Norwegian Intensive Care Units Research Articles

Critical care nurses' competence in mentoring students in intensive care units—A cross-sectional study

BackgroundMentors play an important role in the practical education of critical care nursing students in intensive care units, yet little is known about the mentoring competencies of critical care nurses. AimThe aim of this study was to assess Norwegian critical care nurses' competence in mentoring students in intensive care units. DesignThis study has a descriptive, cross-sectional design, utilising a self-administered online survey. SettingsThe study population consisted of critical care nurses who mentor students in Norwegian intensive care units. Participants178 critical care nurses participated in the study. The participants were recruited by contacting the units directly, through social media, and at a national critical care nursing conference. MethodsThe study utilised the Mentors' Competence Instrument, a self-evaluation tool for evaluating mentoring competence. ResultsThe Norwegian critical care nurses generally evaluated their mentoring competence as middle to high level. The “reflection during mentoring” dimension was rated as the highest and “student-centered evaluation” as the lowest competence dimension. The critical care nurses who had formal mentoring education reported significantly higher mentoring competences, but the other demographic characteristics were not related to mentoring competence. Regardless of previous mentoring education, most participants reported a need to further develop their mentoring competencies. ConclusionsEmployers should collaborate with educational institutions to establish a system for continuous competence development for critical care nurse mentors.

The Effect of Noise and Light on Sedation in Critical Care Patients. A Cross-Sectional Study of Critical Care Nurses in Three Intensive Care Units in Norway

Background: International guidelines for pain, sedation, delirium, immobility, and sleep in critically ill patients recommend the use of noise and light reduction strategies to improve sleep. The aims of this study were: 1) to evaluate critical care nurses’ (CCNs) perceptions regarding sources of noise and light in the intensive care unit (ICU), and 2) to identify factors associated with critical care patients’ need for sedation when their sleep is disturbed by noise or light. Methods: A cross-sectional study was conducted in three Norwegian ICUs (n = 193). Results: A total of 87% of the CCNs stated that critical care patients were exposed to noise, and the most frequent sources were alarms from monitoring equipment (71%) and mechanical ventilators (70%), and nurses talking (65%). The results demonstrated higher odds for critical care patients needing sedation when sleep was disturbed by noise, if the CCNs reported that noise disturbed patients sleep (OR 3.05), and lower odds if the CCN was from ICU C (OR 0.39). Most CCNs (82%) answered that there was a difference in the level of light during day versus night, and that the most frequent source of light at night was from small lamps (46%). It was higher odds that the CCNs perceived that critical care patients needed sedation when sleep was disturbed by light if the light disturbed the patient’s sleep in the unit (OR 4.78). There were lower odds if the CCNs was from ICU A (OR 0.32) or ICU C (OR 0.34). Conclusion: The findings from this study indicate that CCNs use sedatives to induce sleep for critical care patients to compensate for environmental factors such as noise and light. Variations between ICUs indicate different sedation practices between Norwegian ICUs.

ICU nurses’ experiences of medication double-checking: A qualitative study

Patients in the intensive care unit (ICU) are often on potent medications. According to Norwegian medication administration regulations, all intravenous medications should be subject to double-checking before patient administration. The aim of this study was to explore Norwegian ICU nurses’ perceptions of how medication double-checking is practiced in the ICU. We chose a qualitative and explorative design, used the COREQ reporting guideline and performed two focus group interviews in two ICUs. This study found that barriers to performing double-checking included understaffing, physical unit design and a lack of written medication orders. In clinical practice, informal guidelines exist as to which medications should always be double-checked and which medications can be administered without a prior double-check. The informants felt reluctant to administer medications without prior double-checking. The graded approach to medication double-checking practiced in our two ICUs is not in agreement with Norwegian regulations but is more in line with international recommendations.

Symptoms of Anxiety, Depression, and Post-Traumatic Stress Disorder in Health Care Personnel in Norwegian ICUs during the First Wave of the COVID-19 Pandemic, a Prospective, Observational Cross-Sectional Study.

