Objectives: Sedation minimization and ventilator liberation protocols improve outcomes but are challenging to implement. We sought to demonstrate proof-of-concept and impact of an electronic application promoting sedation minimization and ventilator liberation. Design: Multi-ICU proof-of-concept study and a single ICU before-after study. Setting: University hospital ICUs. Patients: Adult patients receiving mechanical ventilation. Interventions: An automated application consisting of 1) a web-based dashboard with real-time data on spontaneous breathing trial readiness, sedation depth, sedative infusions, and nudges to wean sedation and ventilatory support and 2) text-message alerts once patients met criteria for a spontaneous breathing trial and spontaneous awakening trial. Pre-intervention, sedation minimization, and ventilator liberation were reviewed daily during a multidisciplinary huddle. Post-intervention, the dashboard was used during the multidisciplinary huddle, throughout the day by respiratory therapists, and text alerts were sent to bedside providers. Measurements and Main Results: We enrolled 115 subjects in the proof-of-concept study. Spontaneous breathing trial alerts were accurate (98.3%), usually sent while patients were receiving mandatory ventilation (88.5%), and 61.9% of patients received concurrent spontaneous awakening trial alerts. We enrolled 457 subjects in the before-after study, 221 pre-intervention and 236 post-intervention. After implementation, patients were 28% more likely to be extubated (hazard ratio, 1.28; 95% CI, 1.01–1.63; p = 0.042) and 31% more likely to be discharged from the ICU (hazard ratio, 1.31; 95% CI, 1.03–1.67; p = 0.027) at any time point. After implementation, the median duration of mechanical ventilation was 2.20 days (95% CI, 0.09–4.31 d; p = 0.042) shorter and the median ICU length of stay was 2.65 days (95% CI, 0.13–5.16 d; p = 0.040) shorter, compared with the expected durations without the application. Conclusions: Implementation of an electronic dashboard and alert system promoting sedation minimization and ventilator liberation was associated with reductions in the duration of mechanical ventilation and ICU length of stay.

BACKGROUND: The Pennsylvania Respiratory Research Collaborative formed in January 2017 for the purpose of providing mentorship and opportunities to participate in statewide research, quality improvement, and evidence-based practice projects. The inaugural project was designed to investigate and describe the practice of respiratory therapy in Pennsylvania. METHODS: A survey related to the practice and business of in-patient respiratory therapy departments was developed and sent to managers/directors of every hospital within the state of Pennsylvania. The survey period was October 2017 to April 2018. Pennsylvania hospitals were contacted to ask the respiratory therapy manager/director to complete the electronic survey. One hundred eighty-eight hospitals with in-patient respiratory therapy departments were contacted; direct information for the respiratory therapy manager/director was obtained for 159 hospitals. RESULTS: Of the 159 hospitals sent the survey, 101 (63.5%) responded. Of the respondents, 52% were academic medical centers. For staff positions, 50% prefer a bachelor's degree, and 77.3% prefer the Registered Respiratory Therapist certification. However, managers are only able to hire preferred candidates 50% of the time. Clinical ladders are utilized in 29% of the responding institution, and protocols are utilized in 74% of hospitals, with the most common being ventilator (92%), bronchodilator (79%), airway clearance (56%), hyperinflation (41%), and disease-specific (23%). Respiratory therapists in 84% of the hospitals perform nontraditional procedures, with the most common being electrocardiography (35%), advanced procedures including intubation (20%), arterial line placement (14%), blind bronchoalveolar lavage (14%), and electroencephalography (12%). Respiratory therapists are utilized in alternative roles in 42% of hospitals. The most common alternative roles are patient educator (29%), outpatient clinics (21%), patient navigators (19%), transport (14%), extracorporeal membrane oxygenation (6%), case managers (5%), research (5%), and telehealth (2%). CONCLUSIONS: The practice of respiratory therapy in the state of Pennsylvania varies greatly, with a small number of hospitals practicing at the top of their license.

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BACKGROUND: Staffing strategies used to meet the needs of respiratory care departments during the COVID-19 pandemic included the deployment of respiratory therapist extenders. The purpose of this study was to evaluate respiratory therapist extenders' comfort level with critical care ventilators while caring for patients with COVID-19. To our knowledge, this is the first study to evaluate the deployment of certified registered nurse anesthetists (CRNAs) in a critical care setting. METHODS: A qualitative survey method was used to assess CRNA experience with critical care ventilators. Prior to deployment in the ICU, CRNAs were trained by clinical lead respiratory therapists. Education included respiratory clinical practices and ventilator management. Sixtyminute sessions were held with demonstration stations set up in ICUs for hands-on experience. RESULTS: Fifty-six CRNAs responded to our survey (63%). A mean 6 SD of 9.48 6 12.27 h was spent training prior to deployment in the ICU. CRNAs were at the bedside a mean 6 SD of 73.0 6 40.6 h during the pandemic. While CRNA comfort level with critical care ventilators increased significantly (P < .001) from the beginning to the end of their work experience, no statistically significant differences were found between CRNA comfort based on years of experience. Differences in comfort level were not found after training (chi-squared test 23.82, P 5 .09) or after ICU experience was completed (chi-squared test 5 15.99, P 5 .45). Similarly, mean comfort level did not increase based on the number of hours spent working in the ICU (chi-squared test 5 13.67, P 5 .55). CONCLUSIONS: Comfort level with mechanical ventilation increased for CRNAs working alongside respiratory therapists during the COVID-19 pandemic.

The use of humidified high-flow nasal cannula (HFNC) has expanded greatly in the last several years despite any published trials regarding its safety and/or efficacy in neonates, essentially becoming the treatment of choice over nasal CPAP (NCPAP) in many centers.ObjectiveTo describe the prevalence of usage of HFNC vs NCPAP in two large tertiary care hospitals in neonates admitted with respiratory disease.MethodsData were retrospectively reviewed for all NICU admissions from both Wilford Hall MC and Santa Rosa Children's Hospital during the study period. June 2004 was identified as a time point in both centers when the use of HFNC became readily available. Given this, data were collected for those admissions occurring 11 months prior to June 2004 (Era 1) and compared to those admissions occurring 11 months after (Era 2). Subgroup analysis was additionally done for VLBW (defined as < 30 weeks' gestation). This study was independently approved by the IRB of both institutions.ResultsThe use of NCPAP in Era 2 vs Era 1 decreased remarkably from 15% to 2.5% for all NICU admissions and from 39% to 6.7% in VLBW infants. During this same period, the use of HFNC increased from 14% to 61% overall and from 39% to 97% in VLBW infants. In Era 1, there were 566 total admissions and 72 for VLBW infants, compared to 597 and 89 admissions, respectively, for Era 2. Mortality rate (4.0% vs 3.6%) and mean ventilator days (4.0 vs 3.0) overall were similar between the two eras. In VLBW infants, mortality rate decreased from 12.5% to 8.9% and mean ventilator days decreased from 16.2 6 SD to 11.2 6 SD days in Era 1 vs Era 2, respectively. Similar complication rates to include nosocomial infections were found in both eras.ConclusionsIn our study, the use of HFNC has largely replaced NCPAP for the routine treatment of neonatal respiratory disease and is almost universally used in VLBW infants. HFNC therapy additionally appears to be as efficacious and safe as NCPAP therapy. Further analysis needs to be done to determine whether HFNC improves neonatal outcomes.