respiratory support and long-term ventilator use. Using different ventilators and calculating important variables can be helpful in meeting therapeutic needs of patients.

Objectives

The aim of present study was to investigate the effect of expiratory time constant (RCEXP) on the course of treatment and duration of mechanical ventilation in patients with acute respiratory failure hospitalized in ICU.

Methods

The present cross-sectional study was conducted on 60 patients with acute respiratory failure who were hospitalized in the ICU and underwent mechanical ventilation due to COVID-19 in the first six months of 2020. The variables of RCEXP, lung compliance and lung resistance in all patients were recorded daily and analyzed. Then, based on clinical outcome, the patients were divided into two groups: the patients with wean outcome (N = 40) and those with death outcome (N = 20).

Results

The mean ± SD of lung compliance in patients who were separated from ventilator and patients with death outcome were 74.73 (18.58) mL/cm H₂O and 36.92 (10.56) mL/cm H₂O, respectively, which was statistically significant (P = 0.001). The mean ± SD of lung resistance in patients who were separated from ventilator and patients with death outcome were calculated at 9.25 (4.62) and 14 (6.5), respectively, which was statistically significant (P = 0.015). Also, there was a statistically significant difference between the two groups in terms of mean ± SD of RCEXP (0.67 (0.23) vs. 0.49 (0.19), P = 0.010).

Conclusions

According to the results of this study, there was a significant difference between high resistance, low compliance, RCEXP, and weaning success of intubation in patients hospitalized in the ICU.

A Multifaceted Extubation Protocol to Reduce Reintubation Rates in the Surgical ICU

BACKGROUND

Reintubation is associated with significant morbidity and mortality. The reintubation rate in surgical ICUs (SICUs) is ∼10% nationally but was 17.0% in our SICU. The objective of this study was to determine if the reintubation rate could be reduced with a protocol for extubation assessment and post-extubation care consisting of standardized extubation criteria and targeted interventions for patients at high risk for reintubation.

METHODS

Standardized extubation criteria for all SICU patients were identified via literature review and best-practice guidelines. High reintubation risk criteria were identified (age ≥ 65 years, chronic cardiopulmonary disease, ≥ 4 days intubated, emergency intubation, and fluid balance ≥ 5 liters) through a literature review and 13-month retrospective review of reintubations in our institution's SICU. Patients meeting at least one criterion putting them at higher risk for reintubation received interventions including post-extubation high-flow nasal cannula for 24 hours and algorithm-guided respiratory therapy.

RESULTS

During the 12-month period following protocol implementation, 36 of 402 extubations resulted in reintubations (9.0% vs. 17.0% preintervention, p < 0.001). Among all extubations, 305 (75.9%) were identified as high risk. Among reintubated patients, 34 (94.4%) met high-risk criteria. The mortality rate for reintubated patients was 40.0%, compared to 3.3% in those not reintubated (p < 0.001). The high-risk screening tool had a negative predictive value of 98%.

CONCLUSION

A multifaceted and pragmatic extubation and post-extubation care protocol significantly reduced one SICU's reintubation rate. This protocol can be easily implemented in any SICU to improve patient outcomes following extubation.

A Scoping Review of Implementation Science in Adult Critical Care Settings

OBJECTIVES

The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation.

DATA SOURCES

A librarian-assisted search was performed using three electronic databases.

STUDY SELECTION

Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included.

DATA EXTRACTION

Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system.

DATA SYNTHESIS

Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes.

CONCLUSIONS

The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.

The Effectiveness of Workshop and Multimedia Training Methods on the Nurses' Decision-Making Skills Regarding Weaning From Mechanical Ventilation

BACKGROUND

Nurses can safely and effectively wean patients from mechanical ventilation (MV) by the use of proper instruments and planning.

OBJECTIVE

The aim of this study was to compare the effectiveness of 2 training methods on the decision-making skill of intensive critical care (ICU) nurses with regard to weaning from MV.