Background: The COVID-19 pandemic has induced demanding work situations in intensive care units (ICU). The objective of our study was to survey psychological reactions, the disturbance of social life, work effort, and support in ICU nurses, physicians, and leaders. Methods: From May to July 2020, this cross-sectional study included 484 ICU professionals from 27 hospitals throughout Norway. Symptoms of anxiety and depression were measured on Hopkins Symptom Checklist-10 (HSCL-10). Symptoms of post-traumatic stress disorder (PTSD) were measured on the PCL-5. Results: The study population were highly educated and experienced professionals, well prepared for working with COVID-ICU patients. However, 53% felt socially isolated and 67% reported a fear of infecting others. Probable cases of anxiety and depression were found in 12.5% of the registered nurses, 11.6% of the physicians, and 4.1% of the leaders. Younger age and <5 years previous work experiences were predictors for high HSCL-10 scores. Reported symptom-defined PTSD for nurses 7.1%; the leaders, 4.1%; and 2.3% of physicians. Conclusions: ICU health care professionals experienced talking with colleagues as the most helpful source of support. The COVID-ICU leaders reported a significantly higher mean score than physicians and nurses in terms of pushing themselves toward producing high work effort.

Acute kidney injury in patients with COVID-19 in the intensive care unit: evaluation of risk factors and mortality in a national cohort

ObjectivesAcute kidney injury (AKI) is a frequent complication among critical ill patients with COVID-19, but the actual incidence is unknown as AKI-incidence varies from 25% to 89% in intensive care...

Interhospital transport of critically ill patients: A prospective observational study of patient and transport characteristics.

The cohort of critically ill patients transported between Intensive Care Units (ICUs) in Norway has not been studied previously. The aim of this study was to describe the characteristics of patients and transports for different types of interhospital transfers and explore whether there were differences in morbidity and mortality between the different transfer categories and the general Norwegian ICU population. All transports of critically ill adult patients transferred between two geographically different Intensive Care Units during a one-year period were registered. Patient and transport data were obtained from The Norwegian Intensive Care Registry, The Norwegian Cause of Death Registry, the hospital Electronic Patient Journal, the Air Ambulance Journal System, and the Emergency Medical Communication Centre database. 821 transports of 788surgical and medical patients were enrolled. Simplified Acute Physiology Scores (SAPSII) were 43, 36 and 38 for urgent secondary transport, non-urgent secondary transport and return transfers, respectively. These were comparable to nationwide SAPSII scores that were 40 for university hospitals and 34 for local hospitals during the same time period. The return transfers had a median SOFA-score of 4.7 and 53% were mechanically ventilated. Only 33% of return transfers were performed by established teams. Intensive care patients transferred between ICUs are as critically ill as the rest of the ICU population, with a similar morbidity and mortality. The return transfers of ICU-patients appear under-triaged compared to secondary transports in terms of allocated resources.

Characteristics, management and survival of ICU patients with coronavirus disease-19 in Norway, March-June 2020. A prospective observational study.

BackgroundNorwegian hospitals have operated within capacity during the COVID‐19 pandemic. We present patient and management characteristics, and outcomes for the entire cohort of adult (>18 years) COVID‐19 patients admitted to Norwegian intensive care units (ICU) from 10 March to 19 June 2020.MethodsData were collected from The Norwegian intensive care and pandemic registry (NIPaR). Demographics, co‐morbidities, management characteristics and outcomes are described. ICU length of stay (LOS) was analysed with linear regression, and associations between risk factors and mortality were quantified using Cox regression.ResultsIn total, 217 patients were included. The male to female ratio was 3:1 and the median age was 63 years. A majority (70%) had one or more co‐morbidities, most frequently cardiovascular disease (39%), chronic lung disease (22%), diabetes mellitus (20%), and obesity (17%). Most patients were admitted for acute hypoxaemic respiratory failure (AHRF) (91%) and invasive mechanical ventilation (MV) was used in 86%, prone ventilation in 38% and 25% of patients received a tracheostomy. Vasoactive drugs were used in 79% and renal replacement therapy in 15%. Median ICU LOS and time of MV was 14.0 and 12.0 days. At end of follow‐up 45 patients (21%) were dead. Age, co‐morbidities and severity of illness at admission were predictive of death. Severity of AHRF and male gender were associated with LOS.ConclusionsIn this national cohort of COVID‐19 patients, mortality was low and attributable to known risk factors. Importantly, prolonged length‐of‐stay must be taken into account when planning for resource allocation for any next surge.

