Frequency of screening and SBT Technique Trial-North American Weaning Collaboration (FAST-NAWC): an update to the protocol and statistical analysis plan.

BACKGROUND: This update summarizes key changes made to the protocol for the Frequency of Screening and Spontaneous Breathing Trial (SBT) Technique Trial-North American Weaning Collaborative (FAST-NAWC) trial since the publication of the original protocol. This multicenter, factorial design randomized controlled trial with concealed allocation, will compare the effect of both screening frequency (once vs. at least twice daily) to identify candidates to undergo a SBT and SBT technique [pressure support + positive end-expiratory pressure vs. T-piece] on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American intensive care units. METHODS/DESIGN: Protocols for the pilot, factorial design trial and the full trial were previously published in J Clin Trials ( https://doi.org/10.4172/2167-0870.1000284 ) and Trials (https://doi: 10.1186/s13063-019-3641-8). As planned, participants enrolled in the FAST pilot trial will be included in the report of the full FAST-NAWC trial. In response to the onset of the coronavirus disease of 2019 (COVID-19) pandemic when approximately two thirds of enrollment was complete, we revised the protocol and consent form to include critically ill invasively ventilated patients with COVID-19. We also refined the statistical analysis plan (SAP) to reflect inclusion and reporting of participants with and without COVID-19. This update summarizes the changes made and their rationale and provides a refined SAP for the FAST-NAWC trial. These changes have been finalized before completion of trial follow-up and the commencement of data analysis. TRIAL REGISTRATION: Clinical Trials.gov NCT02399267.

Automated APACHE II and SOFA score calculation using real-world electronic medical record data in a single center.

The integration of illness severity and organ dysfunction scores into clinical practice, including the APACHE II and SOFA scores, has been challenging due to constraints associated to manual score calculation. With electronic medical records (EMR), score calculation automation using data extraction scripts has emerged as a solution. We aimed to demonstrate that APACHE II and SOFA scores calculated with an automated EMR-based data extraction script predict important clinical endpoints. In this retrospective cohort study, every adult patient admitted to one of our three ICUs, between July 1, 2019, and December 31, 2020, were enrolled. For every patient, an automated ICU admission APACHE II score was calculated using EMR data and minimal clinician input. Fully automated daily SOFA scores were calculated for every patient. 4 794 ICU admissions met our selection criteria. Of these ICU admissions, 522 deaths were recorded (10.9% in-hospital mortality rate). The automated APACHE II was discriminant for in-hospital mortality (AU-ROC = 0.83 (95% CI 0.81-0.85)). We observed an association between the APACHE II score and ICU LOS, with a statistically significant mean increase of 1.1 days of ICU LOS (1.1 [1-1.2]; p = < .0001) for each 10 units increase in APACHE score. SOFA score curves did not discrimate significantly between survivors and non-survivors. A partially automated APACHE II score, calculated with real-world EMR data using an extraction script, is associated with in-hospital mortality risk. The automated APACHE II score could potentially constitute an acceptable surrogate of ICU acuity to be used in resource allocation and triaging, especially in time of high demand for ICU beds.

Factors influencing the implementation of a ventilation weaning protocol in an adult intensive care unit: a qualitative multidisciplinary evaluation.

PURPOSE: Development of protocolized care in the intensive care unit (ICU) improves patient outcomes, but presents multiple challenges. A mechanical ventilation weaning protocol (WP) was adopted in our institution but was underused. This study aimed to determine the factors that influenced the implementation of this protocol locally. METHODS: We performed a qualitative descriptive study using semidirected interviews in small profession-specific focus groups. The interviews were based on a standardized guide covering the major domains found in the Consolidated Framework for Implementation Research. A total of 32 participants across four key professions were recruited. The interviews were transcribed and codified sequentially, followed by categorization and analysis. RESULTS: Three broad factors emerged that negatively impacted the implementation of the WP. First, the goals of the WP differed between professional groups. This difference led to significant frustration and breaches in collaboration. Second, there was a lack of a continuous quality improvement process. Third, the WP was incompatible with the routine and procedures already in place at the time of implementation. Time-of-day of WP application and patient safety concerns were specifically identified issues. CONCLUSIONS: Implementation of a continuous improvement process with regular and specific follow-up may help identify potential challenges and thus help ensure a more consistent use of the WP.

