SCCM Resource Library-B: Both Spontaneous Awakening Trials and Spontaneous Breathing Trials

Video Transcription

What is this? This is going to give you the data points and the reference ability i.e. we're going to give you these slides and you can go back and  use these slides to teach others. So what's the SBT part? Let's explore how the SBT intersects with the SAT. Spontaneous awakening trial turning  drugs off spontaneous breathing trial letting them breathe on their own and getting them off the ventilator. So we worked very hard to assemble a list of  articles and look at the right of the author. So the right of my name there the top one SBT's New England Journal the right of Riker SAS the Riker scale  Cress the SAT's Sessler the RAS scale another RAS paper from us and JAMA Gerard the ABC study which we've reviewed already  Strom a no sedation study the one I told you about when I went to Denmark Shahabi deep sedation ballast ABCD ease and so on now another slide light  sedation Loray's the Pam predicts delirium diurnal sedation reducing deep goal-directed this is all the stuff that you've been asking about you know I  think it was Sean you asked about the goal-directed in the and the targeting these papers are all right there so we've built you the library and the  other B and the in the C and the D and E all these slide sets have the literature built into you you can have access to this library you don't have  to go find it on your own all right so we won't go over them now but that's what that's what's there when I was a chief resident I generated this paper in  the New England that showed reduction of time on the ventilator then JP Cress did it in the New England Journal with the SAT spontaneous awakening trials this is  what became the icy liberation bundle we put them together in this study that Kathleen Bowman already showed and here's the study here's the graph I  wanted to show you the first time ever in the literature that reducing sedation improved survival so the dark magenta line on the bottom has a lower percent  alive and they got the standard amount of benzos and propofol etc the light blue line above it which has a higher percent alive less death more alive they  got half as much benzo and propofol okay so you can go back and find this literature use it in your ICUs etc now what I want to do is show you very  quickly about six or so studies that have studied the bundle aspect of this because you might find the the individual studies like the SPT study I  just showed you but what about taking them together as a bundle so Heidi Engel Heidi is here now how do you raise your hand look in the back of the  room there there's Heidi she's the physical therapist that I was bragging about earlier she has become incredibly important at popularizing early mobility  so she's going to be your go-to person here to talk to about mobilizing ventilated patients etc she'll be in the lectures later today and tomorrow but  she and I worked with the IHI the Institute for Healthcare Improvement this abbreviation here and we published this paper by Rick Bassett and then Mike  Klompas and what we found was three take-home messages test changes on a small scale we've said this earlier feedback regularly data every month  here's how we're doing on compliance and the third thing build will through seeking seeing the work in action this is where a nurse has a patient and the  other ten beds watch one person walk and they start to be become believers I told you you have to have data and stories data and stories small check sets of  change all right this is a study from the CDC I was sitting at my desk one day and the Center for Disease Control the coronavirus h1n1 people called by phone  and said hey we're going to work with this ID doctor named Mike Klompas see his name at the bottom and we're going to do a VAE prevention study and Klompas  thinks that the bundle is how we're going to reduce VAE okay so look what happened look at the graphs SATs started low and went up through the  through the implementation program SBTs started low and went up and look at this 20 ICUs 12 got the full collaborative eight were surveillance only the eight  surveillance only ICUs in this CDC program no change in the 12 they got full collaborative 5,000 patients opting out of SATs SBTs so it was this  it was a default opt-in I mean default you're going to get them unless you manually opt out that was the program that was set up in our world now you're  going to get this unless you say you're not and look what happened a quadrupling of completion 35% less VAE risk ventilator associated events and 65%  infection related ventilator associated complications so I didn't even include these people earlier when I said we had 25,000 patients of data here's another  5,000 but this was just the ABCs so we took that Lancet paper and I showed you a minute ago the ABC study and we put it into real-world 20 ICUs there's  another 5,000 people so that's really over 30,000 people we have data on with this bundle all right now Babur Khan went to India excuse me Indiana 700  patients they implemented the SATs SBTs RAS levels went were more arousable delirium went down by 10% and delirium coma combination down by 6% just another  single center example Miller in Michigan this is super interesting 51 hospitals across Michigan those that implemented the SATs and delirium screening with  three and a half times more likely to exercise a vented patient so this is what Heidi's going to teach us how do you do it well you can't exercise a  person if you are not stopping sedation and screening for delirium here's a number for you to write down what percentage of the time do you miss  delirium if you don't actively screen for it well over 10 studies have have studied that 75% so that's a number to remember if you don't actively measure  delirium you miss it three out of four cases ten published papers have shown that so that's across different countries across different states  basically would you allow it let me ask you a question would you allow it to miss shock three out of four times no would you allow it to miss hypoxemia  three out of four times no you would consider that malpractice but yet we don't monitor delirium and we miss