Background: Data regarding delivery of evidence-based care to critically ill patients in Intensive Care Units (ICU) during the COVID-19 pandemic is crucial but lacking. This study aimed to evaluate the implementation rate of the ABCDEF bundle, which is a collection of six evidence-based ICU care initiatives which are strongly recommended to be incorporated into clinical practice, and ICU diaries for patients with and without COVID-19 infections in ICUs, and to analyze the impact of COVID-19 on implementation of each element of the bundle and independent associated factors. Methods: A world-wide 1-day point prevalence study investigated the delivery of the ABCDEF bundle and ICU diary to patients without or with COVID-19 infections on 27 January 2021 via an online questionnaire. Multivariable logistic regression analysis with adjustment for patient demographics evaluated the impact of COVID-19 and identified factors in ICU administrative structures and policies independently associated with delivery. Results: From 54 countries and 135 ICUs, 1,229 patients were eligible, and 607 (49%) had COVID-19 infections. Implementation rates were: entire bundle (without COVID-19: 0% and with COVID-19: 1%), Element A (regular pain assessment: 64 and 55%), Element B (both spontaneous awakening and breathing trials: 17 and 10%), Element C (regular sedation assessment: 45 and 61%), Element D (regular delirium assessment: 39 and 35%), Element E (exercise: 22 and 25%), Element F (family engagement/empowerment: 16 and 30%), and ICU diary (17 and 21%). The presence of COVID-19 was not associated with failure to implement individual elements. Independently associated factors for each element in common between the two groups included presence of a specific written protocol, application of a target/goal, and tele-ICU management. A lower income status country and a 3:1 nurse-patient ratio were significantly associated with non-implementation of elements A, C, and D, while a lower income status country was also associated with implementation of element F. Conclusions: Regardless of COVID-19 infection status, implementation rates for the ABCDEF bundle, for each element individually and an ICU diary were extremely low for patients without and with COVID-19 infections during the pandemic. Strategies to facilitate implementation of and adherence to the complete ABCDEF bundle should be optimized and addressed based on unit-specific barriers and facilitators.

/pdf/implementation-of-the-abcdef-bundle-for-critically-ill-icu-3kx9rziuzp.pdf

Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study.

Background Aerosol delivery via mechanical ventilation has been reported to vary significantly among different intensive care units (ICU). The optimal technique for using each aerosol generator may need to be updated with the available evidence. Methods A 2-week prospective multicenter observational cohort study was implemented to record aerosol delivery for mechanically ventilated adult patients in Chinese ICUs. Our data included the type of aerosol device and its placement, ventilator type, humidification, and aerosolized medication administered. A guide for the optimal technique for aerosol delivery during mechanical ventilation was summarized after a thorough literature review. Results A total of 160 patients (105 males) from 28 ICUs were enrolled, of whom 125 (78.1%) received aerosol therapy via invasive ventilation. Among these 125 patients, 53 received ventilator-integrated jet nebulizer, with 64% (34/53) of them placed the nebulizer close to Y piece in the inspiratory limb. Further, 56 patients used continuous nebulizers, with 84% (47/56) of them placed the nebulizer close to the Y piece in the inspiratory limb. Of the 35 patients who received aerosol therapy via noninvasive ventilation, 30 received single limb ventilators and continuous nebulizers, with 70% (21/30) of them placed between the mask and exhalation port. Only 36% (58/160) of the patients received aerosol treatments consistent with optimal practice. Conclusions Aerosol delivery via mechanical ventilation varied between ICUs, and only 36% of the patients received aerosol treatments consistent with optimal practice. ICU clinicians should be educated on the best practices for aerosol therapy, and quality improvement projects aim to improve the quality and outcome of patients with the optimal technique for aerosol delivery during mechanical ventilation are warranted.