RéSUMé: OBJECTIF : La mise au point de soins protocolisés à l'unité de soins intensifs (USI) améliore les issues pour les patients, mais présente de nombreux défis. Un protocole de sevrage de la ventilation mécanique a été adopté dans notre établissement mais a été sous-utilisé. Cette étude visait à déterminer les facteurs qui ont influencé la mise en œuvre de ce protocole au niveau local. MéTHODE: Nous avons réalisé une étude descriptive qualitative en nous fondant sur des entrevues semi-dirigées dans de petits groupes de discussion alloués par profession. Les entrevues étaient fondées sur un guide normalisé couvrant les principaux domaines du cadre CFIR (Consolidated Framework for Implementation Research). Au total, 32 participants de quatre professions clés ont été recrutés. Les entrevues ont été transcrites et codifiées séquentiellement, suivies d'une catégorisation et d'une analyse. RéSULTATS: Trois grands facteurs ayant un impact négatif sur la mise en œuvre du protocole de sevrage sont apparus. Premièrement, les objectifs du protocole de sevrage différaient d'un groupe professionnel à l'autre. Cette différence a entraîné une frustration importante et des bris de collaboration. Deuxièmement, il n'y avait pas de processus d'amélioration continue de la qualité. Troisièmement, le protocole de sevrage était incompatible avec la routine et les procédures déjà en place au moment de sa mise en œuvre. Le moment de la journée de l'application du protocole de sevrage et les préoccupations en matière de sécurité des patients ont été spécifiquement identifiés. CONCLUSION: La mise en œuvre d'un processus d'amélioration continue avec un suivi régulier et spécifique pourrait aider à identifier les défis potentiels, et ainsi assurer une utilisation plus cohérente du protocole de sevrage de la ventilation mécanique.

The evolution of mean arterial pressure in critically ill patients on vasopressors before and during a trial comparing a specific mean arterial pressure target to usual care.

BACKGROUND: In randomized clinical controlled trials, the choice of usual care as the comparator may be associated with better clinician uptake of the study protocol and lead to more generalizable results. However, if care processes evolve to resemble the intervention during the course of a trial, differences between the intervention group and usual care control group may narrow. We evaluated the effect on mean arterial pressure of an unblinded trial comparing a lower mean arterial pressure target to reduce vasopressor exposure, vs. a clinician-selected mean arterial pressure target, in critically ill patients at least 65 years old. METHODS: For this multicenter observational study using data collected both prospectively and retrospectively, patients were recruited from five of the seven trial sites. We compared the mean arterial pressure of patients receiving vasopressors, who met or would have met trial eligibility criteria, from two periods: [1] at least 1 month before the trial started, and [2] during the trial period and randomized to usual care, or not enrolled in the trial. RESULTS: We included 200 patients treated before and 229 after trial initiation. There were no differences in age (mean 74.5 vs. 75.2 years; p = 0.28), baseline Acute Physiology and Chronic Health Evaluation II score (median 26 vs. 26; p = 0.47) or history of chronic hypertension (n = 126 [63.0%] vs. n = 153 [66.8%]; p = 0.41). Mean of the mean arterial pressure was similar between the two periods (72.5 vs. 72.4 mmHg; p = 0.76). CONCLUSIONS: The initiation of a trial of a prescribed lower mean arterial pressure target, compared to a usual clinician-selected target, was not associated with a change in mean arterial pressure, reflecting stability in the net effect of usual clinician practices over time. Comparing prior and concurrent control groups may alleviate concerns regarding drift in usual practices over the course of a trial or permit quantification of any change.

Acute plastic bronchitis after Ross procedure treated with veno-venous extracorporeal membrane oxygenation.

