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Delirium is a healthcare issue that continues to challenge critical care nurses. Providing doula services under the supervision of critical care nurses to critically ill older adults with delirium may be an innovative model for addressing these care needs. [ABSTRACT FROM AUTHOR]

Herein, we propose a blueprint for action to completely measure and recognize the care provided by acute and critical care nurses to be incorporated into policy that shapes and supports practice. We address the nature of nurses' work by identifying nine practice domains, hospital practice environment assumptions, and expected outcomes. Nurses' work, as a cross-system process, needs to be included in hospital-based core measures to fully reflect nurses' impact on patient care. We call for a balanced measurement portfolio focused on patient/family-, unit-, and systems-level outcomes. We focus on what nurses do and what patients and their families can expect rather than only on the elimination of select adverse events. We provide a way forward to allow measure development and implementation with incentives for their use. This approach to making nurses' contributions and impact on outcomes visible will enhance acute and critical care nursing practice and benefit patients and their families., Competing Interests: Declaration of Competing Interest Lauren R. Sorce is an elected member of the Executive Committee and serves as President of the Society of Critical Care Medicine (SCCM) 2024 to 2025. The views presented are those of the author and are not intended to represent the views of SCCM., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Adoption of early mobility interventions into intensive care unit (ICU) practice has been slow and varied., Objectives: To examine factors associated with early mobility performance in critically ill adults and evaluate factors' effects on predicting next-day early mobility performance., Methods: A secondary analysis of 66 ICUs' data from patients admitted for at least 24 hours. Mixed-effects logistic regression modeling was done, with area under the receiver operating characteristic curve (AUC) calculated., Results: In 12 489 patients, factors independently associated with higher odds of next-day mobility included significant pain (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.23), documented sedation target (AOR, 1.09; 95% CI, 1.01-1.18), performance of spontaneous awakening trials (AOR, 1.77; 95% CI, 1.59-1.96), spontaneous breathing trials (AOR, 2.35; 95% CI, 2.14-2.58), mobility safety screening (AOR, 2.26; 95% CI, 2.04-2.49), and prior-day physical/occupational therapy (AOR, 1.44; 95% CI, 1.30-1.59). Factors independently associated with lower odds of next-day mobility included deep sedation (AOR, 0.44; 95% CI, 0.39-0.49), delirium (AOR, 0.63; 95% CI, 0.59-0.69), benzodiazepine administration (AOR, 0.85; 95% CI, 0.79-0.92), physical restraints (AOR, 0.74; 95% CI, 0.68-0.80), and mechanical ventilation (AOR, 0.73; 95% CI, 0.68-0.78). Black and Hispanic patients had lower odds of next-day mobility than other patients. Models incorporating patient, practice, and between-unit variations displayed high discriminant accuracy (AUC, 0.853) in predicting next-day early mobility performance., Conclusions: Collectively, several modifiable and nonmodifiable factors provide excellent prediction of next-day early mobility performance., (©2024 American Association of Critical-Care Nurses.)

Objectives: Research on Black maternal populations often focuses on deficits that can reinforce biases against Black individuals and communities. The research landscape must shift towards a strengths-based approach focused on the protective assets of Black individuals and communities to counteract bias. This study engaged the local Black community using a strengths-based approach to discuss the assets of Black maternal populations and to inform the design of a future clinical trial focused on reducing Black maternal health disparities., Design: Guided by the Theory of Maternal Adaptive Capacity, we conducted three purposive focus group sessions with Black adult community members. The focus groups were semi-structured to cover specific topics, including the strengths of the local community, strengths specific to pregnant community members, how the strengths of community members can support pregnant individuals, and how the strengths of pregnant community members can facilitate a healthy pregnancy. The focus group interviews were transcribed verbatim and analyzed using thematic content analysis., Results: Three focus group sessions were conducted with sixteen female individuals identifying as Black or African American. Central themes include (1) the power of pregnancy and motherhood in Black women, (2) challenging negative perceptions and media representation of Black mothers, (3) recognizing history and reclaiming cultural traditions surrounding birth, and (4) community as the foundation of Black motherhood., Conclusion: Black community members identified powerful themes on Black maternal health through a strengths-based lens. These focus groups fostered relationships with the Black community, elucidated possible solutions to improve Black women's health and wellness, and offered direction on our research design and intervention.