it 75% so they could they studied this in  Michigan and I love their conclusion the authors wrote this is another layer of evidence that for the ABCD ease this is pre-f the whole is greater than the sum  of the parts that's why I was showing you earlier how integrated this whole thing is you can't just say I'm gonna do the B and I'll pick up the C later it  just doesn't work like that because real patient care these intersect this may be one of the last studies that I'm going to show you I'm trying to be fast  here and let Joanna get get up here for the C part 21 studies looked at they were doing a systematic review of implementation of assessment prevention  and management of delirium so this was a study of the D actually and what they found in these 21 studies was the following they got it right 92% of the  time in the programs more implementation strategies six or more to be specific showed a lower mortality six strategies that meant they weren't trying to do a  one magic bullet to reduce delirium and mortality they were saying this is an interprofessional multi what do you call a multi-pronged I can like a  multi-component intervention they concluded that if you had six or more pieces to the multi-component intervention well watch my hands a b c d  e f 6 just so happened that the bundle was six multi-component pieces and that's what they found but they also found this third bullet which is  crucial strategies tardy targeting organizational changes in addition to provider behavior were associated with lower mortality so you have to talk to  your bean counters you have to do compliance checks you have to strategize data management organizational changes were critical and this is from a  systematic review we're trying to build your library for you okay this is the SVT protocol it builds on what Kathleen just showed you on the SAT protocol I  have one teaching point on this slide it's related to the green box when we built this back in 2005 2006 we used the best data available at the time so we  said screen for the SVT and if they pass the screen then move on to the SVT but look we had no agitation oxygenation greater than 88% fi2 is less than 50  peep less than or equal to 7.5 and no vasopressors that's because when we were designing this we wanted to be as safe as possible let me tell you something we  do not adhere to that rigid of a screen anymore we we are doing SVTs with people who are on vasopressors we're doing them with people who are on who come in on  peep of 8 or 10 that morning and we're just saying they're on 8 or 10 right now well maybe they don't need 8 or 10 let's do an SVT and see if they need it so my  point the teaching point is that we have loosened up these rigid screening criteria I remember when I first I'll just give you a personal reveal here  when I was in 1995 when I wanted to go in academics my mentor said we'll go design your trial and I wanted to study ventilator weaning protocols I was  petrified I had all these papers I pulled out literature I had them spread out on a sheet on a desk and I'm building a protocol recipes and I just  thought I hope I don't kill anybody I mean I'm just totally serious with you right now that I was worried that we would do these SVTs and it might kill  people and what if I was responsible for that so I felt an intense amount of conservativeness in designing that study and these are too conservative we  have learned over time and that's why you need to realize this is not a one-shoe-fits-all you have to figure out what your team is comfortable doing  guidelines but personalize it so the end of my talk barriers to consider staff will be concerned you're gonna have some late adopters I don't know John if  you're willing to read your Marcus Aurelius quote but if you've got it on your phone pull it up he sent me an email a minute ago with this quote from  Marcus Aurelius about late adopters and it's pretty it's pretty poignant let me let me finish this list here I want you to read as I move off the stage workload  and productivity concerns absolutely fear of patient discomfort and asynchrony inadvertent extubation you know in the ABC study we did have more  extubations more self extubations but we didn't have more reintubations the patients were right and they said to hell with you if you're not going to  pull this tube out I am so interesting so it takes a team timing matters you have to have people speaking on rounds none of this will happen if you don't  change your rounds to have nurses and therapists speaking up on rounds giving their part of the report and that's enough for me John read that Marcus  Aurelius quote you want to tell who Marcus Aurelius was not everybody might know who he was and Joanna you're up

Video Summary

In this video, the speaker discusses the concept of Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) in the context of ventilator weaning in the ICU. They also mention various studies and research papers related to sedation reduction and early mobility in critically ill patients. The speaker emphasizes the importance of implementing a multi-component intervention approach, involving organizational changes and provider behavior, to improve patient outcomes and reduce mortality. They highlight the need for personalized guidelines and address barriers that may arise when implementing these interventions, such as staff concerns and fear of patient discomfort.

Asset Subtitle

Quality and Patient Safety, Procedures, 2020

Asset Caption

This is a presentation from the 2020 Critical Care Congress precourse, ICU Liberation. B: Both Spontaneous Awakening Trials and Spontaneous Breathing Trials was presented by E. Wes Ely, MD, MPH, FCCM.

The course covered knowledge developed to improve ICU patient care through the implementation of the ICU Liberation Bundle based on the pain, agitation/sedation, delirium, immobility, and sleep disruption (PADIS) guidelines.

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Area Procedures

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Guidelines

Tag Mechanical Ventilation

Year 2020

Keywords

Spontaneous Awakening Trial

Spontaneous Breathing Trial

Ventilator weaning

ICU

sedation reduction

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