Study protocol to test the efficacy of self-administration of dexmedetomidine sedative therapy on anxiety, delirium, and ventilator days in critically ill mechanically ventilated patients: an open-label randomized clinical trial.

BACKGROUND: Administration of sedative and opioid medications to patients receiving mechanical ventilatory support in the intensive care unit is a common clinical practice. METHODS: A two-site randomized open-label clinical trial will test the efficacy of self-management of sedative therapy with dexmedetomidine compared to usual care on anxiety, delirium, and duration of ventilatory support after randomization. Secondary objectives are to compare self-management of sedative therapy to usual care on level of alertness, total aggregate sedative and opioid medication exposure, and ventilator-free days up to day 28 after study enrolment. Exploratory objectives of the study are to compare self-management of sedative therapy to usual care on 3- and 6-month post-discharge physical and functional status, psychological well-being (depression, symptoms of post-traumatic stress disorder), health-related quality of life, and recollections of ICU care. ICU patients (n = 190) who are alert enough to follow commands to self-manage sedative therapy are randomly assigned to self-management of sedative therapy or usual care. Patients remain in the ICU sedative medication study phase for up to 7 days as long as mechanically ventilated. DISCUSSION: The care of critically ill mechanically ventilated patients can change significantly over the course of a 5-year clinical trial. Changes in sedation and pain interventions, oxygenation approaches, and standards related to extubation have substantially impacted consistency in the number of eligible patients over time. In addition, the COVID-19 pandemic resulted in mandated extended pauses in trial enrolment as well as alterations in recruitment methods out of concern for study personnel safety and availability of protective equipment. Patient triaging among healthcare institutions due to COVID-19 cases also has resulted in inconsistent access to the eligible study population. This has made it even more imperative for the study team to be flexible and innovative to identify and enrol all eligible participants. Patient-controlled sedation is a novel approach to the management of patient symptoms that may be able to alleviate mechanical ventilation-induced distress without serious side effects. Findings from this study will provide insight into the efficacy of this approach on short- and long-term outcomes in a subset of mechanically ventilated patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02819141. Registered on June 29, 2016.

Operationalizing Ethical Guidance for Ventilator Allocation in Minnesota: Saving the Most Lives or Exacerbating Health Disparities?

A statewide working group in Minnesota created a ventilator allocation scoring system in anticipation of functioning under a Crisis Standards of Care declaration. The scoring system was intended for patients with and without coronavirus disease 2019. There was disagreement about whether the scoring system might exacerbate health disparities and about whether the score should include age. We measured the relationship of ventilator scores to in-hospital and 3-month mortality. We analyzed our findings in the context of ethical and legal guidance for the triage of scarce resources. DESIGN: Retrospective cohort study. SETTING: Multihospital within a single healthcare system. PATIENTS: Five-hundred four patients emergently intubated and admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Ventilator Allocation Score was positively associated with higher mortality (p < 0.0001). The 3-month mortality rate for patients with a score of 6 or higher was 96% (42/44 patients). Age was positively associated with mortality. The 3-month mortality rate for patients 80 and older with scores of 4 or greater was 93% (40/43 patients). Of patients assigned a score of 5, those with end stage renal disease had lower mortality than patients without end stage renal disease although the difference did not achieve statistical significance (n = 27; 25% vs 58%; p = 0.2). CONCLUSIONS: The Ventilator Allocation Score can accurately identify patients with high rates of short-term mortality. However, these high mortality patients only represent 27% of all the patients who died, limiting the utility of the score for allocation of scarce resources. The score may unfairly prioritize older patients and inadvertently exacerbate racial health disparities through the inclusion of specific comorbidities such as end stage renal disease. Triage frameworks that include age should be considered. Purposeful efforts must be taken to ensure that triage protocols do not perpetuate or exacerbate prevailing inequities. Further work on the allocation of scarce resources in critical care settings would benefit from consensus on the primary ethical objective.

Letting the Patient Decide: A Case Report of Self-Administered Sedation During Mechanical Ventilation.