Background: Evidence indicates continuous positive airway pressure (CPAP) therapy improves several important patient-centered outcomes. However, adherence to this safe and effective intervention remains poor., Objectives: Assess nine feasibility outcomes of a nurse practitioner-led, virtually delivered motivational enhancement and device support (MENDS) intervention to improve CPAP adherence in adults with Obstructive Sleep Apnea (OSA). Secondary aims compared the changes in CPAP adherence to patient-reported outcomes, patient activation, and perceived self-efficacy., Methods: This two-group feasibility randomized controlled trial included 29 patients newly diagnosed with OSA and prescribed CPAP therapy. The study was conducted from July 2020 through December 2021 at a midwestern sleep/pulmonary clinic. Participants were randomized to the MENDS intervention group (n=14) (30-45 minute interactive tele-discussions on weeks 2, 4, 6, and 8) or to the usual care (n=15) group. Feasibility, patient-reported outcomes, and behavioral constructs were measured at baseline and 12 weeks. CPAP adherence was measured weekly., Results: Feasibility of the MENDS sessions was demonstrated (56 sessions offered, 52 completed remotely without technical difficulties) with minimal participant attrition and no missing CPAP data. Generalized linear mixed models showed no statistically significant time-by-group interactions on adherence or patient-reported outcomes. Higher adherence and lower CPAP apnea-hypopnea index (AHI) scores were associated with declines in pre- to post-changes in fatigue and sleep disturbance. Lower CPAP AHI scores were associated with pre- to post-decreases in PROMIS Anxiety scores (r=.532, p=.005)., Conclusion: The virtual MENDS intervention was feasible. Higher CPAP adherence and lower AHI levels led to positive improvements in fatigue, sleep disturbance, and anxiety., Competing Interests: Declaration of Competing Interest The authors report no competing interests to declare. All co-authors contributed to the manuscript's review, analysis, content expertise, and revision. Grant funding for this study was provided through the University of Nebraska Medical Center: Center for Patient, Family, and Community Engagement in Chronic Care Management (CENTRIC) (no grant #). The authors report no conflicts of interest or investigational use of the product in developing this manuscript. The authors report that there are no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Intensive care unit (ICU) clinicians struggle to routinely implement the ICU Liberation bundle (ABCDEF bundle). As a result, critically ill patients experience increased risk of morbidity and mortality. Despite extensive research related to the barriers and facilitators of bundle use, little is known regarding which implementation strategies are used to facilitate its adoption and sustainability., Objectives: To identify implementation strategies used to increase adoption of the ABCDEF bundle and how those strategies are perceived by end-users (i.e., ICU clinicians) related to their helpfulness, acceptability, feasibility, and cost., Methods: We conducted a national, cross-sectional survey of ICU clinicians from the 68 ICU sites that previously participated in the Society of Critical Care Medicine's ICU Liberation Collaborative. The survey was structured using the 73 Expert Recommendations for Implementing Change (ERIC) implementation strategies. Surveys were delivered electronically to site contacts., Results: Nineteen ICUs (28%) returned completed surveys. Sites used 63 of the 73 ERIC implementation strategies, with frequent use of strategies that may be readily available to clinicians (e.g., providing educational meetings or ongoing training), but less use of strategies that require changes to well-established organizational systems (e.g., alter incentive allowance structure). Overall, sites described the ERIC strategies used in their implementation process to be moderately helpful (mean score >3<4 on a 5-point Likert scale), somewhat acceptable and feasible (mean score >2<3), and either not-at-all or somewhat costly (mean scores >1<3)., Conclusions: Our results show a potential over-reliance on accessible strategies and the possible benefit of unused ERIC strategies related to changing infrastructure and utilizing financial strategies., Competing Interests: Declaration of Competing Interest Dr. Balas is current Co-Chair of the Society of Critical Care Medicine's PADIS guideline update and a member of the American Psychiatric Association Delirium Guideline Writing Group. She has also served as a consultant for Ceribell., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Over 50% of all critically ill children develop preventable intensive care unit-acquired morbidity. Early and progressive mobility is associated with improved outcomes in critically ill adults including shortened duration of mechanical ventilation and improved muscle strength. However, the clinical effectiveness of early and progressive mobility in the pediatric intensive care unit has never been rigorously studied. The objective of the study is to evaluate if the PICU Up! intervention, delivered in real-world conditions, decreases mechanical ventilation duration (primary outcome) and improves delirium and functional status compared to usual care in critically ill children. Additionally, the study aims to identify factors associated with reliable PICU Up! delivery., Methods: The PICU Up! trial is a stepped-wedge, cluster-randomized trial of a pragmatic, interprofessional, and multifaceted early mobility intervention (PICU Up!) conducted in 10 pediatric intensive care units (PICUs). The trial's primary outcome is days alive free of mechanical ventilation (through day 21). Secondary outcomes include days alive and delirium- and coma-free (ADCF), days alive and coma-free (ACF), days alive, as well as functional status at the earlier of PICU discharge or day 21. Over a 2-year period, data will be collected on 1,440 PICU patients. The study includes an embedded process evaluation to identify factors associated with reliable PICU Up! delivery., Discussion: This study will examine whether a multifaceted strategy to optimize early mobility affects the duration of mechanical ventilation, delirium incidence, and functional outcomes in critically ill children. This study will provide new and important evidence on ways to optimize short and long-term outcomes for pediatric patients., Trial Registration: ClinicalTrials.gov NCT04989790. Registered on August 4, 2021., (© 2023. The Author(s).)

