Call to action: Blueprint for change in acute and critical care nursing.

Herein, we propose a blueprint for action to completely measure and recognize the care provided by acute and critical care nurses to be incorporated into policy that shapes and supports practice. We address the nature of nurses' work by identifying nine practice domains, hospital practice environment assumptions, and expected outcomes. Nurses' work, as a cross-system process, needs to be included in hospital-based core measures to fully reflect nurses' impact on patient care. We call for a balanced measurement portfolio focused on patient/family-, unit-, and systems-level outcomes. We focus on what nurses do and what patients and their families can expect rather than only on the elimination of select adverse events. We provide a way forward to allow measure development and implementation with incentives for their use. This approach to making nurses' contributions and impact on outcomes visible will enhance acute and critical care nursing practice and benefit patients and their families.

Protective Assets Reinforced With Integrated Care and Technology (PARITY): Protocol for a Randomized Controlled Trial.

BACKGROUND: Black women are significantly more likely to experience severe maternal morbidity and are 3 times as likely to die from pregnancy-related causes compared to White women. Using a strengths-based wellness approach within an integrated supportive care program provided by a community doula could offer pragmatic solutions for Black maternal disparities. The Protective Assets Reinforced with Integrated Care and Technology (PARITY) program consists of a wellness technology platform, including informational links to wellness content and reinforcing motivational SMS text messages, as well as community-based doula support delivered both in person and through the technology platform to improve Black maternal wellness. OBJECTIVE: This pilot randomized controlled trial (RCT) and mixed methods evaluation aims to (1) determine the feasibility and acceptability of the PARITY intervention; (2) investigate the preliminary efficacy of the PARITY intervention on clinical outcomes (maternal blood pressure, gestational weight gain, and cesarean birth); and (3) investigate changes to wellness behavioral outcomes (nutrition, physical activity, sleep, and health care adherence) and empowered strengths (self-efficacy, social support, motivation, resilience, problem-solving, and self-regulation) in the intervention group compared to a control group. METHODS: A 2-arm RCT and mixed methods evaluation will be conducted. Overall, 60 Black pregnant individuals will be randomized in a ratio of 1:1 to either the intervention or informational control group. Participants in the intervention group will receive access to the technology platform over a 12-week period that ends before birth. Intervention participants will be assigned a doula interventionist, who will meet with them 4 times during the intervention. All participants (intervention and control) will receive a referral for a birth doula at no cost, printed materials about having a healthy pregnancy, and community resources. Feasibility and acceptability will be assessed at the end of the program. Measures will be obtained at baseline (20-28 weeks), the 36th week of pregnancy, birth, and 6-12 weeks post partum. Summary statistics and distribution plots will be used to describe measured variables at each time point. A generalized linear mixed model with a shared random component will be used to analyze the effects of PARITY on clinical, wellness behavioral, and empowered strength outcomes, including baseline nutrition, physical activity, and sleep measures as covariates. For significant effects, post hoc contrasts will be adjusted using the Holm method to maintain comparison-wise error at or <.05. Missing data will be addressed using a pattern-mixture model. RESULTS: The National Institute of Nursing Research funded this pilot RCT. Recruitment, enrollment, and data collection are ongoing, and the estimated study completion date is October 2024. CONCLUSIONS: The expected results of this study will provide the feasibility and preliminary efficacy of the PARITY intervention, to be used in a larger trial with a 12-month PARITY program intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT05802615; https://clinicaltrials.gov/study/NCT05802615. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/58580.

Patient, Practice, and Organizational Factors Associated With Early Mobility Performance in Critically Ill Adults.