Nurses’ experiences of ICU diaries following implementation of national recommendations for diaries in intensive care units: A quality improvement project

ObjectivesTo evaluate critical care nurses’ experiences of ICU diaries following the implementation of national recommendations for the use of diaries for critically ill patients. DesignA quality improvement project describing the development and implementation of national recommendations (2011), as well as the assessment of the use of diaries in intensive care nursing practice (2014). SettingNorwegian intensive care units (ICUs). ParticipantsThirty-nine Norwegian ICUs took part in the study. InterventionA multi-component process for developing national recommendations for the use of diaries in Norwegian ICUs, including recommendations for the target group, when to start, health professionals as authors, diary content, structure, language, use of photographs, handover, access and storage within patient medical records. Main outcome measureA questionnaire asking about experiences of implementing national recommendations on diaries in Norwegian ICUs, as well as their impact and how they are used. ResultsThree years after the implementation of the national recommendations, diaries were provided in 24 (61.5%) of the responding ICUs. Fifty-six per cent of the ICUs had revised their routines, of which 62% had updated and 38% had developed new protocols. Most ICUs kept the diary along with other medical information describing patient care, but only 50% of the ICUs scanned handwritten diaries into the electronic medical records before handing them over to patients or the bereaved. ICU nurses reported that implementing national recommendations had increased their awareness and knowledge on patient and family needs, as well as the long-term effects of critical illness. ConclusionThe results of this quality improvement project indicate that access to national recommendations on the use of diaries for critically ill patients have a potential of changing routines and increase standardisation.

Movements and trends in intensive care pain treatment and sedation: What matters to the patient?

Oversedation, delirium and immobilisation in the intensive care unit are associated with increased length of stay in the unit. Routines of systematic pain and sedation assessment and the use of valid tools are highly stressed in international guidelines. For improving the quality of pain treatment and sedation in a Norwegian intensive care unit, in 2009-2015, we compared supplementation with an analgosedation approach and the existing systematic approach, measured by the adherence to current international pain, sedation and delirium guidelines. In a longitudinal study following the Standards for Reporting Implementation Studies, pain, sedation, delirium and mobilisation data from patients' complete intensive care unit stays, encompassing three separate periods of 4-6months, were compared. The primary outcome was adherence to current protocol including assessment and documentation of patients' level of pain, sedation and prevalence of delirium at least every 8hr, early mobilisation and titration towards a light level of sedation. We included 205 patients, corresponding to 1,607 patient intensive care unit days. The patient sedation levels, measured by the Richmond Agitation and Sedation Scale, decreased significantly, from -2.2 in 2009--1.7 in 2015, so did the amount of administrated propofol. Mean pain scores measured by the numeric rating scale during activity were maximum 3.1 in 2014, decreasing to 2.2 in 2015. In patients not able to self-report, pain mean scores were 1.7 in 2014 and 1.6 in 2015, measured by the Critical Care Pain Observational Tool. The number of patients unable to assess for delirium decreased significantly. By discounting the group of patients unable to assess, the prevalence of delirium varied from 32%, 25% and 33%. The goal of having an awake patient able to cooperate, with acceptable levels of pain, was gradually achieved during a 6-year period. The results showed that pain treatment and sedation in the intensive care unit primarily succeeded in the setting of an established routine of systematic assessment and documentation. The results of the study draw attention to pain treatment, sedation and delirium in intensive care patients, as well as implementation strategies aimed at achieving healthcare personnel's adherence to international guidelines in clinical practice.

The creation of meaning – Intensive care nurses’ experiences of conducting nurse-led follow-up on intensive care units

ObjectiveTo explore and describe the experiences of Norwegian intensive care unit nurses providing nurse-led follow-up to patients and their families. Design and methodsThe study had a qualitative design with a phenomenological approach. Three focus-group interviews were conducted with nurses on three intensive care units. Giorgi’s phenomenological method guided the analysis. FindingsThe creation of meaning emerged as a general structure describing intensive care nurses’ experiences of nurse-led follow-up. When caring for critically ill patients, nurses described becoming emotionally moved, which motivated them to perform nurse-led follow-up procedures, such as writing in patient diaries. A general wish to give context to the patients’ time spent in intensive care emerged. When conducting nurse-led follow-up, the nurses made personal contributions, which could be emotionally challenging for them. Overall, nurse-led follow-up was found to increase nurses’ insight into and motivation for their own practice. ConclusionThe performance of nurse-led follow-up appears to be grounded in care for and engagement in individual patients and families. The nurses studied wanted to help patients and families to be able to handle their experiences during an intensive care stay. In addition, nurse-led follow-up gave meaning to the intensive care nurses’ own practice.

Attention-seeking actions by patients on mechanical ventilation in intensive care units: A phenomenological-hermeneutical study.