The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation., Design: Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used., Setting: Sixty-eight academic, community, and federal ICUs., Participants: A total of 121 ICU professionals consisting of frontline and leadership professionals., Interventions: None., Measurements and Main Results: A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol., Conclusions: In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Abstract: Post-intensive care syndrome is a costly and complicated collection of physical, cognitive, and mental health problems experienced by survivors of critical illness. The primary care NP is uniquely positioned to assess, monitor, manage, and treat patients with this syndrome following hospital discharge., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Broad-scale adoption of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) into everyday practice has been slow, and uncertainty exists regarding what factors facilitate or impede their routine delivery., Research Question: What patient, practice, and pharmacologic factors are associated with SAT and SBT performance and to what extent do they predict overall SAT/SBT performance?, Study Design and Methods: This secondary analysis used data collected from a national quality improvement collaborative composed of 68 diverse ICUs. Adults with critical illness adults who received mechanical ventilation and/or continuously infused sedative medications were included. We performed mixed-effects logistic regression modeling, created receiver operating characteristic curves, and calculated the area under the curve (AUC)., Results: Included in the SAT and SBT analysis were 4,847 and 4,938 patients, respectively. In multivariable models controlling for admitting patient characteristics, factors independently associated with higher odds of a next-day SAT and SBT included physical restraint use (adjusted odds ratio [AOR], 1.63; 95% CI, 1.42-1.87; AOR, 1.83; 95% CI, 1.60-2.09), documented target sedation level (AOR, 1.68; 95% CI, 1.41-2.01; AOR, 1.46; 95% CI, 1.24-1.72), more frequent level of arousal assessments (AOR, 1.22; 95% CI, 1.03-1.43; AOR, 1.32; 95% CI, 1.13-1.54), and dexmedetomidine administration (AOR, 1.23; 95% CI, 1.05-1.45; AOR, 1.52; 95% CI, 1.27-1.80). Factors independently associated with lower odds of a next-day SAT and SBT included deep sedation/coma (AOR, 0.69; 95% CI, 0.60-0.80; AOR, 0.33; 95% CI, 0.28-0.37) and benzodiazepine (AOR, 0.83; 95% CI, 0.72-0.95; AOR, 0.67; 95% CI, 0.59-0.77) or ketamine (AOR, 0.34; 95% CI, 0.16-0.71; AOR, 0.40; 95% CI, 0.18-0.88) administration. Models incorporating admitting, daily, and unit variations displayed moderate discriminant accuracy in predicting next-day SAT (AUC, 0.73) and SBT (AUC, 0.72) performance., Interpretation: There are a number of modifiable factors associated with SAT/SBT performance that are amenable to the development and testing of implementation interventions., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Abstract: BACKGROUND: Delirium is a common, often iatrogenically induced syndrome that may impede the physical, cognitive, and psychological recovery of critically ill adults. The effect delirium has on outcomes of intensive care unit patients having acute neurologic injury remains unclear because previous studies frequently exclude this vulnerable population. The aim of this scoping review was to describe the incidence, predictors, and outcomes of delirium among adults admitted to an intensive care unit experiencing an acute ischemic stroke, intracerebral hemorrhage, or aneurysmal subarachnoid hemorrhage. METHODS: PubMed, CINAHL, Web of Science, EMBASE, and Scopus were searched with the terms (1) stroke, (2) critical care, and (3) delirium. Inclusion criteria were original peer-reviewed research reporting the incidence, outcomes, or predictors of delirium after acute stroke among critically ill adults. Editorials, reviews, posters, conference proceedings, abstracts, and studies in which stroke was not the primary reason for admission were excluded. Title and abstract screening, full-text review, and data extraction were performed by 2 authors, with disagreements adjudicated by a third author. RESULTS: The initial search yielded 1051 results. Eighteen studies met eligibility criteria and were included in the review. Stroke type was not mutually exclusive and included persons given a diagnosis of acute ischemic stroke (11), intracerebral hemorrhage (12), aneurysmal subarachnoid hemorrhage (8), and other (1) strokes. Incidence of delirium among stroke patients ranged from 12% to 75%. Predictors of delirium included older age, preexisting dementia, higher severity of illness, and physical restraint use. Outcomes associated with delirium included higher mortality, longer length of stay, worse cognition and quality of life, and lower functional status. CONCLUSIONS: Current findings are limited by heterogenous populations, assessments, and measurement parameters. Detection and management of delirium among critically ill stroke patients requires an approach with specific considerations to the complexities of acute neurological injury and concomitant critical illness., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 American Association of Neuroscience Nurses.)

Background: The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor., Objective: To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance., Methods: This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation., Results: Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility., Conclusions: Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices., (©2022 American Association of Critical-Care Nurses.)