It is common for critical care nurses to administer sedative medications to patients receiving mechanical ventilation. Although patient-controlled analgesia is frequently used in practice to promote effective self-management of pain by patients, it is not known if patient-controlled sedation can be used to promote effective self-management of distressing symptoms associated with mechanical ventilation. A randomized pilot trial was conducted to evaluate whether patient self-administered sedation with dexmedetomidine is safe and acceptable for self-management of anxiety during ventilator support. This case report details the experiences of one patient enrolled in the pilot trial who was randomly assigned to the experimental dexmedetomidine intervention, completed the study protocol, and provided feedback. In a poststudy survey, the patient responded positively to the use of self-administered sedation with dexmedetomidine during ventilator support.

Clinical and Sociocultural Factors Associated With Failure to Escalate Care of Deteriorating Patients.

In-hospital medical emergencies occur frequently. Understanding how clinicians respond to deteriorating patients outside the intensive care unit (ICU) could improve "rescue" interventions and rapid response programs. This was a qualitative study with interviews with 40 clinicians caring for patients who had a "Code Blue" activation or an unplanned ICU admission at teaching hospitals over 7 months. Four study physicians independently analyzed interview transcripts; refined themes were linked to the transcript using text analysis software. Nine themes were found to be associated with clinicians' management of deteriorating patients. Multiple human biases influence daily care for deteriorating hospitalized patients. A novel finding is that "moral distress" affects escalation behavior for patients with poor prognosis. Most themes indicate that ward culture influences clinicians to wait until the last minute to escalate care despite being worried about the patients' condition.

Safety and Acceptability of Patient-Administered Sedatives During Mechanical Ventilation.

BACKGROUND: Safety and acceptability of sedative self-administration by patients receiving mechanical ventilation is unknown. OBJECTIVES: To determine if self-administration of dexmedetomidine by patients is safe and acceptable for self-management of anxiety during ventilatory support. METHODS: In a pilot trial in 3 intensive care units, 17 intubated patients were randomly assigned to dexmedetomidine and 20 to usual care. Dexmedetomidine was administered via standard pumps for patient-controlled analgesia, with a basal infusion (0.1-0.7 µg/kg per hour) titrated by the number of patient-triggered doses (0.25 µg/kg per dose). Safety goals were heart rate greater than 40/min, systolic blood pressure greater than 80 mm Hg, and diastolic blood pressure greater than 50 mm Hg. Acceptability was based on patients' self-reported satisfaction and ability to administer the sedative. A 100-mm visual analog scale was used daily to assess patients' anxiety. RESULTS: The sample was 59% male and 89% white. Mean values were age, 50.6 years; score on the Acute Physiology and Chronic Health Evaluation, 60.1; and protocol duration, 3.4 days. Five dexmedetomidine patients had blood pressure and/or heart rate lower than safety parameters, necessitating short-term treatment. Nurses' adherence to reporting of safety parameters was 100%; adherence to the dexmedetomidine titration algorithm was 73%. Overall baseline anxiety score was 38.4 and did not change significantly (ßday = 2.1; SE, 2.5; P = .40). Most dexmedetomidine patients (92%) were satisfied or very satisfied with their ability to self-administer medication. CONCLUSIONS: For select patients, self-administration of dexmedetomidine is safe and acceptable.

Predictive Associations of Music, Anxiety, and Sedative Exposure on Mechanical Ventilation Weaning Trials.

BACKGROUND: Weaning from mechanical ventilation requires increased respiratory effort, which can heighten anxiety and later prolong the need for mechanical ventilation. OBJECTIVES: To examine the predictive associations of music intervention, anxiety, sedative exposure, and patients' characteristics on time to initiation and duration of weaning trials of patients receiving mechanical ventilation. METHODS: A descriptive, correlational design was used for a secondary analysis of data from a randomized trial. Music listening was defined as self-initiated, patient-directed music via headphones. Anxiety was measured daily with a visual analog scale. Sedative exposure was operationalized as a daily sedation intensity score and a sedative dose frequency. Analyses consisted of descriptive statistics, graphing, survival analysis, Cox proportional hazards regression, and linear regression. RESULTS: Of 307 patients, 52% were women and 86% were white. Mean age was 59.3 (SD, 14.4) years, mean Acute Physiology and Chronic Health Evaluation III score was 62.9 (SD, 21.6), mean duration of ventilatory support was 8 (range, 1-52) days, and mean stay in the intensive care unit was 18 (range, 2-71) days. Music listening, anxiety levels, and sedative exposure did not influence time to initial weaning trial or duration of trials. Clinical factors of illness severity, days of weaning trials, and tracheostomy placement influenced weaning patterns in this sample. CONCLUSIONS: Prospective studies of music intervention and other psychophysiological factors during weaning from mechanical ventilation are needed to better understand factors that promote successful weaning.