BACKGROUND: Adoption of early mobility interventions into intensive care unit (ICU) practice has been slow and varied. OBJECTIVES: To examine factors associated with early mobility performance in critically ill adults and evaluate factors' effects on predicting next-day early mobility performance. METHODS: A secondary analysis of 66 ICUs' data from patients admitted for at least 24 hours. Mixed-effects logistic regression modeling was done, with area under the receiver operating characteristic curve (AUC) calculated. RESULTS: In 12 489 patients, factors independently associated with higher odds of next-day mobility included significant pain (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.23), documented sedation target (AOR, 1.09; 95% CI, 1.01-1.18), performance of spontaneous awakening trials (AOR, 1.77; 95% CI, 1.59-1.96), spontaneous breathing trials (AOR, 2.35; 95% CI, 2.14-2.58), mobility safety screening (AOR, 2.26; 95% CI, 2.04-2.49), and prior-day physical/occupational therapy (AOR, 1.44; 95% CI, 1.30-1.59). Factors independently associated with lower odds of next-day mobility included deep sedation (AOR, 0.44; 95% CI, 0.39-0.49), delirium (AOR, 0.63; 95% CI, 0.59-0.69), benzodiazepine administration (AOR, 0.85; 95% CI, 0.79-0.92), physical restraints (AOR, 0.74; 95% CI, 0.68-0.80), and mechanical ventilation (AOR, 0.73; 95% CI, 0.68-0.78). Black and Hispanic patients had lower odds of next-day mobility than other patients. Models incorporating patient, practice, and between-unit variations displayed high discriminant accuracy (AUC, 0.853) in predicting next-day early mobility performance. CONCLUSIONS: Collectively, several modifiable and nonmodifiable factors provide excellent prediction of next-day early mobility performance.

Reclaiming narratives of empowerment around Black maternal health: a strengths-based, community-informed focus group study.

OBJECTIVES: Research on Black maternal populations often focuses on deficits that can reinforce biases against Black individuals and communities. The research landscape must shift towards a strengths-based approach focused on the protective assets of Black individuals and communities to counteract bias. This study engaged the local Black community using a strengths-based approach to discuss the assets of Black maternal populations and to inform the design of a future clinical trial focused on reducing Black maternal health disparities. DESIGN: Guided by the Theory of Maternal Adaptive Capacity, we conducted three purposive focus group sessions with Black adult community members. The focus groups were semi-structured to cover specific topics, including the strengths of the local community, strengths specific to pregnant community members, how the strengths of community members can support pregnant individuals, and how the strengths of pregnant community members can facilitate a healthy pregnancy. The focus group interviews were transcribed verbatim and analyzed using thematic content analysis. RESULTS: Three focus group sessions were conducted with sixteen female individuals identifying as Black or African American. Central themes include (1) the power of pregnancy and motherhood in Black women, (2) challenging negative perceptions and media representation of Black mothers, (3) recognizing history and reclaiming cultural traditions surrounding birth, and (4) community as the foundation of Black motherhood. CONCLUSION: Black community members identified powerful themes on Black maternal health through a strengths-based lens. These focus groups fostered relationships with the Black community, elucidated possible solutions to improve Black women's health and wellness, and offered direction on our research design and intervention.

Nurse practitioner-led, virtually delivered, motivational enhancement and device support intervention to improve CPAP adherence: A feasibility randomized control trial.

BACKGROUND: Evidence indicates continuous positive airway pressure (CPAP) therapy improves several important patient-centered outcomes. However, adherence to this safe and effective intervention remains poor. OBJECTIVES: Assess nine feasibility outcomes of a nurse practitioner-led, virtually delivered motivational enhancement and device support (MENDS) intervention to improve CPAP adherence in adults with Obstructive Sleep Apnea (OSA). Secondary aims compared the changes in CPAP adherence to patient-reported outcomes, patient activation, and perceived self-efficacy. METHODS: This two-group feasibility randomized controlled trial included 29 patients newly diagnosed with OSA and prescribed CPAP therapy. The study was conducted from July 2020 through December 2021 at a midwestern sleep/pulmonary clinic. Participants were randomized to the MENDS intervention group (n=14) (30-45 minute interactive tele-discussions on weeks 2, 4, 6, and 8) or to the usual care (n=15) group. Feasibility, patient-reported outcomes, and behavioral constructs were measured at baseline and 12 weeks. CPAP adherence was measured weekly. RESULTS: Feasibility of the MENDS sessions was demonstrated (56 sessions offered, 52 completed remotely without technical difficulties) with minimal participant attrition and no missing CPAP data. Generalized linear mixed models showed no statistically significant time-by-group interactions on adherence or patient-reported outcomes. Higher adherence and lower CPAP apnea-hypopnea index (AHI) scores were associated with declines in pre- to post-changes in fatigue and sleep disturbance. Lower CPAP AHI scores were associated with pre- to post-decreases in PROMIS Anxiety scores (r=.532, p=.005). CONCLUSION: The virtual MENDS intervention was feasible. Higher CPAP adherence and lower AHI levels led to positive improvements in fatigue, sleep disturbance, and anxiety.