PURPOSE: Plastic bronchitis is a rare condition characterized by the formation of airway casts occluding the lower respiratory tract. It is described more commonly in children, especially following correction of congenital heart disease. It involves lymphatic abnormalities leading to endobronchial lymph precipitating airway cast formation. When it presents acutely, it can lead to acute airway obstruction, which can be life-threatening. Plastic bronchitis has been rarely described in adults and is potentially underdiagnosed. The purpose of this case report is to emphasize, for the adult anesthesiologist and adult critical care physician, the importance of prompt diagnosis and respiratory support in a case of plastic bronchitis. CLINICAL FEATURES: A 40-yr-old female with severe aortic stenosis underwent a Ross procedure. The surgery was uneventful, but within two hours of arrival in the intensive care unit, the patient developed severe hypoxemia. Despite attempts to optimize her respiratory status, the patient remained severely hypoxemic, and veno-venous extracorporeal membrane oxygenation (ECMO) was initiated using a percutaneous femoro-femoral cannulation. A bronchoscopy showed bronchial secretions casting the proximal bronchus, suggestive of plastic bronchitis. After numerous bronchoscopies, we were able to clean the airways and wean the ECMO support on postoperative day 3. CONCLUSION: Plastic bronchitis can present in adult patients and be life-threatening when associated with acute respiratory failure. We report an unusual case of an adult patient treated with veno-venous ECMO for plastic bronchitis following cardiac surgery. Use of ECMO support while providing airway cleaning can be lifesaving in patients with respiratory failure secondary to plastic bronchitis.

RéSUMé: OBJECTIF: La bronchite plastique est une affection rare caractérisée par la formation de bouchons muqueux qui moulent et obstruent les voies aériennes inférieures. Elle est plus fréquemment décrite chez les enfants, en particulier après la correction d'une cardiopathie congénitale. Elle découle d'anomalies lymphatiques conduisant à l'accumulation de lymphe endobronchique, précipitant la formation de bouchons muqueux dans les voies aériennes. Lorsqu'elle se présente de manière aiguë, la bronchite plastique peut entraîner une obstruction aiguë des voies aériennes, une complication potentiellement fatale. La bronchite plastique a rarement été décrite chez l'adulte et est potentiellement sous-diagnostiquée. L'objectif de cette présentation de cas est de souligner, pour l'anesthésiologiste et l'intensiviste s'occupant d'une population adulte, l'importance d'un diagnostic rapide et d'un support respiratoire en cas de bronchite plastique. CARACTéRISTIQUES CLINIQUES: Une femme de 40 ans souffrant d'une sténose aortique sévère a bénéficié d'une procédure de Ross. La chirurgie s'est déroulée sans incident, mais dans les deux heures suivant son arrivée à l'unité de soins intensifs, la patiente a présenté une hypoxémie sévère. Malgré les tentatives d'optimisation de son état respiratoire, la patiente est restée gravement hypoxémique et une oxygénation par membrane extracorporelle (ECMO) veino-veineuse a été amorcée à l'aide d'une canulation fémoro-fémorale percutanée. Une bronchoscopie a montré des sécrétions bronchiques moulant les bronches proximales, évoquant une bronchite plastique. Après de nombreuses bronchoscopies, nous avons pu nettoyer les voies aériennes et sevrer la patiente du soutien ECMO au 3ème jour postopératoire. CONCLUSION: La bronchite plastique peut se présenter chez les patients adultes et être potentiellement fatale lorsqu'elle est associée à une insuffisance respiratoire aiguë. Nous rapportons un cas inhabituel d'une patiente adulte traitée par ECMO veino-veineuse pour une bronchite plastique après une chirurgie cardiaque. L'utilisation du soutien par ECMO simultanément au nettoyage des voies aériennes peut être nécessaire chez les patients atteints d'insuffisance respiratoire secondaire à une bronchite plastique.

Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65): protocol and statistical analysis plan for a randomised clinical trial.

