Spontaneous Awakening Research Articles

Implementing the comprehensive unit-based safety program model to improve the management of mechanically ventilated patients in Saudi Arabia

Ventilator-associated events are common in mechanically ventilated patients. They are associated with more days on mechanical ventilation, longer intensive care unit (ICU) stay, and increased risk of mortality. Theoretically, interventions that prevent ventilator-associated events should also reduce associated morbidity. We evaluated the Comprehensive Unit-based Safety Program approach to improve the care of mechanically ventilated patients. All mechanically ventilated patients admitted to the ICU between October 1, 2015, and October 31, 2016, were prospectively monitored for the development of ventilator-associated events according to the National Healthcare Safety Network criteria. A process care bundle (endotracheal intubation with subglottic suctioning, head-of-bed elevation ≥30°, target sedation scores, daily spontaneous awakening trials, spontaneous breathing trials), daily delirium assessment, and an early mobility protocol were instituted. The bundle compliance, ventilator-associated events rates, ICU length of stay, and mortality rate were noted. The database allowed viewing of current rates, trends, and averages of all participating sites. In the study period, 2,321 patients were admitted to the ICU, and 1,231 required mechanical ventilation (10,342 ventilator days). There were 115 ventilator-associated events: 82 ventilator-associated conditions, 15 infection-related ventilator-associated conditions, and 18 possible cases of ventilator-associated pneumonia. The ICU mortality rate was 13.3%, compared with 28.7% for those mechanically ventilated patients with ventilator-associated events (P = .0001). There was increased compliance for spontaneous awakening trials (51.5%-76.9%, P = .0008) and spontaneous breathing trials (54.2%-72.2%, P = .02) and a decrease in infection-related ventilator-associated conditions (4.2-3.5 per 1,000 days), possible cases of ventilator-associated pneumonia (2.1-1.7 per 1,000 days), ICU mortality (45.3%-19.1%, P = .045), and ventilator-associated events associated mortality rates (33.3%-8.3%, P < .37). Physical therapy participation and mobility were 60.8% and 26.4%, respectively. The implementation of a multipronged program like the Comprehensive Unit-based Safety Program could improve the care processes and outcomes of mechanically ventilated patients.

Challenges of pain management in neurologically injured patients: systematic review protocol of analgesia and sedation strategies for early recovery from neurointensive care

BackgroundA recent paradigm shift within the intensive care discipline has led to implementation of protocols to drive early recovery from the intensive care unit (ICU). These protocols belong to a large knowledge, translation and quality improvement initiative lead by the Society of Critical Care Medicine, aiming to “liberate” patients from the ICU. They “bundle” evidence-based elements shown to lower ICU stay and mortality and optimize pain management. The bundled elements focus on Assessing, preventing and managing pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; assessment, prevention, and management of Delirium; Early mobility and exercise; and Family engagement and empowerment (ABCDEF). It is evident that analgesia and sedation protocols either directly relate to or influence most of the bundle elements. A paucity of literature exists for neurologically injured patients, who create unique challenges to bundle implementation and often have limited external validity in existent studies. We will systematically search the literature, present the unique challenges of neurointensive care patients, conduct a stratified analysis of subgroups of interest, and disseminate the evidence of analgesia and sedation protocols in the neurointensive care unit (NICU). We hope the relevant stakeholders can adapt this information through knowledge translation—to make formal recommendations in clinical practice guidelines or a position statement.Methods/designThe authors will search MEDLINE (PubMed), EMBASE, Cochrane Library, Cochrane Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. The title, abstract, and full-text screening will be completed in duplicate, and a Cohen’s Kappa coefficient of agreement will be reported. Provided the data retrieved from studies is suitable, results will be combined statistically using meta-analysis. We aim to evaluate the impact of ABCDEF bundle components on multiple endpoints of NICU recovery. Our primary outcomes will be time to successful discontinuation of mechanical ventilation and time to early mobility. The authors will guide the methodological design of the study using the PRISMA-statement and the checklist compliance will be available.DiscussionUsing the evidence from this systematic review, we anticipate disseminating knowledge of analgesia and sedation protocols in the NICU. The results of this systematic review are imperative to close the knowledge gap in a patient population that is often excluded from studies, and to add to the body of literature aiming to enhance early recovery from the NICU and mitigate iatrogenic harm.Systematic review registrationPROSPERO CRD42017078909

