Background To promote the use of appropriate testing, and decrease unnecessary treatments, the ABIM Foundation established the Choosing Wisely campaign in 2012. Initially targeting physicians, the campaign has evolved to encourage all providers to promote high-value care; however, information related to critical care nursing is limited. Objectives To assess nurses’ reports of the use of Choosing Wisely recommendations in critical care settings. Methods Responses from nurses were examined as part of a critical care survey of members of 4 societies in order to assess awareness and use of the Choosing Wisely recommendations. Results Of the 1651 acute and critical care nurses who were members of the American Association of Critical-Care Nurses and responded to the survey, 632 (38.3%) reported being familiar with the Choosing Wisely campaign. Of these respondents, 200 identified as advanced practice nurses. A total of 620 reported implementing the 5 Critical Care Society Collaborative recommendations, including reducing diagnostic testing (n = 311 [50.2%]), reducing the number of red blood cell transfusions (n = 530 [85.5%]), not using parenteral nutrition in adequately nourished patients (n = 293 [47.3%]), not using deep sedation in patients receiving mechanical ventilation (n = 499 [80.5%]), and offering comfort care for patients at high risk for death (n = 416 [67.1%]). Staff education, specific protocols, electronic medical record alerts, and order sets all raised nurses’ awareness of the recommendations. Conclusions Acute and critical care nurses are directly involved with measures to reduce unnecessary testing and treatments. Greater awareness and championing of the Choosing Wisely recommendations by acute and critical care nurses can help to promote high-value care for acute and critically ill patients.

Burnout syndrome (BOS) occurs in all types of health care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health care professionals and diminish the harmful consequences of BOS, both for critical care health care professionals and for patients.

Objectives To describe the number and type of stimulation events and the relationship of stimulation to sedation level in patients receiving mechanical ventilation. Methods A 4-hour direct observation was conducted in 103 patients receiving mechanical ventilation. Stimulation events and sedation level before and after the stimulation were documented. Eight categories of stimulation events were developed in a previous pilot study of 36 patients receiving mechanical ventilation. Sedation was measured continuously by using a processed electroencephalographic score (patient state index [PSI]) and intermittently by using the Richmond Agitation-Sedation Scale. Results Patients were mostly alert/mildly sedated (54.4%) at study enrollment. During the 349 hours of observation, 58.8% of the time included stimulation events. General auditory types of stimulation were most common (41.2% of observed time), followed by respiratory management and tactile family stimulation. For all events, auditory-talking, tactile-general, tactile-noxious, and tactile-highly noxious stimuli were associated with higher PSIs (all P < .001) after stimulation; other stimuli were not. Level of consciousness influenced response to stimuli, with almost all types of stimuli increasing PSI for patients more deeply sedated (PSI < 60) just before the stimuli. However, the effect of stimulation on PSI for more alert patients (PSI > 60) was small and variable. Discussion Critically ill patients receiving mechanical ventilation are subjected to various forms of auditory and tactile stimulation frequently throughout the day. All types of stimuli increased arousal in patients who were more deeply sedated. The effect of stimulation in patients who were not deeply sedated was minimal and inconsistent.

Background Agitation in critically ill adults is a frequent complication of hospitalization and results in multiple adverse outcomes. Potential causes of agitation are numerous; however, data on factors predictive of agitation are limited. Objectives To identify predictors of agitation by examining demographic and clinical characteristics of critically ill patients. Methods A medical record review was performed. Documentation of agitation was indicated by scores on the Richmond Agitation-Sedation Scale or the use of an agitation keyword. Records of 200 patients from 1 medical and 1 surgical intensive care unit were used for the study. Risk factors were determined for 2 points in time: admission to the intensive care unit and within 24 hours before the first episode of agitation. Data on baseline demographics, preadmission risk factors, and clinical data were collected and were evaluated by using logistic multivariable regression to determine predictors of agitation. Results Predictors of agitation on admission to intensive care were history of use of illicit substances, height, respiratory and central nervous system subscores on the Sequential Organ Failure Assessment, and use of restraints. Predictors of agitation within 24 hours before the onset of agitation were history of psychiatric diagnosis, height, score on the Sequential Organ Failure Assessment, ratio of Pa o 2 to fraction of inspired oxygen less than 200, serum pH, percentage of hours with restraints, percentage of hours of mechanical ventilation, pain, and presence of genitourinary catheters. Conclusions Predictors of agitation on admission and within 24 hours before the onset of agitation were primarily clinical variables.