INTRODUCTION: Vasodilatory hypotension is common among intensive care unit (ICU) patients; vasopressors are considered standard of care. However, optimal mean arterial pressure (MAP) targets for vasopressor titration are unknown. The objective of the Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65) trial is to ascertain the effect of permissive hypotension (vasopressor titration to achieve MAP 60-65 mm Hg) versus usual care on biomarkers of organ injury in hypotensive patients aged ≥65 years. METHODS AND ANALYSIS: OVATION-65 is an allocation-concealed randomised trial in 7 Canadian hospitals. Eligible patients are ≥65 years of age, in an ICU with vasodilatory hypotension, receiving vasopressors for ≤12 hours to maintain MAP ≥65 mm Hg during or after adequate fluid resuscitation, and expected to receive vasopressors for ≥6 additional hours. Patients are excluded for any of the following: active treatment for spinal cord or acute brain injury; vasopressors given solely for bleeding, ventricular failure or postcardiopulmonary bypass vasoplegia; withdrawal of life-sustaining treatments expected within 48 hours; death perceived as imminent; previous enrolment in OVATION-65; organ transplant within the last year; receiving extracorporeal life support or lack of physician equipoise. Patients are randomised to permissive hypotension versus usual care for up to 28 days. The primary outcome is high-sensitivity troponin T, a biomarker of cardiac injury, on day 3. Secondary outcomes include biomarkers of injury to other organs (brain, liver, intestine, skeletal muscle); lactate (a biomarker of global tissue dysoxia); resource utilisation; adverse events; mortality (90 days and 6 months) and cognitive function (6 months). Assessors of biomarkers, mortality and cognitive function are blinded to allocation. ETHICS AND DISSEMINATION: This protocol has been approved at all sites. Consent is obtained from the eligible patient, the substitute decision-maker if the patient is incapable, or in a deferred fashion where permitted. End-of-grant dissemination plans include presentations, publications and social media platforms and discussion forums. TRIAL REGISTRATION NUMBER: NCT03431181.

Correction to: Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay.

This editorial, "Internal Medicine Point of Care Ultrasound: Indicators It's Here to Stay" (DOI: 10.1007/s11606-019-05268-0), was intended to accompany "Education Indicators for Internal Medicine Point-of-Care Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group".

Frequency of Screening and SBT Technique Trial - North American Weaning Collaboration (FAST-NAWC): a protocol for a multicenter, factorial randomized trial.

RATIONALE: In critically ill patients receiving invasive mechanical ventilation (MV), research supports the use of daily screening to identify patients who are ready to undergo a spontaneous breathing trial (SBT) followed by conduct of an SBT. However, once daily (OD) screening is poorly aligned with the continuous care provided in most intensive care units (ICUs) and the best SBT technique for clinicians to use remains controversial. OBJECTIVES: To identify the optimal screening frequency and SBT technique to wean critically ill adults in the ICU. METHODS: We aim to conduct a multicenter, factorial design randomized controlled trial with concealed allocation, comparing the effect of both screening frequency (once versus at least twice daily [ALTD]) and SBT technique (Pressure Support [PS] + Positive End-Expiratory Pressure [PEEP] vs T-piece) on the time to successful extubation (primary outcome) in 760 critically ill adults who are invasively ventilated for at least 24 h in 20 North American ICUs. In the OD arm, respiratory therapists (RTs) will screen study patients between 06:00 and 08:00 h. In the ALTD arm, patients will be screened at least twice daily between 06:00 and 08:00 h and between 13:00 and 15:00 h with additional screens permitted at the clinician's discretion. When the SBT screen is passed, an SBT will be conducted using the assigned technique (PS + PEEP or T-piece). We will follow patients until successful extubation, death, ICU discharge, or until day 60 after randomization. We will contact patients or their surrogates six months after randomization to assess health-related quality of life and functional status. RELEVANCE: The around-the-clock availability of RTs in North American ICUs presents an important opportunity to identify the optimal SBT screening frequency and SBT technique to minimize patients' exposure to invasive ventilation and ventilator-related complications. TRIAL REGISTRATION: Clinical Trials.gov, NCT02399267 . Registered on Nov 21, 2016 first registered.

Education Indicators for Internal Medicine Point-of-Care Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group.