The aim of this study was to explore the interaction between mechanically ventilated patients and healthcare personnel in intensive care units (ICUs), with a special emphasis on patients' initiative to communicate. Patients on mechanical ventilation in ICUs tend to be less sedated today compared to standard care in the past. Their experiences of being voiceless may cause emotional distress, and for many patients, communication is difficult. Healthcare personnel are reported to be the main initiators of the communication exchanges that occur. An observational study with a phenomenological-hermeneutical approach. Video recording was used to collect data on the naturally occurring communication and interaction. Ten conscious and alert patients from two Norwegian ICUs were recruited. Two relatives and a total of sixty healthcare personnel participated. Content analysis was conducted, with focus on both the manifest and latent content meaning. We found a total of 66 situations in which patients attempted to attract the attention of others on their own initiative in order to express themselves. Attention-seeking actions, defined as the act of seeking attention and understanding without a voice, became an essential theme. Four patterns of interaction were identified: immediately responded to, delayed response or understanding, intensified attempts or giving up. Patients had a variety of reasons for seeking attention, which were classified into four domains: psychological expressions, physical expressions, social expressions and medical treatment. Patients' attention-seeking actions varied in content, form and the types of responses they elicited. The patients had to fight to first gain joint attention and then joint understanding. This was both energy-draining and time-consuming. Healthcare personnel need to spend more time for communication purposes, giving attention and being more alert to bodily or symbolic gestures to understand the patient's needs.

The provision of nurse-led follow-up at Norwegian intensive care units.

To describe the prevalence, content and administration of intensive care unit diaries and follow-up practices offered to patients and their families in Norway. Intensive care treatment has been associated with risks for new or increased health impairments affecting both patients and their families. These impairments have the potential of continuing beyond the acute phase of treatment. In parallel, preventive actions have gradually become an integrated part of critical care nursing, and in Norway, national recommendations for the use of intensive care unit diaries have been established. A survey was conducted in Norwegian intensive care units offering care for adult patients, using a questionnaire asking about the frequency, administration and content of the follow-up offered to patients, their relatives, as well as bereaved family members. Thirty-nine of 66 (59.1%) invited intensive care units answered the questionnaire. The majority (n=33, 84.6%) of the responding units had follow-up routines. The provision of diaries was the most frequent follow-up activity (n=24, 61.5%), and consultations postdischarge formed an integrated part of the diary practice. Consultations with bereaved were conducted in 21 (53.8%) of the intensive care units. About one quarter of the responding intensive care units had positions for follow-up nursing staff. Nurse-led follow-up after critical care was a common activity in Norwegian intensive care units, comprising diaries and consultations offered to patients and family members. The follow-up was mainly driven by bottom-up processes conducted by dedicated nurses motivated by the patients' and their families' situation and feedback. Adherence to recommendations, as well as the availability of defined positions for aftercare nurses or teams, may improve the implementation of follow-up practices and reduce suffering after discharge from Norwegian intensive care units.

Effects of implementing a clinical pharmacist service in a mixed Norwegian ICU

ObjectivesAn unacceptably high proportion of patients admitted to intensive care units (ICUs) develop drug-related problems (DRPs). DRPs might cause harm and increase costs and length of stay. The implementation of...

Relation of Reported Sedation and Ventilator Weaning Practices to Ventilator Time in Norwegian Intensive Care Units

Background. Guidelines for sedation, ventilator weaning, and delirium screening are helpful to avoid too deep sedation and to identify signs of delirium in the intensive care unit (ICU). Methods. National ICU registry members (n=37) were surveyed regarding use of scoring instruments and guidelines for sedation and ventilator weaning, choice of drugs, and daily sedation interruption practices. Results were merged with registry data on ventilator time and length of stay for ICU patients ventilated &gt;24 hours (7.075 ICU stays). Results. Eighty-five percent of the 33 responding ICUs used sedation scales and 39% and 55% had sedation and weaning protocols, respectively. An association was found between using protocols and longer mean ventilator time and mean length of ICU stay. Thirty three percent (11/33) practiced daily sedation interruption. Regular delirium assessment was associated with significantly shorter mean ventilator time and mean length of ICU stay but used by few. Conclusion. More ICUs had guidelines for weaning than for sedation. The ventilator time and length of ICU stay compared well with other studies. Although having guidelines was associated with longer ventilator time and ICU stay, the differences were rather small. Daily sedation interruption was seldom used. Few units used delirium scoring instruments.