Metabolomics in COPD Acute Respiratory Failure Requiring Noninvasive Positive Pressure Ventilation.

We aimed to investigate whether metabolomic analysis can discriminate acute respiratory failure due to COPD exacerbation from respiratory failure due to heart failure and pneumonia. Since COPD exacerbation is often overdiagnosed, we focused on those COPD exacerbations that were severe enough to require noninvasive mechanical ventilation. We enrolled stable COPD subjects and patients with acute respiratory failure requiring noninvasive mechanical ventilation due to COPD, heart failure, and pneumonia. We excluded subjects with history of both COPD and heart failure and patients with obstructive sleep apnea and obstructive lung disease other than COPD. We performed metabolomics analysis using NMR. We constructed partial least squares discriminant analysis (PLS-DA) models to distinguish metabolic profiles. Serum (p=0.001, R2 = 0.397, Q2 = 0.058) and urine metabolic profiles (p < 0.001, R2 = 0.419, Q2 = 0.142) were significantly different between the four diagnosis groups by PLS-DA. After excluding stable COPD patients, the metabolomes of the various respiratory failure groups did not cluster separately in serum (p=0.2, R2 = 0.631, Q2 = 0.246) or urine (p=0.065, R2 = 0.602, Q2 = -0.134). However, several metabolites in the serum were reduced in patients with COPD exacerbation and pneumonia. We did not find a metabolic profile unique to COPD exacerbation, but we were able to clearly and reliably distinguish stable COPD patients from patients with respiratory failure in both serum and urine.

Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial.

IMPORTANCE: Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support. OBJECTIVE: To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients. DESIGN, SETTING, AND PATIENTS: Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. INTERVENTIONS: Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). MAIN OUTCOMES AND MEASURES: Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency). RESULTS: Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, -32.2 to -6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by -0.18 (95% CI, -0.36 to -0.004) points/day (P = .05) and had reduced frequency by -0.21 (95% CI, -0.37 to -0.05) points/day (P = .01). The PDM group had reduced sedation frequency by -0.18 (95% CI, -0.36 to -0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity. CONCLUSIONS AND RELEVANCE: Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00440700.

Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU.

BACKGROUND: Patients undergoing alcohol withdrawal in the intensive care unit (ICU) often require escalating doses of benzodiazepines and not uncommonly require intubation and mechanical ventilation for airway protection. This may lead to complications and prolonged ICU stays. Experimental studies and single case reports suggest the α2-agonist dexmedetomidine is effective in managing the autonomic symptoms seen with alcohol withdrawal. We report a retrospective analysis of 20 ICU patients treated with dexmedetomidine for benzodiazepine-refractory alcohol withdrawal. METHODS: Records from a 23-bed mixed medical-surgical ICU were abstracted from November 2008 to November 2010 for patients who received dexmedetomidine for alcohol withdrawal. The main analysis compared alcohol withdrawal severity scores and medication doses for 24 h before dexmedetomidine therapy with values during the first 24 h of dexmedetomidine therapy. RESULTS: There was a 61.5% reduction in benzodiazepine dosing after initiation of dexmedetomidine (n = 17; p < 0.001) and a 21.1% reduction in alcohol withdrawal severity score (n = 11; p = .015). Patients experienced less tachycardia and systolic hypertension following dexmedetomidine initiation. One patient out of 20 required intubation. A serious adverse effect occurred in one patient, in whom dexmedetomidine was discontinued for two 9-second asystolic pauses noted on telemetry. CONCLUSIONS: This observational study suggests that dexmedetomidine therapy for severe alcohol withdrawal is associated with substantially reduced benzodiazepine dosing, a decrease in alcohol withdrawal scoring and blunted hyperadrenergic cardiovascular response to ethanol abstinence. In this series, there was a low rate of mechanical ventilation associated with the above strategy. One of 20 patients suffered two 9-second asystolic pauses, which did not recur after dexmedetomidine discontinuation. Prospective trials are warranted to compare adjunct treatment with dexmedetomidine versus standard benzodiazepine therapy.