Evaluation of a Multidisciplinary Pain, Agitation, and Delirium Guideline in Mechanically Ventilated Critically Ill Adults

Background: A multidisciplinary team updated an institution-specific pain, agitation, and delirium (PAD) guideline based on the recommendations from the Society of Critical Care Medicine (SCCM) PAD guidelines. This institution-specific guideline emphasized protocolized sedation with increased as needed boluses, and nonbenzodiazepine infusions, daily sedation interruption, and pairing of spontaneous awakening (SAT) and breathing trials (SBT). Objective: The purpose of this study was to evaluate the impact of implementation of a PAD guideline on clinical outcomes and medication utilization in an academic medical center intensive care unit (ICU). It was hypothesized that implementation of an updated guideline would improve clinical outcomes and decrease usage of benzodiazepine infusions. Methods: Pre-post retrospective chart review of 2417 (1147 pre, 1270 post) critically ill, mechanically ventilated adults in a medical/surgical ICU over a 2-year period (1 year pre and post guideline implementation). Results: After guideline implementation, average ventilation days was reduced (3.98 vs 3.43 days, P = .0021), as well as ICU and hospital length of stay (LOS) (4.79 vs 4.34 days, P = .048 and 13.96 vs 12.97 days, P = .045, respectively). Hospital mortality (19 vs 19%, P = .96) and acute physiology and chronic health evaluation (APACHE) IV scores (77.28 vs 78.75, P = .27) were similar. After guideline implementation, the percentage of patients receiving midazolam infusions decreased (422/1147 [37%] vs 363/1270 patients [29%], P = .0001). The percentage of patients receiving continuous infusion propofol (679/1147 [59%] vs 896/1270 [70%], P = .0001) and dexmedetomidine (78/1147 [7%] vs 147/1270 [12%], P = .0001) increased. Conclusions: Implementing a multidisciplinary PAD guideline utilizing protocolized sedation and daily sedation interruption decreased ventilation days and ICU and hospital LOS while decreasing midazolam drip usage.

200 Spontaneous Breathing and Awakening Trials Plus a Multimodal Sedation/Agitation Protocol Decrease Vent Days and Benzodiazepine Use in the Burn ICU

200 Spontaneous Breathing and Awakening Trials Plus a Multimodal Sedation/Agitation Protocol Decrease Vent Days and Benzodiazepine Use in the Burn ICU

Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle.

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.

Persistence of Delirium after Cessation of Sedatives and Analgesics and Impact on Clinical Outcomes in Critically Ill Patients.

As delirium is a common manifestation in critically ill patients and is associated with worse clinical outcomes, we sought to characterize the reversibility of delirium after discontinuation of sedation and to determine whether sedation-associated delirium that rapidly reverses impacts clinical outcomes. Post hoc subgroup analysis of prospectively collected data from a previously published study. Seventy adults admitted to a medical intensive care unit (ICU) between March and July 2012 who required mechanical ventilation with continuous analgesia and/or sedation and underwent a spontaneous awakening trial (SAT). Patients were grouped into four categories: delirium free, rapidly reversible delirium (RRD; defined as delirium always resolving within 4hrs of stopping sedatives), persistent delirium (PD; defined as delirium always persisting for ≥ 4 hours after stopping sedatives), or mixed delirium (consisting of RRD and PD episodes). The incidence of the four delirium subtypes and their associations with clinical outcomes were evaluated. A validated, guideline-recommended, bedside delirium monitoring instrument-the Confusion Assessment Method for the ICU (CAM-ICU)-was used to assess for the presence or absence of delirium. Clinical outcomes included ventilator-free days at day 28, ICU and hospital length of stay, 28-day mortality, and patient disposition; time to first CAM-ICU becoming negative (delirium free) for a continuous 48-hour duration was also assessed. A total of 103 SATs were performed in the 70 patients. Of the 103 SATs, 28 (27.2%) were CAM-ICU negative before the SAT. Of the remaining 75 SATs, PD was present for the majority of SATs (62 [82.7%]); RRD was present after 13 (17.3%) SATs. On a patient level, 17 patients (24.3%) were always delirium free before cessation of medications for continuous sedation. Of the 53 patients with delirium before undergoing an SAT, 11 (20.8%) had RRD, 2 (3.8%) had mixed delirium, and 40 (75.5%) had PD. Proportional odds logistic regression adjusting for age, Acute Physiology and Chronic Health Evaluation II score, sepsis, and preexisting hypertension showed that patients with PD had a higher probability of longer ICU length of stay (odds ratio 4.01 [95% confidence interval 1.36-11.77], p=0.011), but those with RRD did not. Despite the cessation of medications for continuous sedation, delirium persisted for the majority of patients and was associated with worse outcomes, which attests to the importance of strategies to minimize sedation.