METHODS

In this quasi-experimental study, 80 nurses working in ICUs participated in 1 of 2 educational groups in 2016. The interventions were workshop and multimedia training for decision-making skill regarding weaning from MV. The data were gathered from a questionnaire based on the Burns Weaning Assessment Program tool before and 1 month after the intervention. Data were analyzed by independent t test, the χ test, and the Fisher exact test using the software SPSS v. 17.

RESULTS

The decision-making skill with regard to awareness of weaning factors (physiological and respiratory) increased in both groups after the intervention (P ≤ .001), but the difference between the 2 groups was not statistically meaningful. Considering the mean scores before and after the intervention, the general skill of decision-making regarding weaning from MV was higher in the multimedia training group compared with the workshop training group (P ≤ .001).

CONCLUSION

The multimedia training method, which has been more successful, is recommended owing to its characteristics of virtual education, such as accessibility, flexibility, learner centeredness, and expansibility, as well as nurses' lack of time.

Nursing implementation of a validated agitation and sedation scale: An evaluation of its outcomes on ventilator days and ICU length of stay

BACKGROUND

Intensive Care Units (ICU) often initiate mechanical ventilation (MV) in conjunction with sedation for patients who cannot maintain adequate oxygenation or ventilation on their own. Continuous use of sedation increases the likelihood of negative events associated with ventilators such as ventilator-associated pneumonia while, at the same time, continuing to increase the length of MV.

OBJECTIVES

This study sought to analyze the effects of implementing a mandated Richmond Agitation and Sedation Scale (RASS) entry with each sedative scan on a unit where no parameters were in place to monitor sedation levels.

METHODS

This was a retrospective cross-sectional study which included chart-review of a Medical ICU. The data was gathered on ventilator days and sedation use for patients prior to and after the implementation of the RASS.

RESULTS

A median weighted analysis and Mann-Whitney U test of 138 pre-RASS ventilator patients and 86 post-RASS ventilator patients appears to indicate that implementation of the RASS resulted in a 31% decrease of ventilator days (p = .0002). The pulmonary diagnosis subgroup showed a significant 39% reduction in ICU length of stay (U = 324, p = .042).

CONCLUSIONS

The results of this study lead to the conclusion that the implementation of the mandated RASS score entry limits over-sedation of ventilated patients, thereby reducing the number of MV days in the ICU. Sufficient evidence suggests that the mandated RASS entry also reduces the length of stay in the ICU.

Comparison between a nurse-led weaning protocol and a weaning protocol based on physician's clinical judgment in ICU patients

PURPOSE

The purpose of this study was to compare a nurse-led weaning protocol with a physician-driven weaning protocol in mechanically ventilated (MV) patients.

METHODS

In this quasi-experimental study with a one-group design, a total of 65 ICU patients, requiring MV for more than 72 h, were selected via convenience sampling. In routine practice, the physician's clinical judgment is needed to determine the patient's readiness for liberation from MV. A physician-driven weaning protocol was compared with a nurse-led protocol, using Burn's Weaning Scale (BWS) in three working phases. Descriptive and inferential statistics were measured for data analysis using SPSS version 16.

RESULTS

Based on BWS, the mean MV duration was 111.75±33.46 h in the nurse-led weaning group and 125.12±43.43 h in the physician-driven weaning group. There was a significant difference in terms of MV duration between the two groups (P = 0.000).

CONCLUSION

The present findings showed that nurses' assessment of patient's readiness for weaning from MV (BWS) is a safe approach during the day, which can reduce MV duration more than other typical methods in ICUs.

The Effect of Sedation Protocol Using Richmond Agitation-Sedation Scale (RASS) on Some Clinical Outcomes of Mechanically Ventilated Patients in Intensive Care Units: a Randomized Clinical Trial

Introduction: Providing for patients’ comfort and reducing their pain is one of the important tasks of health care professionals in the Intensive Care Unit (ICU). The current study was conducted to determine the effect of a protocol using a Richmond Agitation-Sedation Scale (RASS) on some clinical outcomes of patients under mechanical ventilation (MV) in 2017.