Patient-controlled sedation: a novel approach to sedation management for mechanically ventilated patients.

BACKGROUND: Patient self-administration of medications for analgesia and procedural sedation is common. However, it is not known whether mechanically ventilated ICU patients can self-administer their own sedation to manage symptoms. METHODS: This descriptive pilot study examined the safety, adequacy, and satisfaction of patient-controlled sedation (PCS) with a convenience sample of critically ill, mechanically ventilated patients (N = 17) in the ICUs at University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota. Dexmedetomidine was administered via a patient-demand infusion pump system for a maximum of 24 h. Pumps were programmed with basal infusion plus patient-triggered boluses; nurses adjusted the basal infusion based on a dosing algorithm. Data were collected on sedation adequacy, additional dosing of analgesics and sedatives, hemodynamic parameters, safety of PCS, patient satisfaction with PCS, and nurse satisfaction with PCS. RESULTS: Although a majority of the hemodynamic values were within the established safety parameters for the study, 25% of patients experienced mild adverse physiologic effects. Furthermore, despite patients' perception of sedation adequacy with PCS, 70% received supplemental opiates or benzodiazepine medications while participating in the study. Patients rated dexmedetomidine PCS favorably for self-management of anxiety, level of relaxation obtained, and comfort in self-administering sedation. Nurses also were generally satisfied with PCS as a method of sedation, dexmedetomidine as the sedative, and patient response to the sedation. CONCLUSIONS: PCS warrants further investigation as a means to promote comfort in mechanically ventilated critically ill patients.

Opioids and infections in the intensive care unit should clinicians and patients be concerned?

There is a large body of experimental evidence in research animals and in vitro models that opioids suppress the immune system. If this effect occurs in acute human disease, then patients cared for in Intensive Care Units (ICUs) would be a particularly vulnerable population. ICU patients have the most severe forms of acute infection, have the greatest risk of acquiring new infections in the hospital, and are exposed to high doses of opioids for long periods of time. We review the epidemiology of ICU infections and the pharmacoepidemiology of opioid use in critically ill patients. We critique the limited human research examining the relationship between opioids and infection and make recommendations on designing future clinical studies that could close the knowledge gap about the true hazards of opioid use in hospitalized patients.

The science of implementation: changing the practice of critical care.

PURPOSE OF REVIEW: Few would disagree that evidence from clinical research should be brought to the bedside in an efficient and equitable manner. Unfortunately, this common agreement does not result in practice change at the bedside where delayed and variable implementation is common. Recognition of this gap has resulted in a new discipline called implementation science that seeks to understand the reasons for slow adoption of clinical therapeutics and to discover effective strategies that accelerate practice change. This article reviews implementation theory and strategies and their effectiveness and relevance to critical care. RECENT FINDINGS: The absence of a proven effective framework for implementing clinical practice change has resulted in a patchwork of interventions in ambulatory and acute care medicine. There is an increasing appreciation that interventions should be undertaken only after careful, theory-based examination of the source and strength of the evidence, the organizational and professional context in which the change will be made, and the availability of facilitating methods. Barriers to implementing sepsis management programs have been identified and, in some cases, overcome. SUMMARY: Changing clinical practice is sometimes as difficult as the basic science and clinical trials work that led to the discovery of beneficial therapies. Investigators are now beginning to develop and test more theory-based implementation models that are relevant to the clinical environment. A proportion of the resources used in developing an ICU guideline or protocol must be dedicated to the implementation strategy for successful adoption. ICUs are ideal organizations to test new approaches in implementation science. Intensive care professionals should insist that their practice environment have both a culture that is supportive of adopting new practices and adequate resources to implement them into patient care.

Medical residents' self-reported adherence to guidelines during placement of central venous catheters .

