Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs

Clinical Impact of an Electronic Dashboard and Alert System for Sedation Minimization and Ventilator Liberation: A Before-After Study

Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation.

DESIGN

Multi-ICU proof-of-concept study and a single ICU before-after study.

SETTING

University hospital ICUs.

PATIENTS

Adult patients receiving mechanical ventilation.

INTERVENTIONS

An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers.

MEASUREMENTS AND MAIN RESULTS

We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01-1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03-1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09-4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13-5.16 d; p = 0.040) shorter, compared with the expected durations without the application.

CONCLUSIONS

Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury

PURPOSE OF REVIEW

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury.

RECENT FINDINGS

Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.

[Early mobilisation on the intensive care unit : What we know]

BACKGROUND

Early mobilization is defined as intervention within the first 72 h after intensive care unit (ICU) admission. According to the current state of relevant studies, evidence on early mobilization in critically ill patients is still inconsistent. This leads to insecurity in caretakers and subsequently to incomplete implementation in German ICUs.

OBJECTIVES

What type of intervention is suitable for certain patient groups? Which issues remain unresolved?

RESULTS

To obtain best possible outcomes, early mobilization should be initiated during the first 72 h after ICU admission. Implementation of early mobilization improves clinical outcome and should be integrated in a patient-centered bundle (such as ABCDEF). Mechanical ventilation is not a contraindication to intervention. Evidence in neurocritical care as well as functionally dependent patients is still low. Mode of intervention and dosage of early mobilisation remain unclear.

CONCLUSION

Early mobilization is safe and feasible, resulting in improved outcomes in surgical and medical ICU patients. Further studies are necessary to evaluate the optimal dosage and duration of intervention, especially in neurocritical care patients.

Intensive Care Role in Disaster Management Critical Care Clinics

The "daily disasters" within the ebb and flow of routine critical care provide a foundation of preparedness for the less-frequent, larger events that affect most health care organizations at some time. Although large disasters can overwhelm, those who strengthen processes and habits through daily practice will be the best prepared to manage them.