Background Agitation is a frequent complication in critically ill adults, can result in life-threatening events for patients or care providers, and extends the hospital length of stay, thereby increasing hospital costs. Objectives To describe the incidence, onset, and temporal factors related to agitation in critically ill adults. Methods Data were collected for the first 5 days of stay of all adult patients consecutively admitted to a medical respiratory intensive care unit and a surgical trauma intensive care unit during a 2-month period. Agitation was documented by using scores on the Richmond Agitation-Sedation Scale or notation of agitation in the medical record. The hour was used as the documentation epoch, and data were summarized by hour, 4-hour block, and day for each patient. Results Data were collected on 200 patients, 100 from each unit. Among the sample, 118 (59%) were agitated at some time during the 5 days. The overall agitation rate was 7.8% of the total hourly time. Mean onset of agitation was 11.6 hours from time of admission to the unit. Of the 118 patients who were agitated at some time, 102 (86%) had agitation on day 1. Compared with patients in the surgical trauma unit, patients in the medical respiratory unit had significantly more hours of agitation the first day and first hour of admission and significantly earlier onset of agitation. Conclusions Agitation was present in more than one-half of the patients in the sample, typically developed on the first day, and involved consecutive days.

Background Facial expression is often used to evaluate pain in noncommunicative critically ill patients. Objectives To describe facial behavior during endotracheal suctioning, determine facial behaviors that characterize the pain response, and describe the effect of patient factors on facial behavior during pain response. Methods Fifty noncommunicative patients receiving mechanical ventilation were video recorded during 2 phases (rest and endotracheal suctioning). Pain ratings were gathered by using the Behavioral Pain Scale. Facial behaviors were coded by using the Facial Action Coding System for 30 seconds for each phase. Results Fourteen facial actions were associated more with endotracheal suctioning than with rest ( z = 5.78; P < .001). The sum of intensity of the 14 actions correlated with total mean scores on the Behavioral Pain Scale (ρ= 0.71; P < .001) and with the facial expression component of the scale (ρ= 0.67; P < .001) during suctioning. In stepwise multivariate analysis, 5 pain-relevant facial behaviors (brow raiser, brow lower, nose wrinkling, head turned right, and head turned up) accounted for 71% of the variance (adjusted R 2 = 0.682; P < .001) in pain response. The sum of intensity of the 5 actions correlated with total mean scores on the behavioral scale (ρ= 0.72; P < .001) and with the facial expression component of that scale (ρ= 0.61; P < .001) during suctioning. Patient factors had no association with pain intensity scores. Conclusions Upper facial expressions are most frequently activated during pain response in noncommunicative critically ill patients and might be a valid alternative to self-report ratings.

Objective To describe the relationships among sedation, stability in physiological status, and comfort during a 24-hour period in patients receiving mechanical ventilation. Methods Data from 169 patients monitored continuously for 24 hours were recorded at least every 12 seconds, including sedation levels, physiological status (heart rate, respiratory rate, oxygen saturation by pulse oximetry), and comfort (movement of arms and legs as measured by actigraphy). Generalized linear mixed-effect models were used to estimate the distribution of time spent at various heart and respiratory rates and oxygen saturation and actigraphy intervals overall and as a function of level of sedation and to compare the percentage of time in these intervals between the sedation states. Results Patients were from various intensive care units: medical respiratory (52%), surgical trauma (35%), and cardiac surgery (13%). They spent 42% of the time in deep sedation, 38% in mild/moderate sedation, and 20% awake/alert. Distributions of physiological measures did not differ during levels of sedation (deep, mild/moderate, or awake/alert: heart rate, P = .44; respirations, P = .32; oxygen saturation, P = .51). Actigraphy findings differed with level of sedation (arm, P < .001; leg, P = .01), with less movement associated with greater levels of sedation, even though patients spent the vast majority of time with no arm movement or leg movement. Conclusions Level of sedation most likely does not affect the stability of physiological status but does have an effect on comfort.