Norske intensivavdelingers praksis rundt søvn og sedasjon

Aim To get an insight into 1) how Norwegian intensive care registered nurses (RNs) assess patients’ sleep and sedative needs, and 2) to survey factors of importance for critically ill patients in Norwegian intensive care units to promote sleep. Background Patients in intensive care units suffer from sleep disturbances. The lack of sleep may cause physical and psychological disturbances, increased morbidity and prolonged stay. The nurses evaluate patients’ sleep mainly based on their own perception. Method All nurse managers of the adult intensive care units in Norway were contacted to answer a survey. Data were analysed using descriptive statistics, and teaching and non-teaching hospitals were compared. Findings RNs were aware of sleep disturbances and used several strategies to promote sleep. The most commonly used interventions were to turn off lights, to shield the patient with curtains, to reduce noise from staff, to use a clock and to reduce nursing interventions during the nights. Nurses felt that they had a great influence on patients’ sleeping practices. Conclusion RNs reported to have an influence on sleep practice and to actively promote sleep in the intensive care unit. Sleep-assessment tools were not routinely used, but the use of sedation-assessment tools were common.

Family members’ experiences of being cared for by nurses and physicians in Norwegian intensive care units: A phenomenological hermeneutical study

When patients are admitted to intensive care units, families are affected. This study aimed to illuminate the meaning of being taken care of by nurses and physicians for relatives in Norwegian intensive care units. Thirteen relatives of critically ill patients treated in intensive care units in southern Norway were interviewed in autumn 2013. Interview data were analysed using a phenomenological hermeneutical method inspired by the philosopher Paul Ricoeur. Two main themes emerged: being in a receiving role and being in a participating role. The receiving role implies experiences of informational and supportive care from nurses and physicians. The participating role implies relatives' experiences of feeling included and being able to participate in caring activities and decision-making processes. The meaning of being a relative in ICU is experienced as being in a receiving role, and at the same time as being in a participating role. Quality in relations is described as crucial when relatives share their experiences of care by nurses and physicians in the ICU. Those who experienced informational and supportive care, and who had the ability to participate, expressed feelings of gratitude and confidence in the healthcare system. In contrast, those who did not experience such care, especially in terms of informational care expressed feelings of frustration, confusion and loss of confidence. However, patient treatment and care outweighed relatives' own feelings.

A calibration study of SAPS II with Norwegian intensive care registry data.

BackgroundMortality prediction is important in intensive care. The Simplified Acute Physiology Score (SAPS) II is a tool for predicting such mortality. However, the original SAPS II is poorly calibrated to current intensive care unit (ICU) populations because it draws on data, which is more than 20 years old. We aimed to improve the calibration of SAPS II using data from the Norwegian Intensive Care Registry (NIR). This is the first recalibration of SAPS II for Nordic data.MethodsA first-level customization was applied to improve calibration of the original SAPS II model (Model A). NIR data used covered more than 90% of adult patients admitted to ICUs in Norway from 2008 to 2010 (n = 30712).ResultsThe modified SAPS II, Model B, outperformed the original Model A with respect to calibration. Model B gave more accurate predictions of mortality than Model A (Hosmer–Lemeshow's C: 22.01 vs. 689.07; Brier score: 0.120 vs. 0.131; Cox's calibration regression: α = −0.093 vs. −0.747, β = 0.921 vs. 0.735, (α|β = 1) = −0.009 vs. −0.630). The standardized mortality ratio was 0.73 [95% confidence interval (CI) of 0.70–0.76] for Model A and 0.99 (95% CI of 0.95–1.04) for Model B. Discrimination was good for both models (area under receiver operating characteristic curve = 0.83 for both models).ConclusionsAs expected, Model B is better calibrated than Model A, and both models have similar uniformity of fit and equal discrimination. Introducing Model B into Norwegian ICUs may improve precision in decision-making. Units will have a more realistic benchmark for the assessment of ICU performance. Mortality risk estimates from Model B are better than previous SAPS II estimates have been.