Objectives: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators., Design: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process., Participants: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process., Measurements and Main Results: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization., Conclusions: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials., Competing Interests: The views expressed in this article are those of the authors, none of whom have financial conflicts of interest specifically related to the issues discussed in this article. At the time of the meeting (March 28–29, 2019) on which this article is based, several participants were employed by a pharmaceutical company or had received consulting fees or honoraria from one or more pharmaceutical or device companies. Meeting participants of this article who were not employed by industry at the time of the meeting received (or their Universities received) travel stipends, hotel accommodations, and meals during the meeting from the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the Food and Drug Administration. Drs. Ward, Aitken, Colantuoni, Maze, and Needham received funding from Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, and Networks (ACTTION). Dr. Ward received support for article research from the University of Rochester Maine Medical Center Spectrum Medical Partners. Dr. Absalom’s institution received funding from The Medicines Company, Carefusion (BD), and Rigel; he received support for article research from Philips, Janssen Pharma, Johnson & Johnson, Ever Pharma, Orion, and Paion. Drs. Aitken, Brown, and Coursin received funding from Innovations Consulting Group LLC. Dr. Aitken also received funding from Elsevier Australia. Dr. Balas’ institution received funding from the National Institutes of Health (NIH), the National Heart, Lung, and Blood Institute, AACN research grant; she received funding from H3C and received support for article research from the NIH. Dr. Colantuoni received support for article research from ACTTION. Dr. Dexter received funding from the Division of Management Consulting of the University of Iowa’s Department of Anesthesia. Dr. Dworkin’s institution received funding from the U.S. Food and Drug Administration (FDA); he received funding from Abide, Acadia, Adynxx, Analgesic Solutions, Aptinyx, Aquinox, Asahi Kasei, Astellas, AstraZeneca, Biogen, Biohaven, Boston Scientific, Braeburn, Celgene, Centrexion, Chromocell, Clexio, Collegium, Concert, Coronado, Daiichi Sankyo, Decibel, Dong-A, Editas, Eli Lilly, Eupraxia, Glenmark, Grace, Hope, Hydra, Immune, Johnson & Johnson, Lotus Clinical Research, Mainstay, Medavante, Merck, Neumentum, Neurana, NeuroBo, Novaremed, Novartis, NSGene, Olatec, Periphagen, Pfizer, Phosphagenics, Quark, Reckitt Benckiser, Regenacy, Relmada, Sanifit, Scilex, Semnur, SK Life Sciences, Sollis, Spinifex, Syntrix, Teva, Thar, Theranexus, Trevena, Vertex, and Vizuri. Dr. Girard received funding from Haisco Pharmaceutical. Dr. Hopkins’ institution received funding from Intermountain Medical and Research Foundation. Dr. Maze received funding from the University of California Office of the President and Cambridge University Press; he received support for article research from the NIH. Dr. Needham received funding from the FDA, Haisco-USA Pharmaceuticals, GlaxoSmithKline, and Novartis Pharma; he disclosed he is a principal investigator on a NIH-funded, multicentered randomized trial (R01HL132887) funded by Baxter Healthcare Corporation and Reck Medical Devices. Dr. Pandharipande’s institution received funding from Pfizer. Dr. Shehabi’s institution received funding from Orion Pharma and Pfizer; he received funding from Pfizer, Orion Pharma, Abbott Laboratories, and Ever Pharma. Dr. Sun received funding from UpToDate; she disclosed she is the Editor in Chief for UpToDate/Anesthesiology. Dr. Tung received funding from Anesthesia and Analgesia. Dr. Urman’s institution received funding from Medtronic/Covidien and AcelRx; he received funding from Merck, Sandoz, Heron, Takeda, and Pfizer. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Background: Spontaneous breathing trials (SBTs) are an evidence-based way of identifying patients ready for mechanical ventilation (MV) liberation. Despite their effectiveness, global SBT performance rates remain suboptimal, and many patients who demonstrate the ability to breathe on their own remain on MV. The factors that influence clinicians' decision to discontinue MV following a successful SBT remain unclear., Aims: The aim of this study was to explore the underlying causes of extubation delays in the intensive care unit (ICU) from an interprofessional perspective., Methods: An exploratory, descriptive, cross-sectional design was used. An online survey was administered in December 2019 to clinicians practicing in three ICUs at a single medical center in the U.S. Survey questions focused on clinicians' perceptions of current MV liberation practices and perceived barriers or facilitators to timely extubation after a successful SBT., Results: Of 425 eligible clinicians, 135 completed the survey (31.7% response rate). The majority of clinicians believed the current SBT and extubation process took too long (n = 108; 80.0%) and that this delay negatively affected patient outcomes. While professional groups differed in their rankings of importance, factors perceived to contribute to extubation delays most commonly included SBT timing, low provider confidence levels in making extubation decisions, and patient-specific factors. Potential strategies to overcome these barriers included developing an automated extubation protocol, performing SBTs when the provider responsible for final extubation decisions is physically present, and decreasing clinician perception of reprimand or condemnation for failed extubations., Linking Evidence to Action: The MV liberation process is complex and dependent on the decisions of various ICU professionals. Clinicians perceive a number of potentially modifiable provider- and organizational-level factors that cause extubation delays in everyday practice. Understanding and addressing these barriers is essential for improving ICU quality and patient outcomes. Future research should explore the effect of nurse and respiratory therapist-driven extubation protocols on MV liberation rates., (© 2021 Sigma Theta Tau International.)