Methods: This single-blind clinical trial was conducted on 79 traumatic patients in the ICU who were randomly allocated into the intervention (N=40) and the control groups (N=39). The sedation was achieved, using a sedation protocol in the intervention group and the routine care in the control group. The clinical outcomes of the patients (duration of MV, length of staying in ICU, final outcome) were measured. As the participants had different lengths of MV and staying in ICU, the data were restructured, and were analyzed, using proper statistical methods.

Results: The patients’ level of sedation in the intervention group was significantly closer to the ideal score of RASS (-1 to +1). The duration of MV was significantly reduced in the intervention group, and the length of stay in the ICU was also significantly shorter. There was no difference in terms of final outcome. The ICU cost in the control group was twice as high as the cost in of the intervention group.

Conclusion: The applied sedation protocol in this study would provide better sedation and could consequently lead to significantly better clinical outcomes, and the cost of caring as a result.

Variation in the practice of discontinuing mechanical ventilation in critically ill adults: study protocol for an international prospective observational study

INTRODUCTION

Research supports the use of specific strategies to discontinue mechanical ventilation (MV) in critically ill patients. Little is known about how clinicians actually wean and discontinue MV in practice or the association between different discontinuation strategies and outcomes. The primary objective of this study is to describe international practices in the use of (1) daily screening for readiness to discontinue MV, (2) modes of MV used before initial discontinuation attempts, (3) weaning and spontaneous breathing trial (SBT) protocols, (4) SBT techniques and (5) sedation and mobilisation practices to facilitate weaning and discontinuation. The secondary objectives are to identify patient characteristics and time-dependent factors associated with use of selected strategies, investigate associations between SBT outcome (failure vs success) and outcomes, explore differences between patients who undergo an SBT early versus later in their intensive care unit (ICU) stay, and investigate the associations between different SBT techniques and humidification strategies on outcomes.

METHODS AND ANALYSIS

We will conduct an international, prospective, observational study of MV discontinuation practices among critically ill adults who receive invasive MV for at least 24 hours at approximately 150 ICUs in six geographic regions (Canada, USA, UK, Europe, India and Australia/New Zealand). Research personnel at participating ICUs will collect demographic data, data to characterise the initial strategy or event that facilitated discontinuation of MV (direct extubation, direct tracheostomy, initial successful SBT, initial failed SBT or death before any attempt could be made), clinical outcomes and site information. We aim to collect data on at least 10 non-death discontinuation events in each ICU (at least 1500 non-death discontinuation events).

ETHICS AND DISSEMINATION

This study received Research Ethics Approval from St. Michael's Hospital (11-024) Research ethics approval will be sought from all participating sites. The results will be disseminated through publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03955874.

A systematic review of nurse-led weaning protocol for mechanically ventilated adult patients

OBJECTIVES

The aim of this systematic review is to synthesize the current best evidence for the effectiveness of weaning protocols led by nurses compared with usual physician-led care.

BACKGROUND

Protocol-directed weaning has been shown to reduce the duration of mechanical ventilation. Studies have reported that a weaning protocol administered by nurses leads to a reduction in the duration of mechanical ventilation and has a major effect on weaning outcomes. This can have especially positive consequences for critically ill patients.

STUDY DESIGN

Systematic review with meta-analysis.

SEARCH STRATEGY

The databases CINAHL, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched from as far back as the database allowed until January 2016.

INCLUSION AND EXCLUSION CRITERIA

Searches were performed to identify the best available evidence including quantitative studies of nurse-led weaning protocols for mechanically ventilated adult patients. We excluded all studies of weaning protocols implemented by non-nurses and non-invasive mechanical ventilation and studies that addressed patient populations younger than 18 years of age.

