Abstract & Commentary

Hospital Organizational Characteristics Associated with Use of Daily Sedation Interruption in Mechanically Ventilated Patients

By David J. Pierson, MD, Editor, Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, is Editor for Critical Care Alert.

SYNOPSIS: In a nationally representative sample of U.S. hospitals, reported routine use of daily interruption of sedation for mechanically ventilated patients was associated with the presence of a leadership emphasis on safety culture, receptivity of the staff to practice change, and participation in a collaborative to prevent health care-associated infections. There was no association with the number of hospital beds or with the presence of a medical school affiliation.

SOURCE: Miller MA, et al. Organisational characteristics associated with the use of daily interruption of sedation in US hospitals: A national study. BMJ Qual Saf 2011; Sep 22. [Epub ahead of print]

Miller and colleagues conducted a survey of daily interruption of sedation (DIS) in U.S. hospitals and sought to determine whether organizational features were associated with DIS use. The survey was mailed to a stratified random sample of non-federal U.S. acute-care hospitals with more than 50 beds. The investigators sent their survey to each hospital's identified lead infection control professional. Respondents were asked whether DIS was routinely used in managing mechanically ventilated adult patients in their institution (using a scale of 1 [never] to 5 [always]), and responses were dichotomized to 1-3 vs 4-5. Other questions dealt with the respondents' perceptions that the hospital had a leadership-driven safety culture, whether the staff was receptive to change, and whether the respondent would feel safe as a patient in the institution — all reported according to a 1-5 Likert scale — as well as whether the hospital participated in a collaborative to prevent health care-associated infections. Hospital size was taken from the 2007 annual survey database of the American Hospital Association (dichotomized into < 250 beds vs > 250 beds), and survey respondents were asked whether the hospital had an academic affiliation.

Complete responses were received from 386 hospitals (69.4% response rate), of which 33.5% had more than 250 beds and 26.4% had a medical school affiliation. Two-thirds of the hospitals were involved in a collaborative to reduce health care-associated infections. DIS for ventilated patients was reported to be used "always" or "almost always" in 79%. Although 75% of the hospitals reported having a leadership focus on safety culture, only 43% reported that the staff were receptive to changes in practice. A total of 77% of the respondents reported that they would feel safe as a patient in their own institution. Hospital size and whether there was an academic affiliation were not associated with DIS use. Three surveyed factors were, however, statistically significantly associated with increased reported use of DIS: a leadership emphasis on safety culture, staff receptivity to change, and involvement in an infection-control collaborative.

COMMENTARY

The use of DIS in this random sample of U.S. hospitals, as reported by the hospitals' lead infection control professionals, was associated with three organizational characteristics of the institutions, including emphasis on safety on the part of hospital leadership, perceived receptivity to practice change on the part of the staff, and participation in a multi-institutional infection-control collaborative. The study thus identifies features whose associations can be studied further and could potentially be modified. Of note is the finding that DIS use did not vary with hospital size or academic affiliation.

For a study of ICU practice related to mechanical ventilation, one might wonder why infection control personnel were selected as survey respondents. This was done because of the multidisciplinary nature of both infection-control practices (such as prevention of central line infections) and DIS, which necessarily involve buy-in and participation by physicians, nurses, and others. The authors point out that DIS requires collaboration between medical teams and nursing staff that is analogous to that necessary to maximize the utilization of maximal sterile barrier precautions for central line placement, studies on which have typically been coordinated by hospital infection control staff.

Like all surveys, this study determined what the respondents said happened in their institutions rather than what was actually done, which would have required direct observation. This feature may have led to overestimation of regular DIS use (which was claimed by four-fifths of the hospitals), and the study may or may not accurately reflect the staff's true preferences and attitudes. However, the authors acknowledge and discuss the study's limitations, and point out the need for a multicenter prospective study linking actual compliance with DIS with organizational characteristics of the individual institutions. This study also focuses attention on the importance of leadership emphasis on safety culture, staff receptivity to change, and institutional involvement with a collaborative to prevent health care-associated infections — all of them important in more aspects of critical care than just DIS during mechanical ventilation.