Clinicians' perceptions on implementation strategies used to facilitate ABCDEF bundle adoption: A multicenter survey.

BACKGROUND: Intensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability. OBJECTIVES: To identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost. METHODS: We conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts. RESULTS: Nineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3). CONCLUSIONS: Our results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies.

An Exploration of Critical Care Professionals' Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study.

The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation. DESIGN: Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used. SETTING: Sixty-eight academic, community, and federal ICUs. PARTICIPANTS: A total of 121 ICU professionals consisting of frontline and leadership professionals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol. CONCLUSIONS: In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation.

Impact of a multifaceted early mobility intervention for critically ill children - the PICU Up! trial: study protocol for a multicenter stepped-wedge cluster randomized controlled trial.

BACKGROUND: Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery. METHODS: The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial's primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery. DISCUSSION: This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT04989790. Registered on August 4, 2021.

Post-intensive care syndrome: A review for the primary care NP.

ABSTRACT: Post-intensive care syndrome is a costly and complicated collection of physical, cognitive, and mental health problems experienced by survivors of critical illness. The primary care NP is uniquely positioned to assess, monitor, manage, and treat patients with this syndrome following hospital discharge.

Interprofessional Team Collaboration and Work Environment Health in 68 US Intensive Care Units.

BACKGROUND: Safe, reliable, high-quality critical care delivery depends upon interprofessional teamwork. OBJECTIVE: To describe perceptions of intensive care unit (ICU) teamwork and healthy work environments and evaluate whether perceptions vary by profession. METHODS: In August 2015, Assessment of Interprofessional Team Collaboration Scale (AITCS) and the American Association of Critical-Care Nurses Healthy Work Environment Assessment Tool (HWEAT) surveys were distributed to all interprofessional members at the 68 ICUs participating in the ICU Liberation Collaborative. Overall scores range from 1 (needs improvement) to 5 (excellent). RESULTS: Most of the 3586 surveys completed were from registered nurses (51.2%), followed by respiratory therapists (17.8%), attending physicians (10.5%), rehabilitation therapists (8.3%), pharmacists (4.9%), nursing assistants (3.1%), and physician trainees (4.1%). Overall, respondents rated teamwork and work environment health favorably (mean [SD] scores: AITCS, 3.92 [0.64]; HWEAT, 3.45 [0.79]). The highest-rated AITCS domain was "partnership/shared decision-making" (mean [SD], 4.00 [0.63); lowest, "coordination" (3.67 [0.80]). The highest-scoring HWEAT standard was "effective decision-making" (mean [SD], 3.60 [0.79]); lowest, "meaningful recognition" (3.30 [0.92]). Compared with attending physicians (mean [SD] scores: AITCS, 3.99 [0.54]; HWEAT, 3.48 [0.70]), AITCS scores were lower for registered nurses (3.91 [0.62]), respiratory therapists (3.86 [0.76]), rehabilitation therapists (3.84 [0.65]), and pharmacists (3.83 [0.55]), and HWEAT scores were lower for respiratory therapists (3.38 [0.86]) (all P ≤ .05). CONCLUSIONS: Teamwork and work environment health were rated by ICU team members as good but not excellent. Care coordination and meaningful recognition can be improved.

A Scoping Review of the Incidence, Predictors, and Outcomes of Delirium Among Critically Ill Stroke Patients.