RESULTS

The database searches resulted in retrieving 369 articles. Three eligible studies with a total of 532 patients were included in the final review. Pooled data showed a statistically significant difference in favour of the nurse-led weaning protocol for reducing the duration of mechanical ventilation (mean differences = -1.69 days, 95% confidence interval = -3.23 to 0.16), intensive care unit length of stay (mean differences = -2.04 days, 95% confidence interval = -2.57 to -1.52, I²  = 18%, and p = 0.00001); and hospital length of stay (mean differences = -2.9 days, 95% confidence interval = -4.24 to -1.56, I²  = 0%, and p = 0.00001).

CONCLUSION

There is evidence that the use of nurse-led weaning protocols for mechanically ventilated adult patients has a positive impact on weaning outcomes and patient safety.

RELEVANCE TO CLINICAL PRACTICE

This review provides evidence supporting intensive care unit nurses' crucial role and abilities to lead weaning from mechanical ventilation.

IMPACT OF A VENTILATORY WEANING PROTOCOL IN AN INTENSIVE CARE UNIT FOR ADULTS

ABSTRACT Objective: to evaluate the impact of a ventilatory weaning protocol on the weaning quality and on the outcomes of the patients. Method: a quasi-experimental quantitative study, consisting of comparing a prospective study with a retrospective study. Data was collected through a weaning log sheet applied between September and December 2015 at an intensive care unit in northern Portugal following the implementation of a weaning protocol and compared with a base-line constituted in the year preceding the implementation of the ventilatory weaning protocol. Results: the experimental group had a score mean of higher overall quality of weaning, with a reduction in the timing for initiating the weaning in 27.3% and the weaning time in 36.6%. Conclusion: the implementation of the ventilatory weaning protocol improved the overall quality of the weaning, facilitating the identification of patients with criteria to initiate the process, starting earlier, resulting in a reduction in ventilatory weaning time.

Preventing ventilator-associated pneumonia-a mixed-method study to find behavioral leverage for better protocol adherence

OBJECTIVE

Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence.

DESIGN

Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs).

SETTING

The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.Patients and participantsAdherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians.

RESULTS

Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%-31%); oral care at 41% (95% CI, 36%-45%); sedation interruption at 81% (95% CI, 74%-85%); and subglottic suctioning at 88% (95% CI, 83%-92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component 'reflective motivation' (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to 'physical capability' (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, 'restructuring environment' and 'enabling HCP') emerged as means to overcome these barriers.

CONCLUSIONS

Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.

Mechanical ventilation weaning protocol improves medical adherence and results

INTRODUCTION

Implementation of a weaning protocol is related to better patient prognosis. However, new approaches may take several years to become the standard of care in daily practice. We conducted a prospective cohort study to investigate the effectiveness of a multifaceted strategy to implement a protocol to wean patients from mechanical ventilation (MV) and to evaluate the weaning success rate as well as practitioner adherence to the protocol.

METHODS

We investigated all consecutive MV-dependent subjects admitted to a medical-surgical intensive care unit (ICU) for >24h over 7years. The multifaceted strategy consisted of continuing education of attending physicians and ICU staff and regular feedback regarding patient outcomes. The study was conducted in three phases: protocol development, protocol and multifaceted strategy implementation, and protocol monitoring. Data regarding weaning outcomes and physician adherence to the weaning protocol were collected during all phases.

RESULTS

We enrolled 2469 subjects over 7years, with 1,943 subjects (78.7%) experiencing weaning success. Physician adherence to the protocol increased during the years of protocol and multifaceted strategy implementation (from 38% to 86%, p<0.01) and decreased in the protocol monitoring phase (from 73.9% to 50.0%, p<0.01). However, during the study years, the weaning success of all subjects increased (from 73.1% to 85.4%, p<0.001). When the weaning protocol was evaluated step-by-step, we found high adherence for noninvasive ventilation use (95%) and weaning predictor measurement (91%) and lower adherence for control of fluid balance (57%) and daily interruption of sedation (24%). Weaning success was higher in patients who had undergone the weaning protocol compared to those who had undergone weaning based in clinical practice (85.6% vs. 67.7%, p<0.001).