/pdf/the-utilization-of-aerosol-therapy-in-mechanical-ventilation-1zjybtk24r.pdf

The utilization of aerosol therapy in mechanical ventilation patients: a prospective multicenter observational cohort study and a review of the current evidence

BACKGROUND: Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored. METHODS: Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made. RESULTS: We identified 261 adverse events (with at least 20 adverse events resulting in death) and 702 near-miss events related to mechanical ventilation in Japan between 2010 and 2017. Furthermore, among all adverse events, 19% (49 of 261 events) caused serious harm (residual disability or death). Human-factor issues were most frequent in both ICU/HCU and general care settings (55% and 53%, respectively), while knowledge-based errors were higher in the general care setting. CONCLUSIONS: Human-factor issues were the most frequent reasons in both settings, while knowledge-based error rates were higher in general care. Our results suggest that proper education and training is needed to minimize patient safety incidents in facilities without respiratory therapists.

http://rc.rcjournal.com/content/respcare/63/10/1246.full.pdf

Mechanical Ventilation-Related Safety Incidents in General Care Wards and ICU Settings

BACKGROUND: Compared with 10 years ago when our last survey was completed, the number of respiratory therapists (RTs) has increased markedly in mainland China. In addition, the education systems for RTs and the working environment have also changed. Thus, we aimed to describe the current situation of respiratory care in mainland China. METHODS: A nationwide survey was initiated from August 15, 2016, to September 2, 2016, through network platforms. RESULTS: We obtained responses from 196 RTs, of whom, 30.6% graduated from a bachelor9s degree program, 25.5% graduated from an associate9s degree program, and 43.9% were nurses who transitioned to be RTs through 6-month on-the-job training programs. Among the 3 groups, no significant differences existed in the basic job responsibility, such as mechanical ventilation and aerosol therapy; however, bachelor9s degree RT graduates participated more in bronchoscopy assistance (96% vs 78%, P = .002), extracorporeal membrane oxygenation management (42% vs 25%, P = .024), and pulmonary ultrasound (40% vs 15%, P CONCLUSIONS: In mainland China, degree programs for students and on-the-job training for Experienced ICU nurses were 2 major ways to train RTs. The absence of credential and/or licensure and the lack of recognition on the value of an RT were deemed as the 2 key obstacles in the development of respiratory care profession.

http://rc.rcjournal.com/content/respcare/early/2018/07/24/respcare.06217.full.pdf

Respiratory Care Education and Clinical Practice in Mainland China

Background: Only limited data are available on the real-life clinical utilization of aerosolized medications in intensive care unit (ICU) patients. Exploring the utilization of aerosolized medicati...

The Use of Aerosolized Medications in Adult Intensive Care Unit Patients: A Prospective, Multicenter, Observational, Cohort Study.

BACKGROUND: Respiratory therapist (RT) is a nascent career in China, so little information is available about intensive care unit (ICU) respiratory care resources and practices, requirements for RTs, and barriers to recruit RTs.

METHODS: Using survey methodology, we designed and mailed a questionnaire to ICU supervisors and staffs at all 106 ICUs within 46 tertiary and university-affiliated hospitals in Beijing.

RESULTS: We obtained responses from 72 of 106 ICUs. There were 644 ICU beds, 18 RTs, 464 physicians, and 1,362 nurses in these 72 ICUs. The ratios of invasive and noninvasive ventilators to beds were 0.7/1 and 0.31/1. Nineteen ICUs were not equipped with noninvasive ventilators; 18 had started using noninvasive ventilation only within the last 5 years; 9 had only nasal cannulas for conventional oxygen therapy. Of 194 responders, 57.8% implemented spontaneous breathing trial before extubation; 23.7% never monitored airway temperature while using heated humidifier; 56.7% changed circuits once a week; and 20.6% every 1–3 days. The survey indicated that 91.2% had heard of the profession of RT before, mostly by attending academic conferences; 86.1% believed respiratory care should be provided by RTs. Due to the paucity of trained RTs, only 9.7% (7/72) ICUs had actually recruited RTs. The specific tasks supposed to be assigned to RTs were mechanical ventilation, chest physiotherapy, and airway care.

CONCLUSIONS: ICU respiratory care equipment and the knowledge to use them are insufficient. Important differences exist in respiratory care practice, which is mostly provided by nurses and physicians. RTs have been gradually recognized and accepted by ICU staff, while professional training and education are needed.

http://rc.rcjournal.com/content/respcare/57/3/370.full.pdf

Respiratory Care Practices and Requirements for Respiratory Therapists in Beijing Intensive Care Units

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Respiratory Care Practices and Requirements for Respiratory Therapists in Beijing Intensive Care Units