Objectives: To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU., Design: A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts., Setting: Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD., Subjects: Interprofessional PICU staff., Interventions: None., Measurements and Main Results: Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement., Conclusions: Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives., Competing Interests: Lung and Blood Institute (NHLBI). Dr. Balas’s institution received funding from NHLBI 1 R01 HL146781-01, American Association of Critical Care Nurses Research Grant, and she received funding from the Society of Critical Care Medicine and H3C. Dr. Needham’s institution received funding from Baxter Pharma and Reck Medical Devices, and he received funding from Haisco USA. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation., Data Sources: A librarian-assisted search was performed using three electronic databases., Study Selection: Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included., Data Extraction: Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system., Data Synthesis: Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes., Conclusions: The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams., Competing Interests: Dr. Mion has research support from the National Institutes of Health (NIH). Dr. Balas currently receives research support from the National Heart, Lung, and Blood Institute of the NIH under award number R01HL14678-01 and the American Association of Critical Care Nurse’s Impact Research Grant. She has received past honoraria from the Society of Critical Care Medicine for her work related to the ICU Liberation Collaborative and is currently an educational consultant for H3C, LLC. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: To identify factors associated with the ABCDEF bundle (Assess, prevent, and manage pain, Both, spontaneous awakening and breathing trials, Choice of sedation/analgesia, Delirium assess, prevent and manage, Early mobility/exercise and Family engagement/empowerment) adherence, in critically ill patients during the first 96 hours of mechanical ventilation., Design: Observational study using electronic health record data., Setting: 15 intensive care units located in seven community hospitals in a western United States health system., Patients: 977 adult patients who were on mechanical ventilation for greater than 24 hours and admitted to an intensive care unit over six months., Measurements and Main Results: Multiple regression analysis was used to examine factors contributing to bundle adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed. ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = 0.01), who received continuous sedation for less than 24 hours (p < 0.001), admitted from skilled nursing facilities (p < 0.05), and over the course of the six-month study period (p < 0.01). Bundle adherence was significantly lower for Hispanic patients (p < 0.01)., Conclusions: Our study identified potentially modifiable factors that could improve the team's performance of the ABCDEF bundle in patients requiring mechanical ventilation., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Physical restraints are frequently used for intensive care patients and are associated with substantial morbidity. The effects of common evidence-based critical care interventions on use of physical restraints remain unclear., Objective: To identify independent predictors of new-onset use of physical restraints in critically ill adults., Methods: Secondary analysis of a prospective cohort study involving 5 adult intensive care units in a tertiary care medical center in the United States. Use of physical restraints was determined via daily in-person assessments and medical record review. Mixed-effects logistic regression analysis was used to examine factors associated with new-onset use of physical restraints, adjusting for covariates and within-subject correlation among intensive care unit days., Results: Of 145 patients who were free of physical restraints within 48 hours of intensive care unit admission, 24 (16.6%) had restraints newly applied during their stay. In adjusted models, delirium (odds ratio [OR], 5.09; 95% CI, 1.83-14.14), endotracheal tube presence (OR, 3.47; 95% CI, 1.22-9.86), and benzodiazepine administration (OR, 3.17; 95% CI, 1.28-7.81) significantly increased the odds of next-day use of physical restraints. Tracheostomy was associated with significantly lowered odds of next-day restraint use (OR, 0.13; 95% CI, 0.02-0.73). Compared with patients with a target sedation level, patients who were in a coma (OR, 2.56; 95% CI, 0.80-8.18) or deeply sedated (OR, 2.53; 95% CI, 0.91-7.08) had higher odds of next-day use of physical restraints, and agitated patients (OR, 0.08; 95% CI, 0.00-2.07) were less likely to experience restraint use., Conclusion: Several potentially modifiable risk factors are associated with next-day use of physical restraints., (©2020 American Association of Critical-Care Nurses.)

Importance: Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death., Objective: To describe structures, processes, and variability of end-of-life care delivered in ICUs in the United States., Design, Setting, and Participants: This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019., Main Outcomes and Measures: Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU., Results: Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units [22.2%]) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units [39.7%]) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units [38.1%]) achieved high rates across all favorable end-of-life events., Conclusions and Relevance: In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.