CONCLUSIONS

A multifaceted strategy consisting of continuing education and regular feedback can increase physician adherence to a weaning protocol for mechanical ventilation.

Tips to Improve Success Rate of Intubation: A Standardized Rapid Sequence Intubation Protocol Attached to the Resuscitation Cart

OBJECTIVES

The purpose of this study was to determine whether the implementation of a standardized rapid sequence intubation (RSI) protocol easily accessed on the resuscitation cart increased the success rate of intubation and reduced intubation-related complications in the emergency department (ED).

METHODS

This work was a retrospective study of patients who were intubated in the ED between February 2006 and June 2007. The RSI protocol and a dosage cross-table were attached to the resuscitation cart beginning in January 2007. Intubated patients before and after application of the protocol were sorted into two groups: pre-intervention and post-intervention.

RESULTS

A total of 147 patients were enrolled in the study, including 72 patients in the pre-intervention group and 75 patients in the post-intervention group. After application of the standardized protocol prompted on the resuscitation cart. The adherence rates to pre-treatment agents (69% vs. 90%; p < 0.01) and neuromuscular blocking agents (NMBA) (72% vs. 90%; p < 0.01) significantly improved. The first-attempt success rate was 57 of 72 (79%) in the pre-intervention group versus 70 of 75 (93%) in the post-intervention group (p = 0.016). The time to intubation did not differ signifi cantly, but the preintervention group had a higher percentage of prolonged time to intubation (13% vs. 3%; p = 0.029). The implementation of a standardized RSI protocol did not induce signifi cant adverse effects.

CONCLUSIONS

Our study demonstrated implementation of a standardized RSI protocol, improved clinician adherence to the RSI, increased success of first-attempt ED intubation and led to a decline in the rate of prolonged time to intubation.

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.

Effect of a quality improvement program on weaning from mechanical ventilation: a cluster randomized trial

PURPOSE

To evaluate the efficacy of a quality improvement (QI) program for protocol-directed weaning from mechanical ventilation.

METHODS

This was a prospective, cluster randomized controlled trial. The study consisted of a baseline phase and a QI phase. Fourteen intensive care units (ICUs) in Beijing, China, were randomized into the QI group and non-QI group. The QI group received a QI program to improve the compliance with protocol-directed weaning during the QI phase.

RESULTS

A total of 444 patients were enrolled in the non-QI group (193 for the baseline, 251 for the QI phase) and 440 in the QI group (199 for the baseline, 241 for the QI phase). During the QI phase in the QI group, compared with the non-QI group, total duration of mechanical ventilation decreased from 7.0 to 3.0 days (p = 0.003), the time before the first weaning attempt decreased from 3.63 to 1.96 days (p = 0.003), length of ICU stay decreased from 10.0 to 6.0 days (p = 0.004), length of hospital stay decreased from 23.0 to 19.0 days (p < 0.001). These differences were also significant in the QI group when the QI phase was compared with the baseline phase. In addition, there was a significant reduction in the percentage of mechanical ventilation exceeding 21 days (p = 0.001) when the baseline phase was compared with the QI phase in the QI group.

CONCLUSIONS

The QI program involving protocol-directed weaning is associated with beneficial clinical outcomes in mechanically ventilated patients.

Knowledge translation interventions for critically ill patients: a systematic review*

OBJECTIVE

We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care.

DATA SOURCES

We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews.

STUDY SELECTION

Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies.

DATA EXTRACTION

Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care.

DATA SYNTHESIS

From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes.

CONCLUSIONS

Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Difficult to wean patients: cultural factors and their impact on weaning decision-making

AIMS AND OBJECTIVES

To examine the elements of the intensive care environment and consider the impact on nurses' involvement in decision-making when weaning from mechanical ventilation.

