This article is an executive summary of a report from the Centers for Disease Control and Prevention Ventilator-Associated Pneumonia Surveillance Definition Working Group, entitled “Developing a New, National Approach to Surveillance for Ventilator-Associatied Events,” published in Critical Care Medicine, by Magill SS, Klompas M, Balk R, Burns SM, Deutschman CS, et al. 2013;41(11):2467–2475. The full report provides a comprehensive description of the Working Group’s process and outcome.

Background The Burns Wean Assessment Program (BWAP) assessment checklist is designed to assist clinicians in the systematic evaluation of 26 clinical factors important to weaning. The authors recently described the relationship of the BWAP score (derived from the checklist) to weaning trial outcomes (weaning success or failure) in patients receiving mechanical ventilation for 3 days or longer in 5 adult critical care units. A BWAP score of 50 or higher was significantly associated with weaning success regardless of the specific category of patient (surgical, medical, cardiovascular, etc). This secondary analysis extends the evaluation of the BWAP checklist as it focuses on the importance of each individual BWAP factor to weaning outcomes in 5 different populations of patients. Objectives To identify the relative importance of the 26 BWAP factors to weaning success in patients undergoing mechanical ventilation for 3 days or longer in 5 adult critical care units. Methods BWAP checklists were completed within 24 hours of a weaning attempt in surgical-trauma, medical, neurological, thoracic-cardiovascular, and coronary care units in a 5-year period. Advanced practice nurses using a multidisciplinary pathway, the BWAP checklist, protocols for weaning trials, and sedation guidelines managed the patients similarly. Results A total of 20 BWAP factors were significantly associated with successful weaning in all units combined ( P ≤ .02). However, some differences in the importance of the BWAP factors to weaning outcome exist between units, with the neuroscience intensive care unit deviating the most from the other units. Conclusions Although not all BWAP factors are significantly associated with weaning success, most are predictive. Restructuring the BWAP as a unit-specific weaning checklist and potential predictor may assist clinicians to address factors that may impede weaning more efficiently and effectively.

Background Recently, clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation. One such process, use of a weaning protocol, has yielded conflicting results, arguably because of the influence of existing context and processes. Objective To compare international data to assess differences in context and processes in intensive care units that could influence weaning. Methods Review of existing national data on provision of care for critically ill patients, including structure, staffing, skill mix, education, roles, and responsibilities for weaning in intensive care units of selected countries. Results Australia, New Zealand, Denmark, Norway, Sweden, and the United Kingdom showed similarities in critical care provision, structure, skill mix, and staffing ratios in intensive care units. Weaning in these countries is generally a collaborative process between nurses and physicians. Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care unit’s health care team. Nurses may be excluded from direct management of ventilator weaning in some institutions, as this role is primarily assumed by respiratory therapists guided by medical directives. Availability of critical care beds was highest in the United States and lowest in the United Kingdom. Conclusion Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries. Further quantification of these contextual influences should be considered when translating research findings into local clinical practice and when designing randomized controlled trials.

Background The Burns Wean Assessment Program is a 26-factor weaning assessment worksheet and scoring instrument used to reduce practice variability in the clinical management of patients receiving mechanical ventilation. The instrument has been tested in patients in a medical-surgical intensive care unit, but further testing in different populations of adult patients is needed. Objectives To determine the relationship between Burns Wean Assessment Program scores and outcomes of weaning trials in patients treated with mechanical ventilation for 3 or more days. Methods For 5 years in 5 adult critical care units (surgical, medical, neurological, thoracic-cardiovascular, and coronary care), advanced practice nurses collected scores within 24 hours of a weaning attempt. All patients were managed similarly by using a multidisciplinary pathway, the Burns Wean Assessment Program checklist, protocols for weaning trials, and sedation guidelines. Results Of 1889 weaning attempts, 1669 (88%) were successful, and 220 (12%) were unsuccessful. Weaning outcomes did not differ according to sex, but significantly more trials were successful in younger patients than in older patients ( P = .002) and in patients in different units ( P = .01). Regardless of unit, patients with Burns Wean Assessment Program scores greater than 50 were significantly more likely to be weaned successfully ( P = .001) than were patients with lower scores. Conclusions Systematic tracking of the factors and scores on the Burns Wean Assessment Program may be helpful in care planning and management and in determining weaning potential.

• Background In the medical intensive care unit at the University of Virginia Health System, capnography is used to detect end-tidal carbon dioxide to protect patients from inadvertent airway cannulation during placement of gastric tubes. • Objectives To compare the method in which capnography is used with a method in which a colorimetric carbon dioxide detector is used and to determine what variables affect accurate placement of gastric tubes. • Methods A prospective convenience sample of 195 gastric tube insertions was studied in 130 adult patients in a medical intensive care unit. Standard insertions of gastric tubes (done with capnography) were simultaneously monitored by using a disposable colorimetric device, with a color change indicating the presence of carbon dioxide. • Results Insertion variables included tube type (60% Salem sump tubes, 40% soft-bore feeding tubes), route of insertion (71% oral, 29% nasal), mechanical ventilation (81%), and decreased mental status (72%). Carbon dioxide was successfully detected with the colorimetric indicator (within seconds) in all insertions in which carbon dioxide was detected by capnography. When carbon dioxide was detected (27% of insertions), the tubes were withdrawn and reinserted. Carbon dioxide detection during tube placement was significantly associated with nasal insertions ( P = .03) and spontaneously breathing/nonintubated status ( P =.01) but not with mental status or tube type. • Conclusions A colorimetric device is as accurate as capnography for detecting carbon dioxide during placement of gastric tubes.

Clinicians commonly sedate critically ill patients. Sedatives should be administered to achieve predetermined end points. Most currently available scales used to assess sedation are inadequate because they focus on a single domain, such as consciousness. The development of the American Association of Critical-Care Nurses’ Sedation Assessment Scale is described. This new scale consists of 5 domains: consciousness, agitation, anxiety, sleep, and patient-ventilator synchrony. A major advantage of the scale is that its domains parallel common goals of sedation therapy for critically ill patients. The proposed measurements for each domain are based on a comprehensive evaluation of the science and expert recommendations. Before the scale is widely used, clinical testing is required to determine its validity and reliability in a variety of critically ill patients and care situations.

• Objective To improve clinical and financial outcomes for neuroscience patients by using an “outcomes-managed” model of care delivery and 2 acute care nurse practitioners as outcomes managers. • Methods Baseline data from the year before implementation of the care model were compared with data from the first 6 months of implementation. A random list of 122 adult patients admitted to the neuroscience intensive care unit or the acute care neurosurgery unit of a university teaching hospital between January and December 1998 was generated to provide the baseline data. The prospective sample included 402 patients admitted to either unit during the first 6 months of the project (January through June 1999). The acute care nurse practitioners used an evidence-based multidisciplinary plan of care to manage all patients. • Results No differences were found in age, sex, or ethnicity between groups. Patients managed by acute care nurse practitioners had significantly shorter overall length of stay (P = .03), shorter mean length of stay in the intensive care unit ( P< .001), lower rates of urinary tract infection and skin breakdown ( P< .05), and shorter time to discontinuation of the Foley catheter and mobilization ( P < .05). The outcomes-managed group was hospitalized 2306 fewer days than the baseline group, at a total cost savings of $2 467 328. • Conclusions Clinical and financial outcomes are improved significantly by identifying patients at risk, monitoring for complications, and having acute care nurse practitioners manage the patients.