In teaching hospitals, the majority of central venous catheters are placed by medical residents. No studies have examined residents' adherence to safe practices during these procedures. We conducted a survey to gather self-reported data on the techniques that internal medicine residents use when placing a central venous catheter to minimize their own risk of infection and their patients' risk of bleeding-related complications.

Post-ICU consequences of patient wakefulness and sedative exposure during mechanical ventilation.

OBJECTIVE: To determine the relationship between measures of critical illness (sedative/analgesic administration, wakefulness and organ dysfunction), intensive care unit (ICU) recall and symptoms of posttraumatic stress disorder. DESIGN: Prospective, observational study with post-ICU follow-up. SETTING: Medical and surgical ICUs at a teaching hospital. PATIENTS: Two hundred seventy-seven subjects requiring >36h of mechanical ventilation were enrolled; 149 completed follow-up interviews 2 months later and 80 at 6 months. INTERVENTIONS: None. RESULTS: ICU recall was greater for events occurring at the end of critical illness; however, 18% of subjects had amnesia for the entire ICU course. Factual ICU recall was weakly associated with increased wakefulness during mechanical ventilation (r2=0.03-0.11, p<0.05). Posttraumatic stress disorder prevalence was 17% at 2 months and 15% at 6 months. The avoidance-numbing cluster had the highest specificity (91%) for a formal diagnosis and the re-experiencing cluster had the lowest (69%). Recall of a delirious memory during critical illness was associated with more severe posttraumatic stress symptoms, but there was no association between posttraumatic stress symptoms and factual recall of ICU events. Neither ICU recall nor posttraumatic stress symptoms were associated with the intensity of sedative administration during mechanical ventilation. Posttraumatic stress symptoms were lowest in patients either the most awake during mechanical ventilation or the least awake. CONCLUSION: Wakefulness during mechanical ventilation has a greater influence on post-ICU recall and posttraumatic stress symptoms than sedative drug exposure or severity of illness. It is difficult to predict the future psychological consequences of an individual patient's critical illness.

Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit.

OBJECTIVE: Describe the pharmacoepidemiology of sedative medications and nurse-rated patients' behavior and sedation adequacy. DESIGN: Cohort study, 2001-2003. PATIENTS: Patients ventilated for >36 hrs in a medical or surgical intensive care unit at a university-affiliated hospital. Proxies for 312 eligible subjects were approached for consent, 277 subjects enrolled, and data from 274 subjects were analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Distribution of Arousal and Motor Activity levels, proportion of inadequate sedation and factors associated with inadequate sedation, variation of sedative therapy intensity, and behavior over time were measured. Sedatives were administered in 85% of 18,050 four-hour intervals during mechanical ventilation. Sedation was judged as adequate in 83% of 12,414 sedation assessments; patients were judged to be undersedated in 13.9% and oversedated in 2.6% of the assessments. Patients were unarousable or minimally arousable 32% of the time and had no spontaneous motor activity (during a 10-min observation period) 21.5% of the time. There was little variation in level of consciousness or motor activity or drug dose over 24 hrs, but daytime caregivers were more likely to judge patients as oversedated (3.7%) compared with nighttime caregivers (1.6%, p<.001). Inadequate sedation was associated with sedative drug intensity and patient behavior as measured by a two-domain sedation scale. Sedative drug intensity and behavior varied during the course of respiratory failure, and survivors received 13% more sedation per 4-hr interval of mechanical ventilation than nonsurvivors (p<.001). CONCLUSIONS: Although patients were minimally arousable or nonarousable in 32% and motionless in 21% of the sedation assessments, surprisingly, an oversedation rating occurred in <3%. This discrepancy, along with findings that time of day influences the interpretation of sedation adequacy and that patients' behavior change over time suggests that collaborative research is needed to define adequate sedation.

Academic and career development of pulmonary and critical care physician-scientists.