Background Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. Objective To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. Methods The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the US Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. Results The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: 1) the traditional “silo-ed” approach to critical care research is counterproductive and should be modified; 2) an approach that more effectively links areas of research (ie, basic and translational research, or clinical research and implementation) should be embraced; 3) future approaches to human research should account for disease complexity and patient heterogeneity; and 4) an enhanced infrastructure for critical care research is essential for future success. Conclusions This document contains the themes/recommendations developed by a large, multiprofessional cross section of critical care scientists, clinicians, and educators. It provides a unique framework for future research in critical care medicine.

Background Ventilator-associated pneumonia is associated with increased morbidity and mortality. Objective To examine the effects of mechanical (toothbrushing), pharmacological (topical oral chlorhexidine), and combination (toothbrushing plus chlorhexidine) oral care on the development of ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation. Methods Critically ill adults in 3 intensive care units were enrolled within 24 hours of intubation in a randomized controlled clinical trial with a 2 x 2 factorial design. Patients with a clinical diagnosis of pneumonia at the time of intubation and edentulous patients were excluded. Patients (n = 547) were randomly assigned to 1 of 4 treatments: 0.12% solution chlorhexidine oral swab twice daily, toothbrushing thrice daily, both toothbrushing and chlorhexidine, or control (usual care). Ventilator-associated pneumonia was determined by using the Clinical Pulmonary Infection Score (CPIS). Results The 4 groups did not differ significantly in clinical characteristics. At day 3 analysis, 249 patients remained in the study. Among patients without pneumonia at baseline, pneumonia developed in 24% (CPIS ≥6) by day 3 in those treated with chlorhexidine. When data on all patients were analyzed together, mixed models analysis indicated no effect of either chlorhexidine ( P = .29) or toothbrushing ( P = .95). However, chlorhexidine significantly reduced the incidence of pneumonia on day 3 (CPIS ≥6) among patients who had CPIS <6 at baseline ( P = .006). Toothbrushing had no effect on CPIS and did not enhance the effect of chlorhexidine. Conclusions Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in patients without pneumonia at baseline.

Background The effect of the depth of sedation on the function of the autonomic nervous system is not well known. Objectives To describe the effect of level of sedation on heart rate variability as a marker of the function of the autonomic nervous system in patients receiving mechanical ventilation. Methods This pilot study was part of a larger study in which sedation level was measured continuously for up to 24 hours. The sample consisted of 14 patients receiving mechanical ventilation. The R-R interval was measured continuously via electrocardiography. Sedation level was determined by using the Patient State Index and was categorized as deep (<60) or light (=60). Continuous heart rate data of 5 to 10 minutes for each sedation level for each patient were analyzed. Results Parasympathetic activity as indicated by root mean square of successive difference of the R-R interval, the high-frequency component, and the percentage of differences of successive N-N intervals (intervals due to normal sinus depolarization) that differed more than 50 milliseconds was significantly lower for deep sedation than for light sedation. The markers indicating sympathetic activity, including the low-frequency component and the ratio of the low-frequency component to the high-frequency component, did not differ significantly between the 2 levels of sedation. Most patients were receiving benzodiazepines. Conclusions Deep sedation may be associated with depression of parasympathetic function in patients receiving mechanical ventilation. Use of benzodiazepines most likely contributed to this finding.

• Background Ventilator-associated pneumonia is a significant cause of morbidity and mortality and may be influenced by oral health. • Objective To describe the relationship between ventilator-associated pneumonia and oral health status, changes in oral health status during the first 7 days after intubation, and microbial colonization of the oropharynx and trachea. • Methods A total of 66 patients were enrolled within 24 hours of intubation and were followed up for up to 7 days. Data on oral health measures and the Clinical Pulmonary Infection Score (CPIS) were collected at baseline, day 4 (n = 37), and day 7 (n = 21). A regression model was used to predict risk of pneumonia at day 4. • Results Dental plaque and oral organisms increased over time. Correlations were significant for baseline and day 4 dental plaque ( P < .001), baseline salivary lactoferrin and day 4 plaque ( P = .01), and lower salivary volume and higher day 4 CPIS ( P = .02). Potential pathogens were identified in oral cultures for 6 patients before or at the same time as the appearance of the organisms in tracheal aspirates. Correlations were significant with day 4 CPIS for score on the Acute Physiology and Chronic Health Evaluation (APACHE) II ( P = .007), day 4 salivary volume ( P = .02), interaction of APACHE II score and day 1 CPIS ( P <.001), and interaction of day 1 CPIS and plaque ( P =.01). • Conclusions Higher dental plaque scores confer greater risk for ventilator-associated pneumonia, particularly for patients with greater severity of illness. Salivary volume and lactoferrin may affect the risk.