BACKGROUND: Curriculum development and implementation for internal medicine point-of-care ultrasound (IM POCUS) continues to be a challenge for many residency training programs. Education indicators may provide a useful framework to support curriculum development and implementation efforts across programs in order to achieve a consistent high-quality educational experience. OBJECTIVE: This study seeks to establish consensus-based recommendations for education indicators for IM POCUS training programs in Canada. DESIGN: This consensus study uses a modified nominal group technique for voting in the initial round, followed by two additional rounds of online voting, with consensus defined as agreement by at least 80% of the participants. PARTICIPANTS: Participants were 22 leaders with POCUS and/or education expertise from 13 Canadian internal medicine residency programs across 7 provinces. MAIN MEASURES: Education indicators considered were those that related to aspects of the POCUS educational system, could be presented by a single statistical measure, were readily understood, could be reliably measured to provide a benchmark for measuring change, and represented a policy issue. We excluded a priori indicators with low feasibility, are impractical, or assess learner reactions. Candidate indicators were drafted by two academic internists with post-graduate training in POCUS and medical education. These indicators were reviewed by two internists with training in quality improvement prior to presentation to the expert participants. KEY RESULTS: Of the 52 candidate education indicators considered, 6 reached consensus in the first round, 12 in the second, and 4 in the third round. Only 5 indicators reached consensus to be excluded; the remaining indicators did not reach consensus. CONCLUSIONS: The Canadian Internal Medicine Ultrasound (CIMUS) group recommends 22 education indicators be used to guide and monitor internal medicine POCUS curriculum development efforts in Canada.

Early Evidence of Sepsis-Associated Hyperperfusion-A Study of Cerebral Blood Flow Measured With MRI Arterial Spin Labeling in Critically Ill Septic Patients and Control Subjects.

OBJECTIVES: Mechanisms underlying sepsis-associated encephalopathy remain unclear, but reduced cerebral blood flow, alone or in conjunction with altered autoregulation, is reported as a potential contributor. We compared cerebral blood flow of control subjects and vasopressor-dependent septic patients. DESIGN: Randomized crossover study. SETTING: MRI with arterial spin labeling. PATIENTS: Ten sedated septic patients on mechanical ventilation (four with controlled chronic hypertension) and 12 control subjects (six with controlled chronic hypertension) were enrolled. Mean ± SD ages were 61.4 ± 10.2 and 44.2 ± 12.8 years, respectively (p = 0.003). Mean Acute Physiology and Chronic Health Evaluation II score of septic patients at ICU admission was 27.7 ± 6.6. INTERVENTIONS: To assess the potential confounding effects of sedation and mean arterial pressure, we measured cerebral blood flow with and without sedation with propofol in control subjects and at a target mean arterial pressure of 65 mm Hg and greater than or equal to 75 mm Hg in septic patients. The sequence of sedation versus no sedation and mean arterial pressure targets were randomized. MEASUREMENTS AND MAIN RESULTS: In septic patients, cerebral blood flow measured at a mean arterial pressure target of 65 mm Hg (40.4 ± 10.9 mL/100 g/min) was not different from cerebral blood flow measured at a mean arterial pressure target of greater than or equal to 75 mm Hg (41.3 ± 9.8 mL/100 g/min; p = 0.65). In control subjects, we observed no difference in cerebral blood flow measured without and with sedation (24.8 ± 4.2 vs 24.9 ± 5.9 mL/100 g/min; p = 0.93). We found no interaction between chronic hypertension and the effect of sedation or mean arterial pressure targets. Cerebral blood flow measured in sedated septic patients (mean arterial pressure target 65 mm Hg) was 62% higher than in sedated control subjects (p = 0.001). CONCLUSIONS: In septic patients, cerebral blood flow was higher than in sedated control subjects and did not vary with mean arterial pressure targets. Further research is required to understand the clinical significance of cerebral hyperperfusion in septic patients on vasopressors and to reassess the neurologic effects of current mean arterial pressure targets in sepsis.

Use of Cold Fluids in Postcardiac Arrest Therapeutic Hypothermia: A Safety Analysis.

Therapeutic hypothermia (TH) has been part of the standard care of postresuscitation patients for more than a decade. Multiple cooling methods are available, including the administration of cold intravenous (IV) fluids. Although this method is widely used, the safety of administration of large volumes of cold IV fluids has not been clearly demonstrated in the literature, and recent evidence points to potential deleterious effects associated with administration of large IV fluid volumes. We conducted a retrospective cohort study among patients who have been treated with TH after cardiac arrest between November 2011 and November 2013 at a tertiary care hospital in Sherbrooke, Quebec, Canada. The primary outcome was the effect of IV fluid quantity on the 28-day survival rate. We reviewed 29 cases, with a total 28-day surviving rate of 51.7%. After adjusting for confounding variables, 28-day surviving rate was not significantly associated with the amount of fluids administrated (odds ratio = 1.034; confidence interval 95% [0.741-1.464]; p = 0.85). The amount of fluids did not influence the variation of the pulmonary component of the sequential organ failure assessment score between days 1 and 3 (ρ = -0.2, p = 0.34). Despite a small sample of patients, cold IV fluids in TH appear safe in the postcardiac arrest population. These findings should be reproduced in a larger, prospective study.