Objective: The purpose of this systematic review was to critically evaluate the safety and effectiveness of various complementary health approaches (CHAs) in treating symptoms experienced by critically ill adults., Methods: The review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Electronic databases (PubMed, Web of Science, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Education Resources Information Center, Medline, PsychInfo) were searched for studies published from 1997-2017. Randomized controlled trials (RCTs), in English with terms ICU/critical care, music, Reiki, therapeutic touch, healing touch, aromatherapy, essential oil, reflexology, chronotherapy, or light therapy were eligible for inclusion. Studies conducted outside the ICU, involving multiple CHAs, or enrolling pediatric patients were excluded. Data were extracted and assessed independently by two authors and reviewed by two additional authors. The Cochrane risk of bias tool was used to assess study quality., Results: Thirty-two RCTs were included involving 2,987 critically ill adults. CHAs evaluated included music (n = 19), nature based sounds (NBSs) (n = 4), aromatherapy (n = 3), light therapy (n = 2), massage (n = 2), and reflexology (n = 2). Half of all studies had a high risk of bias for randomization but had low or unclear biases for other categories. No study-related adverse events or safety-related concerns were reported. There were statistically significant improvements in pain (music, NBSs), anxiety (music, NBSs, aromatherapy, massage, reflexology), agitation (NBSs, reflexology), sleep (music, aromatherapy, reflexology), level of arousal (music, massage), and duration of mechanical ventilation (music, reflexology)., Conclusions: Evidence suggests CHAs may reduce the symptom burden of critically ill adults., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers., (©2019 American Association of Critical-Care Nurses.)

The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle., (©2019 American Association of Critical-Care Nurses.)

Objective: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care., Design: Prospective, multicenter, cohort study from a national quality improvement collaborative., Setting: 68 academic, community, and federal ICUs collected data during a 20-month period., Patients: 15,226 adults with at least one ICU day., Interventions: We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders., Measurements and Results: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001)., Conclusions: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

Objective: To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU., Design: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017., Methods: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified., Results: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation., Conclusions: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Background: Patients admitted to intensive care units (ICUs) often experience pain, oversedation, prolonged mechanical ventilation, delirium, and weakness. These conditions are important in that they often lead to protracted physical, neurocognitive, and mental health sequelae now termed postintensive care syndrome. Changing current ICU practice will not only require the adoption of evidence-based interventions but the development of effective and reliable teams to support these new practices., Objectives: To build on the success of bundled care and bridge an ongoing evidence-practice gap, the Society of Critical Care Medicine (SCCM) recently launched the ICU Liberation ABCDEF Bundle Improvement Collaborative. The Collaborative aimed to foster the bedside application of the SCCM's Pain, Agitation, and Delirium Guidelines via the ABCDEF bundle. The purpose of this paper is to describe the history of the Collaborative, the evidence-based implementation strategies used to foster change and teamwork, and the performance and outcome metrics used to monitor progress., Methods: Collaborative participants were required to attend four in-person meetings, monthly colearning calls, database training sessions, an e-Community listserv, and select in-person site visits. Teams submitted patient-level data and completed pre- and postimplementation questionnaires focused on the assessment of teamwork and collaboration, work environment, and overall ICU care. Faculty shared the evidence used to derive each bundle element as well as team-based implementation strategies for improvement and sustainment., Results: Retention in the Collaborative was high, with 67 of 69 adult and eight of nine pediatric ICUs fully completing the program. Baseline and prospective data were collected on over 17,000 critically ill patients. A variety of evidence-based professional behavioral change interventions and novel implementation techniques were utilized and shared among Collaborative members., Linking Evidence to Action: Hospitals and health systems can use the Collaborative structure, strategies, and tools described in this paper to help successfully implement the ABCDEF bundle in their ICUs., (© 2018 Sigma Theta Tau International.)

Associated with substantial morbidity and mortality, delirium is a syndrome commonly experienced by hospitalized adults. This article presents a case study highlighting how delirium may go unrecognized by the healthcare team and provides 10 suggestions for improving delirium assessment, prevention, and management in the acute care setting.

Delirium, a prevalent organ dysfunction in critically ill patients, is independently associated with increased morbidity. This last decade has witnessed an exponential growth in delirium research in hospitalized patients, including those critically ill, and this research has highlighted that delirium needs to be better understood mechanistically to help foster research that will ultimately lead to its prevention and treatment. In this invited, evidence-based paper, a multinational and interprofessional group of clinicians and researchers from within the fields of critical care medicine, psychiatry, pediatrics, anesthesiology, geriatrics, surgery, neurology, nursing, pharmacy, and the neurosciences sought to address five questions: (1) What is the current standard of care in managing ICU delirium? (2) What have been the major recent advances in delirium research and care? (3) What are the common delirium beliefs that have been challenged by recent trials? (4) What are the remaining areas of uncertainty in delirium research? (5) What are some of the top study areas/trials to be done in the next 10 years? Herein, we briefly review the epidemiology of delirium, the current best practices for management of critically ill patients at risk for delirium or experiencing delirium, identify recent advances in our understanding of delirium as well as gaps in knowledge, and discuss research opportunities and barriers to implementation, with the goal of promoting an integrated research agenda.