BACKGROUND

Optimal management of difficult to wean patients requires the dynamic collaboration of all clinicians and the contribution of their knowledge and skills. The introduction of weaning protocols has increased nurses' input in decision-making, but there are various elements of the decision environment that impact on their involvement, which have been given little consideration.

DESIGN

Ethnography was used as the research design for this study.

METHODS

Fieldwork took place in two tertiary hospitals in Greece and Scotland for five months each to unveil clinicians' behaviour and interactions during the weaning practice. Observation was based on the weaning process of 10 Scottish and 9 Greek long-term ventilated patients. Semi-structured interviews followed with nurses (n = 33) and doctors (n = 9) in both settings to understand nurses' perceived involvement in weaning decision-making. Thematic analysis of interviews and field notes followed using the Qualitative Data Analysis software NVivo. Clinicians' participation was voluntary.

RESULTS

The main themes identified were the (1) organisation of the units (time and structure of the ward rounds, staff levels and staff allocation system), (2) the inter- professional relationships, (3) the ownership and accountability in weaning decision-making and (4) the role of the weaning protocols. These elements described the culture of the ICUs and defined nurses' role in weaning decision-making.

CONCLUSIONS

Clinical decision-making is a multi-dynamic process specifically in complex clinical situations such as weaning from mechanical ventilation. This paper suggests that weaning practice should be considered in relation to the elements of the clinical environment to provide an individualised and patient-centred weaning approach.

RELEVANCE TO CLINICAL PRACTICE

Methods to enhance nurses' role in teamwork and collaborative decision-making are suggested.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

An electronic tool for visual feedback to monitor the adherence to quality indicators in intensive care medicine

Evidence-based medicine is often inadequately implemented in intensive care units (ICU); the aim of this study was to improve its implementation via a technical feedback system, using key performance indicators (KPI). The study evaluated 205 patients treated in a cardiac surgical ICU over a 6-month period (3 months before and 3 months after implementation of the feedback system). KPI adherence rates for sedation, delirium and pain monitoring, and completion of a weaning protocol before and after the implementation of the feedback system, were compared. Adherence rates for pain and delirium monitoring, and implementation of the weaning protocol, were significantly increased by the intervention. Adherence to KPIs for sedation, which were high at baseline, could not be further improved. Daily display of KPI implementation had a positive effect on adherence to standard operating procedures. Adherence to guidelines may be improved by using this feedback system as part of the clinical routine.

Differences in Perceptions of Patient Safety Culture between Charge and Noncharge Nurses: Implications for Effectiveness Outcomes Research

The implementation of evidence-based practice guidelines can be influenced by nurses' perceptions of the organizational safety culture. Shift-by-shift management of each nursing unit is designated to a subset of staff nurses (charge nurses), whom are often recruited as champions for change. The findings indicate that compared to charge nurses, noncharge nurses were more positive about overall perceptions of safety (P = .05) and teamwork (P < .05). Among charge nurses, significant differences were observed based on the number of years' experience in charge: perception of teamwork within units [F(3, 365) = 3.52, P < .01]; overall perceptions of safety, [F(3, 365) = 4.20, P < .05]; safety grade for work area [F(3, 360) = 2.61, P < .05]; number of events reported within the last month [F(3, 362) = 3.49, P < .05]. These findings provide important insights to organizational contextual factors that may impact effectiveness outcomes research in the future.

The role of standardized protocols in unplanned extubations in a medical intensive care unit

BACKGROUND

Many patients admitted to medical intensive care units require mechanical ventilation to assist with respiratory management. Unplanned extubations of these patients are associated with poor outcomes for patients and organizations. No previous research has investigated the role of standardized protocols in unplanned extubations when examined in conjunction with traditional risk factors.

OBJECTIVE

To identify risk factors associated with unplanned extubation among patients receiving mechanical ventilation and determine degree of compliance with pain, sedation, and weaning protocols.

