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Background: Physical restraints remain to be commonly used in agitated intensive care unit (ICU) patients worldwide, despite a lack of evidence on efficacy and safety and reports of detrimental short and long-term consequences, such as prolonged delirium and a longer ICU length of stay. Physical restraint minimization approaches have focused mainly on educational strategies and other non-pharmacological interventions. Combining these interventions with goal-directed light sedation therapy if needed may play an important contributory role in further reducing the use of physical restraints. The aim of the study is to determine the effectiveness of a multicomponent intervention (MCI) program, combining person-centered non-pharmacological interventions with goal-directed light sedation, compared to physical restraints. Methods: A multicenter stepped-wedge cluster randomized controlled trial will be conducted in six Dutch ICUs. A power calculation based total of 480 (expected to become) agitated adult patients will be included in 26 months with a subsequent 2-year follow-up. Patients included in the control period will receive standard care with the current agitation management protocol including physical restraints. Patients included in the intervention period will be treated with the MCI program, consisting of four components, without physical restraints: education of ICU professionals, identification of patients at risk for agitation, formulation of a multidisciplinary person-centered care plan including non-pharmacological and medical interventions, and protocolized goal-directed light sedation using dexmedetomidine. Primary outcome is the number of days alive and outside of the ICU within 28 days after ICU admission. Secondary outcomes include length of hospital stay; 3-, 12-, and 24-month post-ICU quality of life; physical (fatigue, frailty, new physical problems), mental (anxiety, depression, and post-traumatic stress disorder), and cognitive health; and 1-year cost-effectiveness. A process evaluation will be conducted. Discussion: This will be the first multicenter randomized controlled trial determining the effect of a combination of non-pharmacological interventions and light sedation using dexmedetomidine compared to physical restraints in agitated ICU patients. The results of this study, including long-term patient-centered outcomes, will provide relevant insights to aid ICU professionals in the management of agitated patients. Trial registration: NCT05783505, registration date 23 March 2023. [ABSTRACT FROM AUTHOR]

The article discusses the international importance to prepare nurses for a more future-proof ICU environment that aims for sustainability in critical care nurse staffing. Topics include the lessons learned from the COVID-19 crisis can accelerate this transformation process; risk of attrition from work, which might result in an unintentional brain and skills drain, and practical approaches to build and maintain resilience among frontline health care professionals.

Delirium frequently occurs in intensive care unit patients and is associated with worse outcomes. Recently, a multicomponent non-pharmacological nursing intervention program called UNDERPIN-ICU, was implemented in ten Dutch intensive care units. The program was aimed at delirium reduction by optimizing four modifiable risk factors: visual and hearing impairment, cognitive impairment, immobility, and sleep deprivation. Despite its scientific fundament and extensive implementation, this program showed no effect on delirium outcomes. To explore factors that hindered or facilitated the application of the UNDERPIN-ICU delirium program in daily practice as experienced by healthcare professionals. Semi-structured focus group interviews were conducted in all participating centers between April and June of 2019. Directed content and thematic analyses were applied. Interviews were coded. Codes were grouped into categories based on factors that hindered or facilitated program application. In total, 22 ICU nurses, 3 ICU physicians, 5 local delirium group members and one research manager participated in 10 focus group interviews. We found 41 factors that hindered or facilitated program application, grouped into five categories: interventions; individual healthcare professional; patient; implementation process; capacity for change, incentives and resources. Among the factors identified in this study, the facilitating factors included standardized interventions, a structured implementation, interactive educational meetings and, feedback and support. The hindering factors included doubts about usefulness, feasibility, the extensive number of program components, limited knowledge about the program and a focus on physical care. Factors that hindered program application may explain why the UNDERPIN-ICU program did not have positive effects on delirium outcomes. Factors that facilitated application should be strengthened in future non-pharmacological nursing interventions to prevent or reduce delirium in intensive care. ClinicalTrials.gov Identifier: NCT03002701 ; registration date December 26, 2016. [ABSTRACT FROM AUTHOR]

To explore changes in advance care plans of nursing home residents with dementia following pneumonia, and factors associated with changes. Second, to explore factors associated with the person perceived by elderly care physicians as most influential in advance treatment decision making. Secondary analysis of physician-reported PneuMonitor trial data. The PneuMonitor trial took place between January 2012 and May 2015 in 32 nursing homes across the Netherlands; it involved 429 residents with dementia who developed pneumonia. We compared advance care plans before and after the first pneumonia episode. Generalized logistic linear mixed models were used to explore associations of advance care plan changes with the person most influential in decision making, with demographics and indicators of disease progression. Exploratory analyses assessed associations with the person most influential in decision making. For >90% of the residents, advance care plans had been established before the pneumonia. After pneumonia, treatment goals were revised in 15.9% of residents; 72% of all changes entailed refinements of goals. Significant associations with treatment goal changes were not found. Treatment plans changed in 20.0% of residents. Changes in treatment decisions were more likely for residents who were more severely ill (odds ratio 1.5, 95% CI 1.2-1.9) and those estimated to live <3 months (odds ratio 3.3, 95% CI 1.9-5.8). Physicians reported that a family member was often (47.4%) most influential in decision making. Who is most influential was associated with the resident's dementia severity. Overall, changes in advance care plans after pneumonia diagnosis were small, suggesting stability of most preferences or limited dynamics in the advance care planning process. Advance care planning involving family is common for nursing home residents with dementia, but advance care planning with persons with dementia themselves is rare and requires more attention. [ABSTRACT FROM AUTHOR]