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Objectives: To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost., Design: Prospective cohort study., Setting: Two medical ICUs within Montefiore Healthcare Center (Bronx, NY)., Patients: One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014., Interventions: At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD)., Measurements and Main Results: In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively., Conclusions: In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.

Objective: Intensivist-directed intensive care units (ICUs) have been shown to improve clinical outcomes. Numerous barriers exist that limit hospitals adopting this practice. We sought to show this staffing model can be implemented in an austere environment with limited resources resulting in improved outcomes., Design: We conducted a retrospective observational cohort study of consecutive adult patients admitted to the ICU between March 2004 and January 2007., Setting: This study was conducted in an ICU in a U.S. Army Combat Support Hospital deployed to Afghanistan., Patients: North Atlantic Trade Organization members (U.S. military service members, American civilian contractors, members of the North Atlantic Trade Organization Coalition International Security Assistance Force), members of the Afghanistan National Army and National Police, and local Afghani nationals were included in the study. Both traumatic injuries and medical illnesses were treated., Interventions: During the observation period, the ICU was converted from an open model to an intensivist-directed model., Measurements and Main Results: Outcomes compared between the two models included ICU and hospital mortality, duration of mechanical ventilation, and ventilator-associated pneumonia rates. During the observation period, there were 2740 admissions, 965 of which were initially admitted to the ICU. We found significant reductions in ICU mortality (6.6% vs. 4.0%, p < 0.001), duration of mechanical ventilation (4.7 +/- 3.9 days vs. 3.1 +/- 2.7 days, p < 0.001), and rates of ventilator-associated pneumonia (42.5% vs. 8.0%; p < 0.001)., Conclusions: Transition to an intensivist-directed ICU in an Army Combat Support Hospital improved outcomes among ICU patients. This study demonstrates the feasibility of using this model in an austere, combat environment.

Objective: Ambulation of patients with acute respiratory failure may be unnecessarily limited in the acute intensive care setting. We hypothesized that ambulation of patients with acute respiratory failure would increase with transfer to an intensive care unit where activity is a key component of patient care., Design: Pre-post cohort study of respiratory failure patients., Setting: Adult intensive care units at LDS Hospital., Patients: Respiratory failure patients requiring >4 days of mechanical ventilation who were transferred from other LDS Hospital intensive care units to the respiratory intensive care unit., Interventions: We prospectively applied an early activity protocol to all consecutive respiratory failure patients transferred to the respiratory intensive care unit., Measurements and Main Results: We studied 104 respiratory failure patients who required mechanical ventilation for >4 days. Transferring a patient to the respiratory intensive care unit substantially increased the probability of ambulation (p < .0001). After 2 days in the respiratory intensive care unit, the number of patients ambulating had increased three-fold compared with pretransfer rates. Female gender (p = .019), the absence of sedatives (p = .009), and lower Acute Physiology and Chronic Health Evaluation II scores (p = .017) also predicted an increased probability of ambulation. Improvements in ambulation with transfer to the respiratory intensive care unit remained significant after adjustment for Acute Physiology and Chronic Health Evaluation II scores and other covariates., Conclusions: Transfer of acute respiratory failure patients to the respiratory intensive care unit substantially improved ambulation, independent of the underlying pathophysiology. The intensive care environment may contribute unnecessary immobilization throughout the course of acute respiratory failure. Sedatives, even given intermittently, substantially reduce the likelihood of ambulation. Controlled studies are needed to determine whether intensive care unit immobilization contributes to long-term neuromuscular dysfunction or whether early intensive care unit activity improves outcomes.

Objective: We hypothesized that a dual strategy--instituting a closed intensive care unit (ICU) policy and simultaneously appointing an intensivist--would improve patient outcome in a university hospital of a developing country and that the benefit would increase over time., Design: Data were prospectively collected over 5 months before the policy change (open policy) and over an initial 6 mos (early closed policy) and subsequent 12 mos (late closed policy) after the policy change., Setting: The study was conducted at a medical ICU of a university hospital in Turkey., Patients: Two hundred patients were recruited during open policy, 149 during early closed policy, and 210 during late closed policy., Measurements and Results: Instituting a closed policy and simultaneously appointing a critical care specialist was associated with the admission of sicker patients and more frequent use of invasive procedures. Compared with open policy, patients were approximately 4.5 times more likely to survive their hospital stay during early closed policy (p < .001) and approximately five times more likely during late closed policy (p < .0001). Among patients receiving mechanical ventilation, hospital mortality was lower during the early (57%) and late closed periods (59%) than during open period (91%; p < .01). In multivariate analysis, open policy, mechanical ventilation, central venous catheterization, sepsis, and higher Acute Physiology and Chronic Health Evaluation II score each independently predicted mortality. The change in policy resulted in the admission of progressively sicker patients over time and increased the use of mechanical ventilation and central venous catheters., Conclusion: A dual strategy of closed policy and simultaneously appointing an intensivist fostered admission of sicker patients and improved the survival of patients requiring admission to an ICU of a developing country.