METHODS

A prospective cohort study design was used. Data on all patients admitted to the medical intensive care unit who required mechanical ventilation were gathered daily. Additional data were gathered on those patients who experienced unplanned extubation. Descriptive, correlational, and regression analyses were performed.

RESULTS

Weaning protocols were a significant predictor of unplanned extubation: patients who had weaning protocols ordered and followed were least likely to experience unplanned extubation. Only 10% of the 190 patients in the study required reintubation, resulting in a significantly shorter ventilation time and unit length of stay among the unplanned extubation group.

CONCLUSIONS

Weaning protocols were associated with decreased incidence of unplanned extubation. Use of standardized protocols was feasible, as compliance among health care providers was high when protocols were medically prescribed. The reintubation rate in this study was low and associated with a significantly shorter ventilatory period and unit length of stay in the unplanned extubation group.

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.

Systematic review of practice guideline dissemination and implementation strategies for healthcare teams and team-based practice

AIM

To synthesis the literature relevant to guideline dissemination and implementation strategies for healthcare teams and team-based practice.

METHODS

Systematic approach utilising Joanna Briggs Institute methods. Two reviewers screened all articles and where there was disagreement, a third reviewer determined inclusion.

RESULTS

Initial search revealed 12,083 of which 88 met the inclusion criteria. Ten dissemination and implementation strategies identified with distribution of educational materials the most common. Studies were assessed for patient or practitioner outcomes and changes in practice, knowledge and economic outcomes. A descriptive analysis revealed multiple approaches using teams of healthcare providers were reported to have statistically significant results in knowledge, practice and/or outcomes for 72.7% of the studies.

CONCLUSION

Team-based care using practice guidelines locally adapted can affect positively patient and provider outcomes.

Action research studies in the intensive care setting: a systematic review

OBJECTIVES

To review published studies using action research in the intensive care unit (ICU) in order to provide an intervention framework to improve clinical outcomes.

DESIGN

Systematic review.

METHODS

Searches of the electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL); Scopus, Medline, Embase, PsycINFO, and the World Wide Web were undertaken using MeSH key words including: 'action research'; 'health care research', 'health services evaluation'; 'intensive care unit'. Reference lists of retrieved articles was also undertaken to identify further articles. All studies were reviewed by two authors using a critical appraisal tool.

RESULTS

The search strategy generated 195 articles. Only 21 studies projects were identified using action research in the ICU. The majority of studies were conducted in the United Kingdom. The participants in the action research studies ranged from 6 to 253. Predominately studies using action research involved nurses in collaboration with patients and family and other health care practitioners to address identified problems in the ICU.

CONCLUSIONS

Based on this review it appears that action research is a promising methodological approach to address clinical practice improvement in the ICU. Studies retrieved focussed primarily on process and formative evaluation but not on clinical outcomes. There is a need to incorporate outcome assessment in action research in the ICU to increase the framework of action research to improve clinical outcomes.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

Creation of an intermediate respiratory care unit to decrease intensive care utilization

Patients requiring specialized respiratory care often have lengthy stays in the intensive/critical care settings. Financial constraints, patient flow, unit management, and limited resources make finding alternative sites for the care of patients on long-term ventilator (LTV) essential. The authors discuss the efforts of a multidisciplinary team that created, implemented, and evaluated an evidence-based respiratory care unit for LTV patients. The nursing staff development required as part of this initiative is described.

Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review

OBJECTIVES

The objective of this systematic review is to describe and identify the effectiveness of different practice guideline implementation strategies on team-based practice and/or patient outcomes.

METHODS

A systematic review was conducted, using a comprehensive, reproducible search strategy that revealed 88 studies that met the inclusion criteria.

RESULTS

A descriptive analysis revealed multiple approaches using teams of health care providers with 72.7% of the studies reporting statistically significant results in knowledge, practice and/or outcomes. Of 10 dissemination strategies the most effective were reminders, and audit and feedback. The most popular strategy was education meetings. A secondary analysis revealed different populations with chronic or complex disorders where a team approach was effective in practice guideline dissemination and implementation.