Vasopressor Use for Severe Hypotension-A Multicentre Prospective Observational Study.

BACKGROUND: The optimal approach to titrate vasopressor therapy is unclear. Recent sepsis guidelines recommend a mean arterial pressure (MAP) target of 65 mmHg and higher for chronic hypertensive patients. As data emerge from clinical trials comparing blood pressure targets for vasopressor therapy, an accurate description of usual care is required to interpret study results. Our aim was to measure MAP values during vasopressor therapy in Canadian intensive care units (ICUs) and to compare these with stated practices and guidelines. METHOD: In a multicenter prospective cohort study of critically ill adults with severe hypotension, we recorded MAP and vasopressor doses hourly. We investigated variability across patients and centres using multivariable regression models and Analysis of variance (ANOVA), respectively. RESULTS: We included data from 56 patients treated in 6 centers. The mean (standard deviation [SD]) age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were 64 (14) and 25 (8). Half (28 of 56) of the patients were at least 65 years old, and half had chronic hypertension. The patient-averaged MAP while receiving vasopressors was 75 mm Hg (6) and the median (1st quartile, 3rd quartile) duration of vasopressor therapy was 43 hours (23, 84). MAP achieved was not associated with history of underlying hypertension (p = 0.46) but did vary by center (p<0.001). CONCLUSIONS: In this multicenter, prospective observational study, the patient-level average MAP while receiving vasopressors for severe hypotension was 75 mmHg, approximately 10 mmHg above current recommendations and stated practices. Moreover, our results do not support the notion that clinicians tailor vasopressor therapy to individual patient characteristics such as underlying chronic hypertension but MAP achieved while receiving vasopressors varied by site.

Propofol infusion syndrome resuscitation with extracorporeal life support: a case report and review of the literature.

We report a case of propofol infusion syndrome (PRIS) in a young female treated for status epilepticus. In this case, PRIS rapidly evolved to full cardiovascular collapse despite aggressive supportive care in the intensive care unit, as well as prompt discontinuation of the offending agent. She progressed to refractory cardiac arrest requiring emergent initiation of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR). She regained a perfusing rhythm after prolonged (>8 hours) asystole, was weaned off ECMO and eventually all life support, and was discharged to home. We also present a review of the available literature on the use of ECMO for PRIS.

An institutionwide approach to redesigning management of cardiopulmonary resuscitation.

BACKGROUND: Despite widespread training in basic life support (BLS) and advanced cardiovascular life support (ACLS) among hospital personnel, the likelihood of survival from in-hospital cardiac arrests remains low. In 2006 a university-affiliated tertiary medical center initiated a cardiopulmonary (CPR) resuscitation redesign project. REDESIGNING THE HOSPITAL'S RESUSCITATION SYSTEM: The CPR Committee developed the interventions on the basis of a large-scale view of the process of delivering BLS and ACLS, identification of key decision nodes and actions, and compartmentalization of specific functions. It was proposed that arrest management follow a steady progression in a two-layer scheme from BLS to ACLS. Handouts describing team structure and specific roles were given to all code team providers and house staff at the start of their month-long rotations. To further increase role clarity and team organization, daily morning and evening meetings of the arrest team were instituted. Site-specific BLS training, on-site ACLS refresher training, and defibrillator training were initiated. Project elements also included use of unannounced mock codes to provide system oversight; preparation and distribution of cognitive aids (printed algorithms, dosing guides, and other checklists to ensure compliance with ACLS protocols), identification of patients who may be unstable or a source of concern, event review and analysis of arrests and other critical events, and a CPR website. CONCLUSION: A mature hospital-based resuscitation system should include definition of arrest trends and resuscitation needs, development of local methods for approaching the arresting patient, an emphasis on prevention, establishment of training programs tailored to meet specific hospital needs, system examination and oversight, and administrative processes that maximize interaction between all components.