Objective: Recently published clinical practice guidelines of the Society of Critical Care Medicine recommend monitoring for the presence of delirium in all mechanically ventilated patients because of the potential for adverse outcomes associated with this comorbidity, yet little is known about healthcare professionals' opinions regarding intensive care unit delirium or how they manage this organ dysfunction. The aim of this survey was to assess the medical community's beliefs and practices regarding delirium in the intensive care unit., Design: Survey administration was conducted both without a delirium definition (phase 1) and then with a definition of delirium (phase 2)., Setting: Critical care meetings and continuing medical education/board review courses from October 2001 to July 2002., Participants: A convenience sample of physicians (n = 753), nurses (n = 113), pharmacists (n = 13), physician assistants (n = 12), respiratory care practitioners (n = 8), and others (n = 13)., Interventions: Survey., Measurements and Main Results: Participants completed 912 of the surveys. The majority (68%) of respondents thought that >25% of adult mechanically ventilated patients experience delirium. Delirium was considered a significant or very serious problem in the intensive care unit by 92% of healthcare professionals, yet underdiagnosis was acknowledged by 78%. Only 40% reported routinely screening for delirium, and only 16% indicated using a specific tool for delirium assessment. Delirium was considered important in the outcome of elderly and young patients by 89% and 60% of the respondents, respectively (p <.0001). The most serious complications these professionals associated with delirium were prolonged mechanical ventilation, self-injury, and respiratory difficulties. Delirium was treated with haloperidol by 66% of the respondents, with lorazepam by 12%, and with atypical antipsychotics by <5%. More than 55% administered haloperidol and lorazepam at daily doses of < or =10 mg, but some used >50 mg/day of either medication., Conclusions: Most healthcare professionals consider delirium in the intensive care unit a common and serious problem, although few actually monitor for this condition and most admit that it is underdiagnosed. Data from this survey point to a disconnect between the perceived significance of delirium in the intensive care unit and current practices of monitoring and treatment.

Objective: Scoring systems that predict mortality do not necessarily predict prolonged length of stay or costs in the intensive care unit (ICU). Knowledge of characteristics predicting prolonged ICU stay would be helpful, particularly if some factors could be modified. Such factors might include process of care, including active involvement of full-time ICU physicians and length of hospital stay before ICU admission., Design: Demographic data, clinical diagnosis at ICU admission, Simplified Acute Physiology Score, and organizational characteristics were examined by logistic regression for their effect on ICU and hospital length of stay and weighted hospital days (WHD), a proxy for high cost of care., Setting: A total of 34 ICUs at 27 hospitals participating in Project IMPACT during 1998., Patients: A total of 10,900 critically ill medical, surgical, and trauma patients qualifying for Simplified Acute Physiology Score assessment., Interventions: None., Results: Overall, 9.8% of patients had excess WHD, but the percentage varied by diagnosis. Factors predicting high WHD include Simplified Acute Physiology Score survival probability, age of 40 to 80 yrs, presence of infection or mechanical ventilation 24 hrs after admission, male sex, emergency surgery, trauma, presence of critical care fellows, and prolonged pre-ICU hospital stay. Mechanical ventilation at 24 hrs predicts high WHD across diagnostic categories, with a relative risk of between 2.4 and 12.9. Factors protecting against high WHD include do-not-resuscitate order at admission, presence of coma 24 hrs after admission, and active involvement of full-time ICU physicians., Conclusions: Patients with high WHD, and thus high costs, can be identified early. Severity of illness only partially explains high WHD. Age is less important as a predictor of high WHD than presence of infection or ventilator dependency at 24 hrs. Both long ward stays before ICU admission and lack of full-time ICU physician involvement in care increase the probability of long ICU stays. These latter two factors are potentially modifiable and deserve prospective study.

Prolonged therapeutic paralysis with pancuronium is commonly used in ICUs to facilitate mechanical ventilation of patients with respiratory failure. Sedation is usually given concomitantly to reduce patient discomfort, but assessment of its adequacy is made difficult by the paralysis. We recently cared for a former ICU nurse who required prolonged mechanical ventilation and paralysis and received morphine as a sedative. When she recovered, she was able to relate her experiences. She stressed the need for very frequent reorientation to time and her desire for constant explanation and re-explanation of all procedures being done by the nursing and physician staff. Her experiences provide insights that allow all ICU staff to provide better care for patients requiring therapeutic paralysis.

Objective: Predictors of long-term functional impairment in acute respiratory failure of all causes are poorly understood. Our objective was to assess the frequency and predictors of long-term functional impairment or death after invasive mechanical ventilation for acute respiratory failure of all causes.Design: Population-based, observational cohort study.Setting: Eight adult ICUs of a single center.Patients: All adult patients from Olmsted County, Minnesota, without baseline functional impairment who received mechanical ventilation in ICUs for acute respiratory failure of all causes from 2005 through 2009.Interventions: None.Measurements and Main Results: In total, 743 patients without baseline functional impairment received mechanical ventilation in the ICU. At 1- and 5-year follow-up, the rates of survival with return to baseline functional ability were 61% (366/597) and 53% (356/669). Among 71 patients with new functional impairment at 1 year, 55% (39/71) had recovered and were alive without functional impairment at 5 years. Factors predictive of new functional impairment or death at 1 year were age, comorbidities, discharge to other than home, mechanical ventilation of 7 days or longer, and stroke. Of factors known at the time of intubation, the following are predictive of new functional impairment or death: age, comorbidities, nonsurgical condition, Acute Physiology and Chronic Health Evaluation III score, stroke, and sepsis. Post hoc sensitivity analyses revealed no significant change in predictor variables in patient populations when stroke was excluded or who received more than 48 hours of mechanical ventilation.Conclusions: At 1- and 5-year follow-up, many patients who received mechanical ventilation for acute respiratory failure from all causes are no longer alive or have new moderate-to-severe functional impairment. Functional recovery between year 1 and year 5 is possible and common. Sepsis, stroke, illness severity, age, and comorbidities predict long-term functional outcome at intubation. [ABSTRACT FROM AUTHOR]