RATIONALE: The supply of research-oriented physicians is declining. OBJECTIVES: Define barriers to successful career development in academic pulmonary/critical care medicine and discover strategies that promote the recruitment and retention of research physicians. METHODS: Focus groups and Web-based survey of fellows and junior faculty in pulmonary/critical care and neonatology divisions in 2002. Primary survey areas were educational debt, mentoring, institutional resources, information needs, and academic productivity. MAIN RESULTS: Monthly educational debt payments were a small fraction of junior faculty household income, but the debt/income ratio was larger for fellows and less for female faculty. The debt/income ratio was not associated with the perceived likelihood of an academic career. Respondents felt they lacked understanding of the roadmap to success and formal assistance in career development. Mentors were perceived as personally supportive, but less helpful in career development. Perceived likelihood of an academic career was most associated for faculty with institutional research support and for fellows with mentors' academic advising. Better research skills and more career development activities were associated with respondents having a Ph.D. mentor. Perceptions about academic physicians' job security were pessimistic. CONCLUSIONS: Multiple factors influence decisions to pursue an academic medical career. In addition to alleviating financial pressures, academic careers may be aided by (1) providing more information about career pathways, job expectations, and success rates; (2) increasing career development mentoring; and (3) implementing formal curricula similar to Ph.D. programs. For pulmonary/critical care medicine faculty, current federal educational debt relief programs may have only a modest effect on academic retention.

Communication of prognostic information for critically ill patients.

STUDY OBJECTIVES: The purpose of this study was to determine whether the timing of prognostic information delivery by physicians is associated with caregiver satisfaction with communication or decision making in the ICU. DESIGN: Multicenter, prospective, longitudinal observational study. SETTING: Medical and surgical ICUs in a community and university hospital. PARTICIPANTS: Decision makers for critically ill patients. MEASUREMENTS AND RESULTS: Longitudinal surveys assessed both actual and desired frequency of communication with physicians, timing and content of physician prognosis, and subject satisfaction with physician communication and subject's role in decision making. Seventy subjects were enrolled and completed 216 surveys. Fifty-seven caregivers (81%) received prognostic information during the ICU stay, with a mean time between ICU admission and provision of prognostic information (prognostic interval) of 1.7 +/- 2.8 days (median, 1 day). This interval was not associated with patient age, severity of illness, clinical service, hospital, socioeconomic status, or prior patient ICU admission. A shorter prognostic interval was associated with increased satisfaction with communication, with a trend toward statistical significance (p = 0.06). Both the measured communication rate (p < 0.001) and subjects' desired communication rate with physicians decreased over time in the ICU (p < 0.001). Although 78% of subjects rated their overall satisfaction with frequency of communication as "good," "very good," or "excellent," their satisfaction with communication frequency decreased with time in the ICU (p = 0.006). CONCLUSIONS: Families of critically ill patients were generally satisfied with communication in the ICU; however, 19% were unable to recall receiving any prognostic information from physicians. Providing all decision makers with some prognostic information, even if it consists of a statement of uncertainty (as was commonly done in this study), may further improve satisfaction with ICU care. A widening gap between the actual and desired communication rate may result in a decline in communication satisfaction over the course of the ICU stay. This suggests that the capacity of physicians and other ICU personnel to manage families' communication expectations may positively influence caregiver satisfaction.

Impact of randomized trial results on acute lung injury ventilator therapy in teaching hospitals.

Reducing tidal volumes administered to patients with acute lung injury is the only intervention reported to decrease mortality resulting from this life-threatening condition. Whereas many medical advances are slowly brought into practice, clinicians in teaching hospitals are often assumed to be early adopters of new medical advances. Our objective was to examine trends in the ventilatory prescription for 398 patients with acute lung injury treated in three teaching hospitals from 1994 to 2001. There was no change in tidal volumes until mid to late 1998, when volumes started to slowly decline at the rate of 48.0 (95% confidence interval, 21.0 to 74.4) ml/year. In the 2 years after the results were released from a large trial that demonstrated the superiority of 6 ml/kg tidal volume therapy over 12 ml/kg, clinicians prescribed tidal volumes of 651 +/- 128 ml or 10.1 +/- 1.9 ml/kg. Tidal volumes after intubation were minimally reduced over the subsequent 2 days of mechanical ventilation (mean reduction, 33 ml). Hospital category, male sex, and disease onset before May 1999 were associated with higher volumes whereas lung injury severity was inversely associated. We conclude that clinicians practicing at these teaching hospitals have not rapidly adopted low tidal volume ventilation that may reduce mortality.