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Abstract: Purpose: The aim of this study was to determine whether the use of a polyurethane-cuffed endotracheal tube would result in a decrease in ventilator-associated pneumonia rate. Materials and Methods: We replaced conventional endotracheal tube with a polyurethane-cuff endotracheal tube (Microcuff, Kimberly-Clark Corporation, Rosewell, Ga) in all adult mechanically ventilated patients throughout our large academic hospital from July 2007 to June 2008. We retrospectively compared the rates of ventilator-associated pneumonia before, during, and after the intervention year by interrupted time-series analysis. Results: Ventilator-associated pneumonia rates decreased from 5.3 per 1000 ventilator days before the use of the polyurethane-cuffed endotracheal tube to 2.8 per 1000 ventilator days during the intervention year (P = .0138). During the first 3 months after return to conventional tubes, the rate of ventilator-associated pneumonia was 3.5/1000 ventilator days. Use of the polyurethane-cuffed endotracheal tube was associated with an incidence risk ratio of ventilator-associated pneumonia of 0.572 (95% confidence interval, 0.340-0.963). In statistical regression analysis controlling for other possible alterations in the hospital environment, as measured by rate of tracheostomy-ventilator-associated pneumonia, the incidence risk ratio of ventilator-associated pneumonia in patients intubated with polyurethane-cuffed endotracheal tube was 0.565 (P = .032; 95% confidence interval, 0.335-0.953). Conclusions: Use of a polyurethane-cuffed endotracheal tube was associated with a significant decrease in the rate of ventilator-associated pneumonia in our study. [Copyright &y& Elsevier]

Rationale: 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., Objectives: To evaluate self-reported rates of implementation of ABCDE components and their association with outcomes in a state-wide quality improvement collaborative., Methods: 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., Measurements and Main Results: 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., Conclusions: 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.

Objectives: Spontaneous awakening trials (SATs) improve outcomes in mechanically ventilated patients, but implementation remains erratic. We examined variation in reported practice, prevalence of attitudes and fears regarding spontaneous awakening trials, and organizational practices associated with routine implementation of spontaneous awakening trials in an ICU quality improvement collaborative., Design: Written survey., Setting: Michigan Health and Hospital Association's Keystone ICU, a quality improvement collaborative of 73 hospitals., Subjects: Attendees of the yearly Keystone ICU meeting, January 2011, including nurses, physicians, hospital administrators, and other healthcare professionals., Intervention: Respondents were asked about institutional characteristics, spontaneous awakening trial practice, attitudes and barriers regarding spontaneous awakening trials, and organizational cultural characteristics that might influence SAT practice. The association of organizational cultural characteristics and attitudes with reported spontaneous awakening trial use was evaluated using logistic regression., Measurements and Main Results: Three hundred nineteen participants attended the meeting. The survey response rate was 83.4%. Respondents reported wide variation in approach to spontaneous awakening trial performance and patient selection. 48.6% of respondents reported regular spontaneous awakening trial use, defined as greater than 75% of mechanically ventilated patients undergoing spontaneous awakening trials each day. In bivariable analysis, addressing sedation goals routinely in rounds and having spontaneous awakening trials as part of unit culture were positively associated with regular spontaneous awakening trial use, whereas the perception that spontaneous awakening trials increased short-term adverse effects, staff fears of spontaneous awakening trials, and the perception that spontaneous awakening trials are hard work were negatively associated with regular spontaneous awakening trial use. In multivariable analysis, only addressing sedation in rounds (odds ratio, 2.85 [95% CI, 1.55-5.23]), incorporation of spontaneous awakening trials into unit culture (odds ratio, 3.36 [95% CI, 1.75-6.43]), and the perception that spontaneous awakening trials are hard work (odds ratio, 0.53 [95% CI, 0.30-0.96]) remained statistically significantly associated with regular spontaneous awakening trial use. Respondents in managerial positions were less likely to perceive spontaneous awakening trials as hard work (odds ratio, 0.44 [95% CI, 0.22-0.85])., Conclusions: Even in a motivated statewide quality improvement collaborative, spontaneous awakening trial practice varies widely and concerns persist regarding spontaneous awakening trials. Cultural practices may counteract the effect of concerns regarding spontaneous awakening trials and are associated with increased performance of this beneficial intervention. Patient selection should be a focus for continuing medical education. Differences in perception of work between management and staff may also be a focus for improved communication.