Perceived decisional responsibility for mechanical ventilation and weaning: a Norwegian survey

To explore variability in perceptions of nurse managers and physician directors regarding roles, responsibilities and clinical-decision making related to mechanical ventilator weaning in Norwegian intensive care units (ICUs). Effective teamwork is crucial for providing optimal patient care in ICU. More knowledge on nurses' and physicians' perceptions of responsibility in clinical decision-making for mechanical ventilation is needed. Self-administered survey of mechanical ventilation and weaning responsibilities was sent to nurse managers and physician directors of Norwegian adult ICUs. Nurses' decisional influence and autonomy were estimated on a numeric rating scale (NRS) from 0 to 10 (least to most). Response rate was 38/60 (63%) nurses and 38/52 (73%) physicians. On the NRS nurse managers perceived the autonomy and influence of nurses' ventilator decisions higher than physician directors: median of 7 (IQR 5-8) (nurses) versus 5 (3-6) (physicians), (p < 0·01), and 8 (7-9) (nurses) versus 7 (5-8) (physicians), (p < 0·01) respectively. Respondents agreed that nurses collaborated in assessment of patient response to ventilator changes and titrating ventilator settings: 92% of nurses and 87% of physicians, (p = 0·46), and recognizing weaning failure 84% of nurses and 84% of physicians, (p = 0·96). Physician directors perceived significantly less collaborative decision-making on weaning method (p = 0·01), weaning readiness (p = 0·04) and readiness to extubate (p < 0·01) than nurse managers. Both groups acknowledged the importance of 'knowing the patient' for weaning success, and agreed that the assessment of work of breathing, well-being, and clinical deterioration were important for determining weaning tolerance. Nurse managers perceived nurses to have greater autonomy, influence and collaborative interaction regarding decisions on mechanical ventilation than physician directors. Greater awareness and acknowledgment of nurses' role may promote interprofessional collaboration and improve patient care.

Enacting death: contested practices in the organ donation clinic

Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high-tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding of the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law's notion of 'ontological politics' increases our awareness about the non-arbitrary way some but not other practices are considered self-evident whereas others are denigrated as muddled and illogical.

When will we ever learn?

Continuous sedation and analgesia are deemed necessary in most intensive care units (ICUs) worldwide, although there is a large variation in clinical practice. The choice of agents and dosing regimes differs. In particular, the patients on mechanical ventilation are considered an important group within the ICU where sedation and analgesia play an important role. The last decades have continuously given us evidence about various unwanted effects of continuous sedation and analgesia: prolonged length of stay in the ICU, prolonged time on mechanical ventilation, difficult weaning, adverse drug effects, drug tolerance and addiction, and long-term adverse effects as increased post-traumatic stress disorders. A study in this issue of Acta Anaesthesiologica Scandinavica reveals common practice about the administration of sedation and analgesia in Norwegian ICUs. This is in many respects disappointing documentation: most respondents (ICU physicians and nurses in charge of the unit) report that in general, the ICUs to a small extent use written protocols for sedation and analgesia, withdrawal protocols or practice daily sedation stop. This is not unique for Norway and probably reflects the attitude in many ICUs worldwide. Why is evidence regarding sedation and analgesia so hard to transform into daily routines in our ICUs? My response to such a question is that this is not a specific problem with sedation and analgesia. ICUs have problems using low tidal volumes in Adult Respiratory Distress Syndrome (ARDS), to give our patients enough nutrition, in particular using the enteral route, and to prevent nosocomial ICU infections, to mention some other important areas. The long and winding road from finding evidence to its use in individual patient care is complex. The message may be lost at several steps along this way. Often evidence from several sources is forged into clinical guidelines. Such guidelines may be produced by hospitals, by national bodies or by professional societies. Often several ‘competing’ guidelines exist. In the prevention and treatment of ventilator-associated pneumonia, there are several recent guidelines at the moment. This complicates the picture, and the quest for the ‘best’ guideline may be difficult. The validity of guidelines is also questioned in various ways. Guidelines may be corrupted, they may be sponsored by the industry or the authors have significant conflicts of interest. In an analysis of guidelines and consensus reports regarding mechanical ventilation, adherence to methodological standards was found to be low. More than half of the reports were either sponsored by industry funding, or the authors declared conflict of interest. Guidelines are also rapidly outdated. In a study from 2007 of 100 published meta-analysis, the median ‘survival’ (time to new evidence that significantly altered the conclusions) was 2.9 years within cardiovascular guidelines and 6.6 years in noncardiovascular guidelines. The next step is the implementation of clinical guidelines into local treatment protocols. Not all guidelines may directly be transferred into the specific clinical setting of individual ICUs and must at least be translated and adopted in various ways. As an example, a suggested drug may not be available in that country, or case mix of the ICU differs considerably form the original population behind the guidelines. To what extent our ICUs really include good and updated clinical guidelines into local routines are largely unknown. The study in this issue of our journal indicates that in most Norwegian ICUs, this is at least not done with regard to sedation and analgesia. Acta Anaesthesiol Scand 2012; 56: 1–2 Printed in Singapore. All rights reserved © 2012 The Author Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation