Ventilator Liberation: Evaluating Staff Perceptions of Practice and Policy Adherence.

Ventilator weaning and extubation practices in critically ill children: An Australian and New Zealand survey of practice

Multi-ICU proof-of-concept study and a single ICU before-after study. University hospital ICUs. Adult patients receiving mechanical ventilation. An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers. We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01-1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03-1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09-4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13-5.16 d; p = 0.040) shorter, compared with the expected durations without the application. Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

To evaluate contextual factors relevant to implementing pediatric ventilator liberation guidelines and to develop an implementation strategy for a multicenter collaborative. Cross-sectional qualitative analysis of a 2023/2024 survey. International, multicenter Ventilation Liberation for Kids (VentLib4Kids) collaborative. Physicians, advanced practice providers, respiratory therapists, and nurses. None. The survey was distributed to 26 PICUs representing 18 unique centers (17 in North American)-14 general medical/surgical, eight cardiac, and four mixed (1935 solicitations). All 409 responses were analyzed (prescribers 39.8%, nursing 32.8%, and respiratory therapists 27.4%). Three implementation tiers were identified based on perceptions of evidence, feasibility, positive impact, and favorability constructs. Tier A (≥ 80% agreement for all constructs) included extubation readiness testing (ERT) screening, ERT bundle, spontaneous breathing trials (SBTs), upper airway obstruction (UAO) risk mitigation, and risk stratified noninvasive respiratory support (NRS). Tier B (50-79% agreement) included standard risk SBT method, risk stratified SBT duration, and UAO risk assessment. Tier C (< 50% agreement) included high-risk SBT method, respiratory muscle strength testing, and infant NRS. The smallest perceived practice gaps were noted in tier A and the largest in tier C. The smallest practice gap was risk stratified NRS (88% agreement). The largest practice gap was respiratory muscle strength (18% agreement). In regression analysis, independently significant differences in perceptions based on role and unit type for multiple constructs were identified for UAO risk assessment, UAO risk mitigation, risk stratified NRS, and infant NRS. This survey study of the VentLib4Kids collaborative lays the foundation for phased implementation of the 2023 pediatric ventilator liberation guidelines. Early phases should focus on the best implementation profiles and smallest practice gaps. Later phases should address those that are more challenging. Unit- and role-based tailoring of differences should be considered for some recommendations more than others.

BackgroundIntensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams.MethodsThe telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months.DiscussionThe TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days.Trial registrationClinicaltrials.gov, NCT05141396, registered 12/02/2021.

Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. The trial was registered at ClinicalTrials.gov (No. NCT02863237).

Spontaneous awakening and breathing trials have been associated with shorter durations of mechanical ventilation and intensive care unit lengths of stay. Inconsistent spontaneous awakening trials and spontaneous breathing trials, mechanical ventilation weaning strategies, and interdisciplinary rounding processes contributed to prolonged mechanical ventilation duration and length of stay in a 44-bed adult medical intensive care unit. Methods A standardized rounding tool that focused on coordinating spontaneous awakening and breathing trials, and on their outcomes, was integrated into daily multidisciplinary rounds in a medical intensive care unit. Aggregated patient data from the 4-month project implementation phase were compared with historical data collected for 2 months before project implementation. During the 2-month preintervention phase, 613 adult patients were managed in the medical intensive care unit and 41 patients required mechanical ventilation, whereas during the 4-month intervention phase, 1271 patients were managed in the unit and 96 patients required mechanical ventilation. The project was associated with a 24% (0.89-day) reduction in the mean length of stay (3.72 vs 2.83 days) and a 46.3% (2.81 day) reduction in mechanical ventilation duration (6.06 vs 3.25 days) when comparing August 2019 to January 2020. A standardized rounding tool emphasizing a coordinated process for spontaneous awakening and breathing trials was associated with a shorter length of stay and duration of mechanical ventilation among patients in the medical intensive care unit. An evidence-based approach to weaning from mechanical ventilation and standardized rounding may be a cost-effective way to reduce mechanical ventilation duration and length of stay in a medical intensive care unit.

Introduction: The “B” element in the ABCDEF bundle stands for “both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)”. Implementation of this key component has been shown to decrease time on the ventilator, in the intensive care unit (ICU) and hospital, and one-year mortality. We aimed to compare sedation use and SAT and SBT conduct between two randomized controlled trials. Methods: The 2008 Awakening and Breathing Controlled (ABC) Trial found that daily paired SATs and SBTs improved one-year survival. In 2021, the Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial enrolled ventilated ICU patients in similar clinical settings as the ABC trial patients. We compared sedation use and SAT and SBT conduct in the ABC Trial’s interventional group (SAT+SBT; n=167, 1140 patient instances) with that in the PILOT study (n=2083, 8355 patient instances). We also examined reasons for failure of SAT and SBT safety screens and trials. Results: ABC’s interventional group of paired SAT and SBT safety screens had 1140/1140 (100%) patient-instances on sedatives and/or analgesic boluses or infusions while only 4228/8355 (51%) were in the PILOT trial. SAT safety screens were done in all ABC patient-instances on sedation and in 3889/4228 (92%) in PILOT. SAT safety screens were passed in 939/1140 (82%) instances in ABC and in 1897/3889 (49%) in PILOT. SAT was done in 895/939 (95%) in ABC and 1867/1897 (98%) in PILOT and passed in 837/895 (94%) in ABC and 1145/1867 (61%) in PILOT. Anxiety, agitation and pain were more common reasons for SAT failure in PILOT. SBT safety screens were done in 983/983 (100%) in ABC and 2083/2541 (82%) in PILOT and passed in 647/983 (66%) in ABC and 4475/8031 (56%) in PILOT. SBTs trials were done in all ABC’s instances and 8031/8370 (96%) in PILOT and passed in 319/603 (53%) in ABC and 3337/4454 (75%) in PILOT. Conclusions: Over the past 13 years, there has been a dramatic decrease in amount of continuous sedation and/or analgesia given to ICU patients. Performance of SAT/SBT safety screens, SATs, and SBTs remain high many years after the ABC study. Continued optimization of anxiety, agitation, and analgesia needs to occur to improve passing SATs. However, despite this, passing SBTs was higher in the PILOT trial.

Implementation of the "B" element-both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs)-of the ABCDEF bundle improves the outcomes for mechanically ventilated patients. In 2021, the Pragmatic Investigation of optimal Oxygen Targets (PILOT) trial investigating optimal oxygenation targets in patients on mechanical ventilation was completed. To compare SAT and SBT conduct between a randomized controlled trial and current clinical care. The 2008 Awakening and Breathing Controlled (ABC) Trial (2003-2006) randomized mechanically ventilated patients to paired SATs and SBTs versus sedation per usual care plus SBTs. The PILOT trial (2018-2021) enrolled patients years later where SAT + SBT conduct was observed. We compared SAT and SBT conduct in ABC's interventional group (SAT + SBT; n = 167, 1140 patient days) to that in PILOT (n = 2083, 8355 patient days). Spontaneous awakening trial safety screens were done in all 1140 ABC patient-days on sedation and/or analgesia and in 3889 of 4228 (92%) in PILOT. Spontaneous awakening trial safety screens were passed in 939 of 1140 (82%) instances in ABC versus only 1897 of 3889 (49%) in PILOT. Interestingly, SAT was performed in ≥95% of passed SAT safety screens in both trials and was passed in 837 of 895 (94%) in ABC versus 1145 of 1867 (61%) in PILOT. SBT safety screens were performed in all 983 ABC instances and 8031 of 8370 (96%) in PILOT. SBT safety screens were passed in 647 of 983 (66%) in ABC versus 4475 of 8031 (56%) in PILOT. Spontaneous breathing trial was performed in ≥93% of passed SBT safety screens in both trials and was passed in 319 of 603 (53%) in ABC versus 3337 of 4454 (75%) in PILOT. This study compared SAT/SBT conduction in an ideal setting to real-world practice, 13 years later. Performance of SAT/SBT safety screens, SATs, and SBTs between a definitive clinical trial (ABC) as compared to current clinical care (PILOT) remained high.

To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines. Worldwide online survey. Intensive care. A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle. There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was "prescribed" by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits. The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.

Background: Mechanical ventilation is common in critically ill children with cardiac disease, but literature focused on ventilator liberation practices for this unique pediatric subpopulation is limited. We aimed to describe current ventilator liberation practices in critically ill children with cardiac disease. Methods: Through the Pediatric Cardiac Critical Care Consortium, an electronic survey was distributed to pediatric ICU attending physicians caring for patients with cardiac disease evaluating institutional protocols and individual practices around ventilator liberation including criteria for extubation readiness testing (ERT), ERT components, spontaneous breathing trial (SBT) method and duration, timing of extubation, and postextubation respiratory support. Results: We received 133 responses representing 47 hospitals. ERT eligibility screening and SBT protocols were reported at 22 (47%) and 26 (55%) of the 47 institutions, respectively. Most respondents used SBTs in their assessment of extubation readiness (95%) and pressure support augmentation to CPAP for SBT (92%). Most respondents reported a maximum dose threshold for epinephrine (81%), above which they would not extubate. Some indices used for determination of extubation readiness were used by nearly all respondents: pulse oximetry (92%), serum lactate (86%), and arterial pH (85%); but some respondents also report using mixed venous saturation (68%), ventricular function (62%), near-infrared spectroscopy (62%), and systemic atrioventricular valve regurgitation (53%). Reported use of noninvasive respiratory support (NRS) after extubation was common, up to 90% in selected subgroups. There was wide variation in the type of NRS used in all populations. Conclusions: ERT eligibility screening and SBT protocols were reported in only half of the institutions surveyed, and notable variation exists between parameters surrounding extubation readiness assessment and postextubation respiratory support. These data suggest opportunities to increase protocol development to align with established clinical practice guidelines around ERT and conduct multi-center quality improvement to identify best practices for ventilator liberation in this patient population.

BACKGROUND: Incorporation of nurses and advanced practice providers (APPs) creates an opportunity to enhance the work of clinical trial consortia in providing care to children with central nervous system tumors enrolled on clinical trials. Within PNOC, nurses and APPs led an effort to engage nurse scientists in collaborative work. A formalized APP and nursing committee confirmed multi-institutional interest for this effort via a widely distributed, electronic survey. OBJECTIVES: The primary aim was to assess the need for a nursing and APP committee by surveying nurses, APPs, physicians, and CRCs across academic institutions within US and international sites. A secondary aim was to explore educational needs of nurses and APPs and establish resources to augment clinical trial protocol initiation and compliance. METHODS: A de-identified, electronic Qualtrics survey was distributed to all PNOC member institutions in Fall 2021. Participants were divided into 3 groups: physicians, nurses or APPs, and CRCs. RESULTS: A total of 68 participants from 20 different institutions completed surveys. All groups confirmed support for a formalized nursing and APP committee within PNOC. Nurses requested education on targeted therapies, specific study protocols, general neuro-oncology information, and late effects. Barriers for nurse participation included lack of dedicated time (50%) and travel funding for conferences (39%). The surveys elicited physicians overwhelmingly identified key needs for APP or nursing involvement in standardizing protocolized care across institutions (100%), education for patients and staff (95%), and protocol development (89%). CONCLUSIONS: Based on multi-institutional survey results, a nursing and APP working group has been established within PNOC. In response to the needs-based survey, the working group provides a quarterly nursing newsletter, offers education sessions and mentorship opportunities, and participates in multi-disciplinary, disease-specific working groups. Future efforts will review the impact of this committee on protocol development and compliance and overall clinical care of pediatric neuro-oncology patients.

IMPACT OF TWICE-DAILY MULTIDISCIPLINARY ROUNDING IN DECREASING TIME TO EXTUBATION FROM MECHANICAL VENTILATION IN THE ICU

Abstract:&#x0D; Background: The ICU nursing role is to minimize the agitation and suffering experienced by mechanically ventilated sedated patients while facilitating effective and safe clinical care, seeking to optimize outcomes for service users and health systems. This can be achieved with bundled EBP interventions. One care bundle for those patients is the “Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility” (ABCDEF) bundle. It deploys tailored, patient-centered pharmacological and non-pharmacological therapies for implementation in ward management and clinical practice. It seeks to shatter the paradigm of extended mechanical ventilation and associated sedation for ICU patients by guiding clinical decision-making and interventions algorithmically. &#x0D; Method: Randomized controlled studies will be included for the present systematic review with adult and pediatric patients who have been managed using the Awakening and Breathing Coordination protocol compared to the routine care in the ICUs. The Cochrane Library (Wiley), MEDLINE (PubMed), Scopus, and Web of Science electronic databases will be searched for articles published in English. The clinical outcomes of interest include successful weaning, incidence/prevalence of VAP, sedation level, and reduced stay in the ICU/hospital stay time. The reviewers will independently extract data with a standard form, recording observations concerning the reviewed studies’ research design, population, clinical interventions and outcomes, and techniques of data collection and analysis. Their independent findings will then be compared to check for consistency, and in the event of contrasting findings or interpretations, a third-party research expert will arbitrate.&#x0D; Results: The evidence from this review would particularly assist nursing decision-making on using spontaneous awakening trials and spontaneous breathing trials in combination for ventilated patients.&#x0D; Conclusion: The results could drive evidence-based practice to improve the quality of care for mechanically ventilated sedated patients in ICUs by building on the safety and clinical effectiveness of Randomized controlled trials.&#x0D; Protocol registration: PROSPERO CRD42022344884

This chapter will provide an overview of strategies for achieving the ultimate goal of discontinuing ventilator support in children with pediatric acute respiratory distress syndrome. Topics covered include how clinicians can determine whether children are ready to be assessed for extubation readiness, the indications for ventilator weaning and which ventilator and patient parameters to evaluate, and use of spontaneous awakening and spontaneous breathing trials. A review of ventilator modes commonly used in the process of weaning is provided. In some patients, ventilator liberation is facilitated by a tracheostomy. Use of ventilator weaning and extubation protocols is increasingly common across pediatric intensive care units. Multiple criteria can be used for assessing readiness for extubation in infants and children. Use of noninvasive ventilation, high-flow nasal cannula, and other respiratory supports can optimize extubation success.

BackgroundDespite high post-implementation adherence, clinicians may have unresolved questions or concerns regarding use of a protocol to standardize routine daily coordination of the spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) on ventilated patients. Unresolved questions or concerns may unwittingly curtail practice normalization, impacting practice sustainment when implementation support is withdrawn. The objective of this study was to identify unresolved questions or concerns that may persist following successful implementation of a coordinated SAT/SBT (C-SAT/SBT) protocol.MethodsWe used an attributed, cross-sectional survey of physicians, advanced practice providers, nurses and respiratory therapists likely to have participated in a C-SAT/SBT in 12 hospitals (15 intensive care units) in Utah and Idaho. We evaluated clinician perceptions of acceptability, including ease of use, usefulness and confidence, along with perceived practice normalization, six months post implementation of a protocol to routinize C-SAT/SBT use.ResultsC-SAT/SBT adherence was 83.1% at the 6th month post implementation. 606 clinicians completed the survey (response rate: 50.0%). Perceived individual usefulness, ease of use, and confidence using the C-SAT/SBT protocol were high [range: 72.1%-88.1% agree/strongly agree], though individuals not performing an SAT or SBT in more than six months and respiratory therapists scored lower. Perceived practice normalization was similar with 82.0% aggregate agreement [agree/strongly agree]. However, when stratifying respondents into four categories based upon respondent percentage agreement with all statements, 71% did not agree with at least one practice normalization statement and 27% agreed with less than 80% of statements, varying by role and site. Sets of observable characteristics or phenotypes regarding the degree of practice normalization begin to emerge by subgroup.ConclusionsUnresolved questions or concerns may persist regarding implementation of a C-SAT/SBT protocol among certain population subgroups despite current high practice adherence and high levels of perceived acceptability, including ease of use, usefulness and confidence. It is not clear what impact these unresolved questions or concerns may have on practice normalization and multi-year practice sustainment systemwide, including whether targeted late post-implementation strategies are needed to mitigate concerns and promote sustainment when implementation support is withdrawn.Supplementary InformationThe online version contains supplementary material available at 10.1186/s43058-025-00770-5.