CONCLUSIONS

Many of the studies provided caveats to explain how or why the strategies did or did not demonstrate improvements. Overall, authors described complex health care requiring increasingly complex approaches to ensure evidence based guidelines were utilised in practice, including using multiple dissemination and implementation strategies. The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge, practice and patient outcomes.

Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation

OBJECTIVE

To assess whether a systematic approach to weaning and extubation (intervention) is superior to the sole physician's judgment (control) in preventing reintubation secondary to extubation failure in patients with neurologic disorders.

DESIGN

Randomized controlled trial.

SETTING

Intensive care unit of a large teaching hospital.

PATIENTS

Three hundred eighteen intubated patients who had been receiving mechanical ventilation for at least 12 hrs and were able to trigger the ventilator.

INTERVENTIONS

Patients were randomized to the intervention (n = 165) or control group (n = 153).

MEASUREMENTS

Rate of reintubation after extubation failure occurring within 48 hrs (primary end point). Duration of mechanical ventilation, length of intensive care unit stay, mortality, rate of tracheotomy (secondary end points). The perception of the research protocol by the intensive care unit staff was also assessed.

MAIN RESULTS

The rate of reintubation was lower in the intervention (5%) than in the control (12.5%) group (p = 0.047). There was no difference in any of the other outcome variables (secondary end points). Simplified Acute Physiologic Score II (adjusted odds ratio 1.042 per unit; 95% confidence interval 1.006-1.080; p = 0.022) and inclusion in the control group (adjusted odds ratio 2.393; 95% confidence interval 1.000-5.726; p = 0.05) were the only two independent predictive factors for the risk of extubation failure. The protocol was felt by the staff to determine an improvement in patients' clinical outcome, but to increase intensive care unit workload; nurses and physiotherapists considered its impact on their professional role more positively than physicians.

CONCLUSIONS

In patients with neurologic diseases, a systematic approach to weaning and extubation reduces the rate of reintubation secondary to extubation failure without affecting the duration of mechanical ventilation, and is overall positively perceived by intensive care unit professionals.

Sedation and weaning from mechanical ventilation: effects of process optimization outside a clinical trial

PURPOSE

We studied the effects of reorganization and changes in the care process, including use of protocols for sedation and weaning from mechanical ventilation, on the use of sedative and analgesic drugs and on length of respiratory support and stay in the intensive care unit (ICU).

MATERIALS AND METHODS

Three cohorts of 100 mechanically ventilated ICU patients, admitted in 1999 (baseline), 2000 (implementation I, after a change in ICU organization and in diagnostic and therapeutic approaches), and 2001 (implementation II, after introduction of protocols for weaning from mechanical ventilation and sedation), were studied retrospectively.

RESULTS

Simplified Acute Physiology Score II (SAPS II), diagnostic groups, and number of organ failures were similar in all groups. Data are reported as median (interquartile range). Time on mechanical ventilation decreased from 18 (7-41) (baseline) to 12 (7-27) hours (implementation II) (P = .046), an effect which was entirely attributable to noninvasive ventilation, and length of ICU stay decreased in survivors from 37 (21-71) to 25 (19-63) hours (P = .049). The amount of morphine (P = .001) and midazolam (P = .050) decreased, whereas the amount of propofol (P = .052) and fentanyl increased (P = .001). Total Therapeutic Intervention Scoring System-28 (TISS-28) per patient decreased from 137 (99-272) to 113 (87-256) points (P = .009). Intensive care unit mortality was 19% (baseline), 8% (implementation I), and 7% (implementation II) (P = .020).

CONCLUSIONS

Changes in organizational and care processes were associated with an altered pattern of sedative and analgesic drug prescription, a decrease in length of (noninvasive) respiratory support and length of stay in survivors, and decreases in resource use as measured by TISS-28 and mortality.