Critically ill patients experience several severe, distressing, and often life-altering symptoms during their intensive care unit stay. A clinical practice guideline released by the American College of Critical Care Medicine provides a template for improving the care and outcomes of the critically ill through evidence-based pain, agitation, and delirium assessment, prevention, and management. Key strategies include the use of valid and reliable assessment tools, setting a desired sedation level target, a focus on light sedation, choosing appropriate sedative medications, the use of nonpharmacologic symptom management strategies, and engaging and empowering patients and their family to play an active role in their intensive care unit care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

When robust clinical trials are lacking, clinicians are often forced to extrapolate safe and effective evidence-based interventions from one patient care setting to another. This article is about such an extrapolation from the intensive care unit (ICU) to the long-term acute care hospital (LTACH) setting. Chronic critical illness is an emerging, disabling, costly, and yet relatively silent epidemic that is central to both of these settings. The number of chronically critically ill patients requiring prolonged mechanical ventilation is expected to reach unprecedented levels over the next decade. Despite the prevalence, numerous distressing symptoms, and exceptionally poor outcomes associated with chronic critical illness, to date there is very limited scientific evidence available to guide the care and management of this exceptionally vulnerable population, particularly in LTACHs. Recent studies conducted in the traditional ICU setting suggest interprofessional, multicomponent strategies aimed at effectively assessing, preventing, and managing pain, agitation, delirium, and weakness, such as the ABCDEF bundle, may play an important role in the recovery of the chronically critically ill. This article reviews what is known about the chronically critically ill, provide readers with some important historical perspectives on the ABCDEF bundle, and address some controversies and practical implications of adopting the ABCDEF bundle into the everyday care of patients requiring prolonged mechanical ventilation in the LTACH setting. We believe developing new and better ways of addressing both the science and organizational aspects of managing the common and distressing symptoms associated with chronic critical illness and prolonged mechanical ventilation will ultimately improve the quality of life for the many patients and families admitted to LTACHs annually., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness., Data Sources: We searched PubMed, CINAHL, Web of Science and Google Scholar for studies reporting disability outcomes (i.e., activities of daily living, instrumental activities of daily living, and mobility activities) and/or cognitive outcomes among patients treated in an ICU who were 65 years or older. We also reviewed the bibliographies of relevant citations to identify additional citations., Study Selection: We identified 19 studies evaluating disability outcomes in critically ill patients who were 65 years and older., Data Extraction: Descriptive epidemiologic data on disability after critical illness., Data Synthesis: Newly acquired disability in activities of daily living, instrumental activities of daily living, and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less severe cognitive impairment were also highly prevalent. Factors related to the acute critical illness, ICU practices, such as heavy sedation, physical restraints, and immobility, as well as aging physiology, and coexisting geriatric conditions can combine to result in these poor outcomes., Conclusions: Older adults who survive critical illness have physical and cognitive declines resulting in disability at greater rates than hospitalized, noncritically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.

Introduction: Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes., Method: We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described., Results: We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioral change, was also associated with reduced mortality., Conclusion: Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.

The purpose of this descriptive study was to determine if older patients discharged from intensive care units (ICU) would be willing to use mobile phone and sensor technology (aka "mobile monitoring") to measure their functional recovery in the posthospitalization period. Semistructured interviews were conducted with 22 older ICU patients and/or their surrogates 24 to 48 hr prior to hospital discharge. While 11 respondents reported they would agree to participate in a future study involving mobile monitoring, an equal number reported they would not participate. Numerous contextual factors were found to affect older adults' willingness to participate including the belief the research would ultimately benefit themselves or other older adults, concerns about loss of privacy, perception that the research is feasible and valuable, and lack of skills using the technology. Future studies using the mobile monitoring technique with older survivors of a serious illness will require substantial recruitment and educational efforts., (© The Author(s) 2013.)

Rationale: The CDC introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs., Objectives: To assess the preventability of VAEs., Methods: We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance among 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining eight units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, Sequential Organ Failure Assessment score, and comorbidity index., Measurements and Main Results: We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator day but significant decreases in VAE risk per episode of mechanical ventilation (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.42-0.97) and infection-related ventilator-associated complications (OR, 0.35; 95% CI, 0.17-0.71) but not pneumonias (OR, 0.51; 95% CI, 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates., Conclusions: Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registered with www.clinicaltrials.gov (NCT 01583413).