ABSTRACT: BACKGROUND: Delirium is a common, often iatrogenically induced syndrome that may impede the physical, cognitive, and psychological recovery of critically ill adults. The effect delirium has on outcomes of intensive care unit patients having acute neurologic injury remains unclear because previous studies frequently exclude this vulnerable population. The aim of this scoping review was to describe the incidence, predictors, and outcomes of delirium among adults admitted to an intensive care unit experiencing an acute ischemic stroke, intracerebral hemorrhage, or aneurysmal subarachnoid hemorrhage. METHODS: PubMed, CINAHL, Web of Science, EMBASE, and Scopus were searched with the terms (1) stroke, (2) critical care, and (3) delirium. Inclusion criteria were original peer-reviewed research reporting the incidence, outcomes, or predictors of delirium after acute stroke among critically ill adults. Editorials, reviews, posters, conference proceedings, abstracts, and studies in which stroke was not the primary reason for admission were excluded. Title and abstract screening, full-text review, and data extraction were performed by 2 authors, with disagreements adjudicated by a third author. RESULTS: The initial search yielded 1051 results. Eighteen studies met eligibility criteria and were included in the review. Stroke type was not mutually exclusive and included persons given a diagnosis of acute ischemic stroke (11), intracerebral hemorrhage (12), aneurysmal subarachnoid hemorrhage (8), and other (1) strokes. Incidence of delirium among stroke patients ranged from 12% to 75%. Predictors of delirium included older age, preexisting dementia, higher severity of illness, and physical restraint use. Outcomes associated with delirium included higher mortality, longer length of stay, worse cognition and quality of life, and lower functional status. CONCLUSIONS: Current findings are limited by heterogenous populations, assessments, and measurement parameters. Detection and management of delirium among critically ill stroke patients requires an approach with specific considerations to the complexities of acute neurological injury and concomitant critical illness.

Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation.

BACKGROUND: The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor. OBJECTIVE: To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance. METHODS: This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation. RESULTS: Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility. CONCLUSIONS: Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.

Factors Associated With Spontaneous Awakening Trial and Spontaneous Breathing Trial Performance in Adults With Critical Illness: Analysis of a Multicenter, Nationwide, Cohort Study.

BACKGROUND: Broad-scale adoption of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) into everyday practice has been slow, and uncertainty exists regarding what factors facilitate or impede their routine delivery. RESEARCH QUESTION: What patient, practice, and pharmacologic factors are associated with SAT and SBT performance and to what extent do they predict overall SAT/SBT performance? STUDY DESIGN AND METHODS: This secondary analysis used data collected from a national quality improvement collaborative composed of 68 diverse ICUs. Adults with critical illness adults who received mechanical ventilation and/or continuously infused sedative medications were included. We performed mixed-effects logistic regression modeling, created receiver operating characteristic curves, and calculated the area under the curve (AUC). RESULTS: Included in the SAT and SBT analysis were 4,847 and 4,938 patients, respectively. In multivariable models controlling for admitting patient characteristics, factors independently associated with higher odds of a next-day SAT and SBT included physical restraint use (adjusted odds ratio [AOR], 1.63; 95% CI, 1.42-1.87; AOR, 1.83; 95% CI, 1.60-2.09), documented target sedation level (AOR, 1.68; 95% CI, 1.41-2.01; AOR, 1.46; 95% CI, 1.24-1.72), more frequent level of arousal assessments (AOR, 1.22; 95% CI, 1.03-1.43; AOR, 1.32; 95% CI, 1.13-1.54), and dexmedetomidine administration (AOR, 1.23; 95% CI, 1.05-1.45; AOR, 1.52; 95% CI, 1.27-1.80). Factors independently associated with lower odds of a next-day SAT and SBT included deep sedation/coma (AOR, 0.69; 95% CI, 0.60-0.80; AOR, 0.33; 95% CI, 0.28-0.37) and benzodiazepine (AOR, 0.83; 95% CI, 0.72-0.95; AOR, 0.67; 95% CI, 0.59-0.77) or ketamine (AOR, 0.34; 95% CI, 0.16-0.71; AOR, 0.40; 95% CI, 0.18-0.88) administration. Models incorporating admitting, daily, and unit variations displayed moderate discriminant accuracy in predicting next-day SAT (AUC, 0.73) and SBT (AUC, 0.72) performance. INTERPRETATION: There are a number of modifiable factors associated with SAT/SBT performance that are amenable to the development and testing of implementation interventions.

Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III.

OBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.