Don't Hold Your Breath: Implementation of “Bedside Wake-Up and Breathe” Handoff in Improving Compliance With Spontaneous Awakening (SAT) and Breathing Trials (SBT)

SESSION TITLE: Patient Safety and Quality Improvement SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 02:45 PM - 04:15 PM PURPOSE: Studies have shown that compliance with the evidence-based ABCDEF bundle (SAT, SBT, Choice of Sedation, Delirium Screening, Early Mobility and Family Involvement) allows for earlier liberation from mechanical ventilation, reduced delirium, decreased ICU length of stay, and improved survival. There are multiple factors affecting the execution of SAT/SBT in ICU patients such as interdisciplinary communication and coordination of care between respiratory therapists, nurses, and physicians to ensure proper sequence of the individual components. However, there is limited published research on the effectiveness of bedside sign-off by respiratory therapists in improving the execution of SAT/SBTs. After adopting the ABCDEF bundle in 2015, the ICU team at Orange Regional Medical Center (ORMC), Middletown, NY implemented a “Bedside Wake-Up and Breathe” handoff protocol in June 2016 to improve bundle compliance. The protocol required respiratory therapists to perform independent bedside assessments and communicate with nurses to prepare and execute SATs/SBTs at 6 am before morning rounds. The overall aim of the study was to have a structured protocol that optimized the ABCDEF bundle, enhancing early weaning of mechanically ventilated patients and decreasing ICU length of stay at ORMC. METHODS: We used the ABCDEF protocol established by the ICU Delirium and Cognitive Impairment Study Group at Vanderbilt University Medical Center in order to record SAT/SBT data within the first seven days of the ICU length of stay for ventilated patients. Inclusion and exclusion criteria was based on that of the ABCDEF protocol. We collected data from March 2016 to August 2016 on 103 patients. The pre-intervention group (March-May 2016) included 58 patients and the post-intervention group (June-August 2016) included 45 patients. The intervention was implementation of the “Bedside Wake-Up and Breathe” handoff protocol on mechanically ventilated patients. We used a statistical t-test to compare the average number of SATs and SBTs per mechanically ventilated patient within the first seven days of intubation in the ICU and the average length of stay in the ICU between the pre-intervention and post-intervention period. RESULTS: There was a statistically significant increase in the average number of SATs in the first seven days of intubation between the pre-intervention group (n=58) and post-intervention group (n=45), with 0.74 average SATs per patient in pre and 1.46 average SATs per patient in post (t-test, p-value<0.05). Similarly, there was a statistically significant increase in the average number of SBTs per patient, with 0.74 in pre and 1.15 in post (t-test, p-value<0.05). The pre-intervention length of stay in the ICU was 9.33 days, which was significantly more than the post-intervention length of stay at 5.44 days (t-test, p-value<0.05). CONCLUSIONS: Implementation of the “Bedside Wake-Up and Breathe” handoff protocol, which aimed to facilitate the ABCDEF bundle, successfully increased the average number of SATs/SBTs completed in the first seven days of mechanical ventilation and reduced the average length of stay in the ICU. CLINICAL IMPLICATIONS: Bedside sign-off by respiratory therapists can improve interdisciplinary communication in the ICU and patient outcomes. DISCLOSURE: The following authors have nothing to disclose: Nakia Sarad, Kathleen Holsaeter, Bryony Lucas, Donya Nazery, Harshal Lal, Aamir Gilani No Product/Research Disclosure Information