Objective: The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice., Design: Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012., Setting: Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center., Patients: Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions' medical or surgical critical care service., Interventions: Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle., Measurements and Main Results: For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7-26] vs 21 [0-25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33-0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29-3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates., Conclusions: Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

Objective: The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination., Design: Prospective, before-after, mixed-methods study., Setting: Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center, Subjects: : Interprofessional ICU team members at participating institution., Interventions and Measurements: In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle policy. Over the course of an 18-month period, all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts. Three focus group sessions, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption., Main Results: Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds; 2) engagement of key implementation leaders; 3) sustained and diverse educational efforts; and 4) the bundle's quality and strength. Barriers identified included: 1) intervention-related issues (e.g., timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members., Conclusions: In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.

The management of pain, agitation, and delirium in critically ill patients can be complicated by multiple factors. Decisions to administer opioids, sedatives, and antipsychotic medications are frequently driven by a desire to facilitate patients' comfort and their tolerance of invasive procedures or other interventions within the ICU. Despite accumulating evidence supporting new strategies to optimize pain, sedation, and delirium practices in the ICU, many critical care practitioners continue to embrace false perceptions regarding appropriate management in these critically ill patients. This article explores these perceptions in more detail and offers new evidence-based strategies to help critical care practitioners better manage sedation and delirium, particularly in ICU patients.

Forecasted changes in the demographics of the United States suggest there will be an unprecedented need for health care professionals with specific training in geropsychiatric care. An aging society, the dearth of geropsychiatric health care professionals, the shortage of educators, and the lack of interprofessional geropsychiatric education require new strategies for nursing education to address these issues. The vision of the Institute of Medicine serves as a foundation for transforming geropsychiatric nursing and interprofessional education to prepare the next generation of nurses and the geropsychiatric workforce to improve the mental health care of older adults. This article aims to describe the importance and implications of implementing the recently released Geropsychiatric Nursing Competency Enhancements and the Core Competencies for Interprofessional Collaborative Practice to improve the mental health care of older Americans. A secondary aim is to discuss how to overcome barriers in implementing interprofessional education in geropsychiatric nursing care., (Copyright 2013, SLACK Incorporated.)

Background: Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry., Objectives: To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial., Methods: In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates., Results: We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy., Conclusions: Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Complex, interconnected issues challenge the United States health care system and the patients and families it serves. System fragmentation, limited resources, rigid disciplinary boundaries, institutional culture, ineffective communication, and uncertainty surrounding health policy legislation are contributing to suboptimal care delivery and patient outcomes., Methods: These problems are too complex to be solved by a single discipline. Interdisciplinary research affords the opportunity to examine and solve some of these problems from a more integrative perspective using innovative and rigorous methodological designs., Results: In this paper, we explore lessons learned from exemplars funded by the Robert Wood Johnson Foundation's Interdisciplinary Nursing Quality Research Initiative., Discussion: The discussion is framed using an adaptation of the Interdisciplinary Research Model to evaluate improvements in individual health outcomes, health systems, and health policy. Barriers and facilitators to designing, conducting, and translating interdisciplinary research are discussed. Implications for health system and policy changes, including the need to provide funding mechanisms to implement interdisciplinary processes in both research and clinical practice, are provided.

It has been 10 years since the last publication of the clinical practice guidelines for pain, agitation/sedation, and delirium (PAD). The results of new studies have directed significant changes in critical care practice. Using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology, the guidelines were revised, resulting in 32 recommendations and 22 summary statements. This article provides guidance toward guideline implementation strategies and outlines 10 key points to consider. Compared with its predecessor, the 2013 PAD guidelines are less prescriptive in that they recommend approaches to patient care rather than giving specific medication recommendations. This will help focus care teams on the process and structure of patient management and result in more flexibility when choosing specific medications. This article outlines approaches to guideline implementation that take into account the changes in philosophy surrounding medication selection. The manuscript focuses on the areas anticipated to generate the most change such as lighter sedation targets, avoidance of benzodiazepines, and early mobility. A gap analysis grid is provided. The release of any guideline should prompt reevaluation of current institutional practice standards. This manuscript uses the PAD guidelines as an example of how to approach the interprofessional work of guideline implementation., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Delirium in older adults in critical care is associated with poor outcomes, including longer stays, higher costs, increased mortality, greater use of continuous sedation and physical restraints, increased unintended removal of catheters and self-extubation, functional decline, new institutionalization, and new onset of cognitive impairment. Diagnosing delirium is complicated because many critically ill older adults cannot communicate their needs effectively. Manifestations include reduced ability to focus attention, disorientation, memory impairment, and perceptual disturbances. Nurses often have primary responsibility for detecting and treating delirium, which can be extraordinarily complicated because patients are often voiceless, extremely ill, and require high levels of sedatives to facilitate mechanical ventilation. An aggressive, appropriate, and compassionate management strategy may reduce the suffering and adverse outcomes associated with delirium and improve relationships between nurses, patients, and patients' family members.