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

BACKGROUND: Spontaneous breathing trials (SBTs) are an evidence-based way of identifying patients ready for mechanical ventilation (MV) liberation. Despite their effectiveness, global SBT performance rates remain suboptimal, and many patients who demonstrate the ability to breathe on their own remain on MV. The factors that influence clinicians' decision to discontinue MV following a successful SBT remain unclear. AIMS: The aim of this study was to explore the underlying causes of extubation delays in the intensive care unit (ICU) from an interprofessional perspective. METHODS: An exploratory, descriptive, cross-sectional design was used. An online survey was administered in December 2019 to clinicians practicing in three ICUs at a single medical center in the U.S. Survey questions focused on clinicians' perceptions of current MV liberation practices and perceived barriers or facilitators to timely extubation after a successful SBT. RESULTS: Of 425 eligible clinicians, 135 completed the survey (31.7% response rate). The majority of clinicians believed the current SBT and extubation process took too long (n = 108; 80.0%) and that this delay negatively affected patient outcomes. While professional groups differed in their rankings of importance, factors perceived to contribute to extubation delays most commonly included SBT timing, low provider confidence levels in making extubation decisions, and patient-specific factors. Potential strategies to overcome these barriers included developing an automated extubation protocol, performing SBTs when the provider responsible for final extubation decisions is physically present, and decreasing clinician perception of reprimand or condemnation for failed extubations. LINKING EVIDENCE TO ACTION: The MV liberation process is complex and dependent on the decisions of various ICU professionals. Clinicians perceive a number of potentially modifiable provider- and organizational-level factors that cause extubation delays in everyday practice. Understanding and addressing these barriers is essential for improving ICU quality and patient outcomes. Future research should explore the effect of nurse and respiratory therapist-driven extubation protocols on MV liberation rates.

Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up!

OBJECTIVES: To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU. DESIGN: A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts. SETTING: Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD. SUBJECTS: Interprofessional PICU staff. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement. CONCLUSIONS: Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives.

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.

Losing touch.

The need for human touch is universal among critical care patients and is an important component of the nurse-patient relationship. However, multiple barriers to human touch exist in the critical care environment. With little research to guide practice, we argue for the importance of human touch in the provision of holistic nursing care.

Opioid and Benzodiazepine Withdrawal Syndromes in Trauma ICU Patients: A Prospective Exploratory Study.

Trauma ICU patients may require high and/or prolonged doses of opioids and/or benzodiazepines as part of their treatment. These medications may contribute to drug physical dependence, a response manifested by withdrawal syndrome. We aimed to identify risk factors, symptoms, and clinical variables associated with probable withdrawal syndrome. DESIGN: Prospective exploratory observational study. SETTING: Trauma ICU in large medical center in Puerto Rico. PARTICIPANTS: Fifty patients who received opioids and/or benzodiazepines for greater than or equal to 5 days. MEASUREMENTS AND MAIN RESULTS: Using an opioid/benzodiazepine withdrawal syndrome checklist developed from research in adult ICU patients, the Diagnostic and Statistical Manual of Mental Disorders-5, and the International Classification of Diseases, 10th Edition, we evaluated patients at baseline and for 72 hours after drug weaning was initiated. Patients received opioid/benzodiazepine (88%), opioid (10%), or benzodiazepine (2%). Probable withdrawal syndrome occurred in 44%, questionable withdrawal syndrome in 20%, and no withdrawal syndrome in 18 (36%). Signs that were more frequent in the probable withdrawal syndrome group were agitation, diarrhea, fever, tachypnea, lacrimation, and hyperactive delirium. Patients who developed probable withdrawal syndrome spent almost double the amount of time receiving mechanical ventilation, and length of stay was higher in both ICU and hospital when compared with patients in the other two groups. Age, cumulative opioid dose amounts, and previous drug (opioid/benzodiazepine, cannabis, cocaine, or heroin) use were associated with odds of developing withdrawal syndrome. With the addition of Richmond Agitation-Sedation Scale and delirium to the multilevel analysis, older age no longer had its protective effect, whereas increase in Richmond Agitation-Sedation Scale scores, delirium presence, and increased duration of mechanical ventilation were associated with higher odds of withdrawal syndrome. CONCLUSIONS: We identified probable withdrawal syndrome in a sample of trauma ICU patients through observation of several associated symptoms. Significant factors associated with withdrawal syndrome found in this study should be considered when caring for patients being weaned from opioids and/or benzodiazepines. Further validation of the opioid/benzodiazepine withdrawal syndrome checklist is recommended.