What is new in the prevention of nosocomial pneumonia in the ICU?

To summarize and contextualize recent evidence on preventing ventilator-associated pneumonia (VAP). Many centers continue to report dramatic decreases in VAP rates after implementing ventilator bundles. Interpreting these reports is complicated, however, by the subjectivity and lack of specificity of VAP definitions. More objective data suggest VAP rates may not have meaningfully changed over the past decade. If so, this compels us to re-examine and revise the prevention bundles we have been using to prevent VAP. New analyses suggest that most hospitals' ventilator bundles include a mix of helpful and potentially harmful elements. Spontaneous awakening trials, spontaneous breathing trials, head-of-bed elevation, and thromboprophylaxis appear beneficial. Oral chlorhexidine and stress ulcer prophylaxis may be harmful. Subglottic secretion drainage, probiotics, and novel endotracheal cuff designs do not clearly improve objective outcomes. Selective digestive decontamination by contrast appears to lower VAP and mortality rates. Effective implementation is as important as choosing the right bundle components. Best practices include engaging and educating staff, creating structures that facilitate bundle adherence, and providing regular feedback on process measure performance and outcome rates. VAP rates may still be elevated despite multiple reports to the contrary. Recent evidence suggests new ways to optimize the selection of ventilator bundle components and their implementation.

Unplanned Extubations and Falls During Implementation of an ABCDEF Bundle in a Medical ICU

SESSION TITLE: Airway/Mechanical Ventilation SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 08:45 AM - 10:00 AM PURPOSE: To evaluate the patient safety counterbalance measures of unplanned extubations and patient falls while implementing an ABCDEF bundle (Assess for and management of pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of sedation and analgesia, Delirium monitoring and management, Early mobility, and Family engagement) in a medical ICU. METHODS: We conducted a case-control and before-after quality improvement study of patients who were admitted to a medical ICU from June 1st to November 30th, 2016. We measured the baseline incidence of unplanned extubations and number of patient falls in the pre- and post- intervention phase (June 1st to July 12th and July 12th to November 30th, respectively). The intervention was carried out in patients on one of the two ICU services (cases) from July 12th to November 30th and involved protocolized huddles that included a multi-professional team (advanced practice providers, physicians, occupational and physical therapists, nurses, respiratory therapists, and pharmacists). RESULTS: The intervention patients had 180 ventilator-days before and 453 ventilator days after the intervention. The control patients had 157 ventilator-days before and 477 ventilator days after the intervention. The unplanned extubation rate before the intervention was 1.7 per 100 ventilator-days (1.7%) for the intervention team (cases) vs. 1.9% for the controls. During the intervention phase, the intervention group’s unplanned extubation rate was 1.1% vs. 2.1% for the control (P=0.23, two-sample test of proportions). There was no significant increase in the unplanned extubation rate for the intervention group (1.7% before vs 1.1% after P=0.54). There were 0 patient falls before the intervention in either group. There were 4 falls among 1048 patient-days in the control group (0.4 per 100 patient-days) during the intervention period and 2 falls among 1441 patient-days in the intervention group (0.1 per 100 patient-days, P<0.11, two-sample test of proportions). None of the falls occured while implementing the mobility protocol. CONCLUSIONS: Following the implementation of the ABCDEF bundle, there was no significant increase in the unplanned extubation or fall rates before and after the intervention, or between cases and controls during the intervention. We observed statistically non-significant trends for fewer unplanned extubations and falls during ABCDEF bundle implementation as a possible signal of additional value of the intervention. CLINICAL IMPLICATIONS: When implementing a quality improvement program, it is important to look at potential adverse effects, or counterbalancing measures, to ensure patient safety is maintained. Although the ABCDEF bundle is part of current Pain Agitation Delirium guidelines, it is not being practiced in many hospitals. Safety concerns, particularly unplanned extubations and falls, have been cited as barriers to implementing the bundle. Our findings suggest that in the setting of multi-professional protocolized huddles, ABCDEF bundle implementation in an academic tertiary care center does not lead to an increased incidence of unplanned extubations or falls, and in fact might be protective. Larger studies are needed to confirm and extend the external validity of these findings. DISCLOSURE: The following authors have nothing to disclose: Erica Schneider, Amy Dean, George Kallingal, Markos Kashiouris, Ashley Daniels, Kim Varney, Martha Booth, Ken-Nisha Norris, Sarah Knizewski, Curtis Sessler, Lois Rowland, Kristin Miller No Product/Research Disclosure Information

ICU team composition and its association with ABCDE implementation in a quality collaborative

PurposeAwakening, Breathing Coordination, Delirium, and Early Mobility bundle (ABCDE) should involve an interprofessional team, yet no studies describe what team composition supports implementation. Materials & methodsWe administered a survey at MHA Keystone Center ICU 2015 workshop. We measured team composition by the frequency of nurse, respiratory therapist, physician, physical therapist, nurse practitioner/physician assistant or nursing assistant involvement in 1) spontaneous awakening trials (SATs), 2) spontaneous breathing trials, 3) delirium and 4) early mobility. We assessed ABCDE implementation using a 5-point Likert (“routine part of every patient's care” - “no plans to implement”). We used ordinal logistic regression to examine team composition and ABCDE implementation, adjusting for confounders and clustering. ResultsFrom 293 surveys (75% response rate), we found that frequent nurse [OR 6.1 (1.1–34.9)] and physician involvement [OR 4.2 (1.3–13.4)] in SATs, nurse [OR 4.7 (1.6–13.4)] and nursing assistant's involvement [OR 3.9 (1.2–13.5)] in delirium and nurse [OR 2.8 (1.2–6.7)], physician [OR (3.6 (1.2–10.3)], and nursing assistants' involvement [OR 2.3 (1.1–4.8)] in early mobility were significantly associated with higher odds of routine ABCDE implementation. ConclusionsABCDE implementation was associated with frequent involvement of team members, suggesting a need for role articulation and coordination.

Pneumonia in Trauma Patients.

Purpose of ReviewThis article reviews the new definitions of pneumonia, discusses risk factors for pneumonia among trauma patients, presents the latest evidence for prevention strategies, discusses the best ways to make the diagnosis, and reviews the microbiology and treatment for trauma patients with pneumonia.Recent FindingsPneumonia can be prevented by decreasing the duration of mechanical ventilation using daily paired spontaneous awakening and breathing trials, but not with early tracheostomy placement. Other useful prevention strategies include semirecumbent positioning and oral care. Mini-BAL is a sensitive and specific means of securing the diagnosis of pneumonia that does not require a physician to be present and is therefore especially useful in busy trauma centers.SummaryPneumonia is a frequent complication among trauma patients. Risk factors are largely unmodifiable. However, trauma centers can institute routine daily paired spontaneous awakening and breathing trials to decrease the duration of ventilation and incidence of pneumonia. Future research is needed to further characterize the microbiology of pneumonia among trauma patients.

Two-State Collaborative Study of a Multifaceted Intervention to Decrease Ventilator-Associated Events.

Ventilator-associated events are associated with increased mortality, prolonged mechanical ventilation, and longer ICU stay. Given strong national interest in improving ventilated patient care, the National Institute of Health and Agency for Healthcare Research and Quality funded a two-state collaborative to reduce ventilator-associated events. We describe the collaborative's impact on ventilator-associated event rates in 56 ICUs. Longitudinal quasi-experimental study. Fifty-six ICUs at 38 hospitals in Maryland and Pennsylvania from October 2012 to March 2015. We organized a multifaceted intervention to improve adherence with evidence-based practices, unit teamwork, and safety culture. Evidence-based interventions promoted by the collaborative included head-of-bed elevation, use of subglottic secretion drainage endotracheal tubes, oral care, chlorhexidine mouth care, and daily spontaneous awakening and breathing trials. Each unit established a multidisciplinary quality improvement team. We coached teams to establish comprehensive unit-based safety programs through monthly teleconferences. Data were collected on rounds using a common tool and entered into a Web-based portal. ICUs reported 69,417 ventilated patient-days of intervention compliance observations and 1,022 unit-months of ventilator-associated event data. Compliance with all evidence-based interventions improved over the course of the collaborative. The quarterly mean ventilator-associated event rate significantly decreased from 7.34 to 4.58 cases per 1,000 ventilator-days after 24 months of implementation (p = 0.007). During the same time period, infection-related ventilator-associated complication and possible and probable ventilator-associated pneumonia rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1,000 ventilator-days (p = 0.018, p = 0.012), respectively. A multifaceted intervention was associated with improved compliance with evidence-based interventions and decreases in ventilator-associated event, infection-related ventilator-associated complication, and probable ventilator-associated pneumonia. Our study is the largest to date affirming that best practices can prevent ventilator-associated events.

Integration of Spiritually Transformative Experiences: Models, Methods, and Research

Abstract: This article represents my presentation at the inaugural 2012 American Center for the Integration of Spiritually Transformative Experiences (ACISTE) Annual Conference; it contains four main sections. The first section focuses on defining the parameters of the contents and includes discussions of what constitutes healthy and unhealthy integration, spiritual emergence and emergency, quantum change, spiritual conversion, and spontaneous awakening experiences. The second section includes four conceptual models utilized to help understand spiritually transformative experiences (STEs): Wilber's, Rummet's, and Wade's developmental models and Assagioli's model of the self. The third section introduces methods I use when working with clients, and the fourth section further provides recent research on topics related to STEs. My goal throughout was to catalyze further discussion regarding what constitutes integration of an STE and how this process relates to current psychospiritual models, therapeutic approaches, and research.

Timing of Spontaneous Awakening and Breathing Trial Affects Duration of Mechanical Ventilation

Timing of Spontaneous Awakening and Breathing Trial Affects Duration of Mechanical Ventilation

Potential Strategies to Prevent Ventilator-associated Events.

The Centers for Disease Control and Prevention (CDC) released ventilator-associated event (VAE) definitions in 2013. The new definitions were designed to track episodes of sustained respiratory deterioration in mechanically ventilated patients after a period of stability or improvement. More than 2,000 U.S. hospitals have reported their VAE rates to the CDC, but there has been little guidance to date on how to prevent VAEs. Existing ventilator-associated pneumonia prevention bundles are unlikely to be optimal insofar as pneumonia accounts for only a minority of VAEs. This review proposes a framework and potential intervention set to prevent VAEs on the basis of studies of VAE epidemiology, risk factors, and prevention. Work to date suggests that the majority of VAEs are caused by four conditions: pneumonia, fluid overload, atelectasis, and acute respiratory distress syndrome. Interventions that minimize ventilator exposure and target one or more of these conditions may therefore prevent VAEs. Potential strategies include avoiding intubation, minimizing sedation, paired daily spontaneous awakening and breathing trials, early exercise and mobility, low tidal volume ventilation, conservative fluid management, and conservative blood transfusion thresholds. Interventional studies have thus far affirmed that minimized sedation, paired daily spontaneous awakening and breathing trials, and conservative fluid management can reduce VAE rates and improve patient-centered outcomes. Further studies are needed to evaluate the impact of the other proposed interventions, to identify additional modifiable risk factors for VAEs, and to measure whether combining strategies into VAE prevention bundles confers additional benefits over implementing one or more of these interventions in isolation.

What renders dreams more or less narrative? A microstructural study of REM- and Stage 2 dream reports upon morning awakening

A microanalysis of fourteen dream reports was conducted with the aim of understanding which features of these reports rendered them more or less narrative. The result should help us to compare the relative narrative quality of samples of dream reports. The reports described the last dream of the night and they were collected immediately upon spontaneous morning awakening in a sleep laboratory. Half of the dreams reported in our sample were produced in Rapid eye movement (REM) sleep and the other half in Stage 2 sleep. The microanalysis dealt with the relationship between each pair of successive temporal units and with the presence of other elements of the dream content likely to influence the narrative character of a dream. The more important findings were the following. First, coherence is the rule in the relationship between pairs of successive units of the reported dream sequences. Second, two categories of relationship, Psychologically causal links and Plausible links appear to be the main building blocks of the sequences of dream events. Third, most dreams comprised one or several complications, that is, events creating change and often tension. Fourth, the combination of a continuity score and a complication score permitted us to rank the reports ac - cording to their narrative nature or quality, whereas emotions and story-like features were not good candidates to that purpose. Fifth, no differences were observed between REM-sleep and Stage 2 reports of similar length in their sequential regulation and other features. This result shows that the process regulating the sequences of dream events is not de - pendent on the sleep stage, a strong argument in favor of the idea of a single generator which produces dreams across the sleep stages. More generally, most sequences of dream events did not correspond to sequences of recent or older experiences stored in memory. The sequential organization of dream events is regulated during dreaming and reveals an important dreaming production process.

Type 1 diabetes mellitus and its glycemic control affect sleep

Materials and methods Eighteen non-obese adults with T1D (8 males, age=26.3±5.1), without chronic complications were studied. The following instruments were used during ten consecutive days: sleep diaries (with Visual Analogue Scales for rating sleep quality), actimeters, and a home fingertip glucometer (6.41±1.5 tests a day). The analysis was made using fitted inflated beta regression models with GAMLSS for the response variable sleep quality rate (SQR). Subject-level covariables in this dataset included: number of hyperglycemia and hypoglycemia episodes in the previous day, number of awakenings during the night, morning awakening type (spontaneous or not), sleep rate (total sleep time in min divided by 1440), and the corresponding interactions. Results The SQR was negatively associated with the sleep rate (p<0.001), and positively associated with spontaneous awakening (p=0.042). The relationships between the other variables with SQR were the following: the SQR rises with the increase of both, hypoglycemic events and sleep rate (p=0.002). On the other hand, when the hypoglycemic or hyperglycemic events are associated with non-spontaneous awakening, the SQR decreases (p=0.02 for both glycemic conditions). However, the SQR increases when both the number of hyperglycemia and the number of night awakenings increase (p=0.01).

Utilization of Spontaneous Awakening Trials in Mechanically Ventilated Patients

SESSION TITLE: Mechanical Ventilation and Respiratory Failure Posters SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: The purpose of this study is to establish current duration of time from intubation to first spontaneous awakening trial (SAT) and variables that may be associated with decreased likelihood of implementation of this intervention. These results will inform a clinical trial designed to increase adherence to daily spontaneous awakening and spontaneous breathing trials in patients with acute respiratory failure. METHODS: Patients from Northwestern Memorial Hospital (NMH), a tertiary academic medical center in Chicago, Illinois, and Northwestern Lake Forest Hospital, a community hospital affiliated with NMH located in an affluent suburb of Chicago, were included. Patients were excluded if they were less than 18 years of age at intubation, on the ventilator less than 12 hours, had a tracheostomy at time of hospital admission, suffered cardiac arrest immediately prior to or during their admission, were transitioned to comfort-focused care, or were managed on continuous intravenous sedation for alcohol withdrawal or delirium tremens. Based on power calculations, we collected data from the first 377 patients who were intubated in the intensive care units and met our inclusion criteria from June 23, 2013, to October 11, 2013. RESULTS: In our sample, mean age at intubation was 60.6 years, 153 (40.6%) were women, and 214 (56.8%) self-identified as white or Caucasian, 100 (26.5%) as black or African-American. Out of the 377 patients included in the analysis, 39 (10.3%) were never started on sedative infusions and of those who were started on infusions of sedatives (narcotics, benzodiazepines, and/or propofol), median time to first SAT (defined as at least 4 hours off all sedative infusions) was 40.6 hours. Of the patients started on sedative infusions, 270 (79.9%) did not receive an SAT within the first 24 hours of intubation. CONCLUSIONS: Median time to first SAT was substantially longer than recommended by most professional organizations and only a small number of patients had an SAT within the first 24 hours of intubation. CLINICAL IMPLICATIONS: Daily SATs are associated with reduced duration of mechanical ventilation and intensive care unit stay, and this data gives us evidence that adherence to this best practice is low and helps inform the design of a novel intervention to improve these rates. DISCLOSURE: The following authors have nothing to disclose: Margaret Ragland, Shayna Weiner, Curtis Weiss No Product/Research Disclosure Information

ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices.

A bundled approach to intensive care unit (ICU) care known as "Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility" (ABCDE) has been proposed, with evidence supporting individual interventions as well as the bundle as a whole. Few data exist on the bundle's implementation and efficacy in community practice. To evaluate self-reported rates of implementation of ABCDE components and their association with outcomes in a state-wide quality improvement collaborative. A written survey was administered to representatives attending the 2012 annual meeting of the Michigan Health and Hospital Association's Keystone ICU collaborative. Respondents reported on their practices regarding spontaneous awakening trials, delirium assessments, and early mobility. There were 212 respondents, a 76% response rate. Wide variation in focus was noted across the assessed components of ABCDE. Only 12% reported having implemented routine spontaneous awakening trials and delirium assessments as well as early mobility, 36% reported not having early mobility as an active goal in their units (nonmovers), and 52% reported attempts at early mobility without both routine sedation interruption and delirium screening implementation. In adjusted models, those who implemented exercise with sedation interruption and delirium screening were 3.5 (95% confidence interval, 1.4-8.6) times more likely to achieve higher levels of exercise in ventilated patients than those who implemented exercise without both sedation interruption and delirium screening. There is incomplete penetrance of aspects of ABCDE across ICUs in this highly motivated statewide quality improvement collaborative. Yet, implementation of exercise in the context of both sedation interruption and delirium screening was associated with improved self-reported mobility outcomes. Effective knowledge translation and implementation strategies may offer substantial benefits to ICU patients.

Pharmacist leadership in ICU quality improvement: coordinating spontaneous awakening and breathing trials.

Coordinating efforts across disciplines in the intensive care unit is a key component of quality improvement (QI) efforts. Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are considered key components of guidelines, yet unfortunately are often not done or coordinated properly. To determine if a pharmacist-driven awakening and breathing coordination (ABC) QI program would improve compliance (ie, process measures) as compared with the previous protocol, which did not involve pharmacists. The QI program included pharmacist-led education, daily discussion on rounds, and weekly performance reports to staff. Using a pre-QI versus during-QI versus post-QI intervention design, we compared data from 500 control ventilator-days (pre-QI period) versus 580 prospective ventilator-days (during-QI period). We then evaluated the sustainability of the QI program in 216 ventilator-days in the post-QI period. SAT safety screens were performed on only 20% pre-QI patient-days versus 97% of during-QI patient-days (P < 0.001) and 100% of post-QI patient-days (P = 0.25). The rates of passing the SAT safety screen in pre-QI and during-QI periods were 63% versus 78% (P = 0.03) and 81% in the post-QI period (P = 0.86). The rates of SATs among eligible patients on continuous infusions were only 53% in the pre-QI versus 85% in the during-QI (P = 0.0001) and 87% in the post-QI (P = 1) periods. In this QI initiative, a pharmacist-driven, interdisciplinary ABC protocol significantly improved process measures compliance, comparing the pre-QI versus during-QI rates of screening, performing, and coordinating SAT and SBTs, and these results were sustained in the 8-month follow-up period post-QI program.