• Background Ventilator-associated pneumonia is a common complication of mechanical ventilation. Backrest position and time spent supine are critical risk factors for aspiration, increasing the risk for pneumonia. Empirical evidence of the effect of backrest positions on the incidence of ventilator-associated pneumonia, especially during mechanical ventilation over time, is limited. • Objective To describe the relationship between backrest elevation and development of ventilator-associated pneumonia. • Methods A nonexperimental, longitudinal, descriptive design was used. The Clinical Pulmonary Infection Score was used to determine ventilator-associated pneumonia. Backrest elevation was measured continuously with a transducer system. Data were obtained from laboratory results and medical records from the start of mechanical ventilation up to 7 days. • Results Sixty-six subjects were monitored (276 patient days). Mean backrest elevation for the entire study period was 21.7°. Backrest elevations were less than 30° 72% of the time and less than 10° 39% of the time. The mean Clinical Pulmonary Infection Score increased but not significantly, and backrest elevation had no direct effect on mean scores. A model for predicting the Clinical Pulmonary Infection Score at day 4 included baseline score, percentage of time spent at less than 30° on study day 1, and score on the Acute Physiology and Chronic Health Evaluation II, explaining 81% of the variability (F=7.31, P=.003). • Conclusions Subjects spent the majority of the time at backrest elevations less than 30°. Only the combination of early, low backrest elevation and severity of illness affected the incidence of ventilator-associated pneumonia.

Objectives To determine the feasibility of continuous measurement of limb movement via wrist and ankle actigraphy (an activity measure) in critically ill patients and to compare actigraphy measurements with observed activity, subjective scores on sedation-agitation scales, and heart rate and blood pressure of patients. • Methods In a prospective, descriptive, correlational study, all activity of 20 adult patients in medical and coronary care units in a university medical center were observed for 2 hours and documented. Wrist and ankle actigraphy, heart rate, and systolic and diastolic blood pressure data were collected every minute. The Comfort Scale and the Richmond Agitation-Sedation Scale were completed at the beginning of the observation period and 1 and 2 hours later. • Results Wrist actigraphy data correlated with scores on the Richmond Agitation-Sedation Scale (r = 0.58) and the Comfort Scale (r = 0.62) and with observed stimulation and activity events of patients (r = 0.45). Correlations with systolic, diastolic, and mean arterial pressures were weaker. Wrist and ankle actigraphy data were significantly correlated (r = 0.69; P < .001); however, their mean values (wrist, 418; ankle, 147) were significantly different (t = 5.77; P < .001). • Conclusions Actigraphy provides a continuous recording of patients’ limb movement. Actigraphy measurements correlate well with patients’ observed activity and with subjective scores on agitation and sedation scales. Actigraphy may become particularly important as a continuous measurement of activity for use in behavioral research and may enhance early recognition and management of the excessive activity that characterizes agitation.

• Background Use of protocols to reduce weaning time for patients receiving mechanical ventilation helps reduce cost and length of stay. However, implementation of this type of protocol is not easy and requires a consistent collaborative effort. • Objective To provide a systematic approach to the weaning process by developing, implementing, and evaluating a protocol for weaning patients from mechanical ventilation in a medical respiratory intensive care unit. • Methods The weaning protocol used was a modification of a protocol developed by Ely et al. Modifications included a more aggressive approach in proceeding to the spontaneous breathing trial, inclusion of the Richmond Agitation-Sedation Scale, and documentation of the production of secretions. • Results Implementation of the protocol significantly reduced the duration of mechanical ventilation as measured by 8-hour shifts and ventilator days. Although length of stay in the intensive care unit was not significantly reduced (P = .29), a continuing downward trend occurred, from a mean of 8.6 days before the protocol was implemented to 7.9 days during the last 6 months of data collection (P = .07). • Conclusions The need to provide efficient care requires the collaboration of all disciplines involved in providing patients’ care. The weaning protocol introduced in this study demonstrates the benefits of using a collaborative team to identify best practices and implement them in a practice setting.