1. Evaluation of a
Sedation Vacation
Protocol
Georgianne Summer, BSN, RN
Augusta University
DNP Project Final Defense

2. Introduction
 The eradication of healthcare associated infections (HAIs)
is a reimbursement directive set by the US Department of
Health and Human Services (DHHS) and the Centers for
Medicare and Medicaid Services (CMS).
 According to the Centers for Disease Control and
Prevention (CDC), hospital-acquired pneumonia (HAP)
accounts for approximately 15% of all HAIs. HAP carries a
crude mortality rate of 30-70% with the predicted
attributable mortality rate of pneumonia between 27-50%.
(Mendel et al., 2011; Tablan et al., 2003)

3. Introduction
 Prolonged Length of Stay: According to the CDC, hospital
acquired pneumonia prolongs ICU stay 4-6 days and overall
hospitalization 7-9 days.
 Expensive Care: HAP adds $40,000 to the cost of care per
patient
 Mechanical ventilation (MV) is estimated to cost as much
as $1,522 per day. In 2003, U.S. hospitals spent 16
billion dollars on PAMV patients. In 2020, the cost will
escalate to $60 billion.
 Increased Risk: The National Nosocomial Infection
Surveillance System (NNIS) found that patients receiving
mechanical ventilation had 6-21 times the risk of developing
hospital-associated pneumonia
(Bice et al., 2013; Carson et al., 2006; Zilberg et al., 2008; Zilberg et al., 2012)

4. Introduction
 In 2020, an estimated 625,298 patients are projected to require
prolonged acute mechanical ventilation (PAMV), defined as patient
being intubated and using mechanical ventilation ≥ 96 hours.
 Due to the significant risk of mechanical ventilation, most of the
research on hospital-associated pneumonia has been focused on
ventilator-associated pneumonia (VAP) for the last 3 decades.
 In 2011, the Agency for Healthcare Research and Quality (AHRQ)
developed guidelines to assist in preventing VAP which contains daily
sedation vacation and spontaneous breathing trials.
 As healthcare institutions follow the recommended guidelines and
initiate infection prevention and treatment programs, it is essential to
regularly reevaluate their effectiveness.
(Agency for Healthcare Research and Quality, 2011; Tablan et al., 2003)

5. Background
 Mechanical ventilation (MV) is a method to assist or replace
spontaneous breathing and indicated when natural ventilation or
respiration is insufficient.
 Goals of MV include: maintain gas exchange, reduce myocardial
oxygen consumption, attain lung expansion, and stabilization of
the thoracic wall.
 Patient dependency on MV may linger long after the gas
exchange and/or impaired ventilation has resolved.
 Comorbidities and severity of underlying disease processes
increases the risk for hospital mortality. This risk increases with
age, hospital acquired infections and multiple organ failure.
(Hamed et al.,2006; Tabers’s Cyclopedic Medical Dictionary, 2013)

6. Background
 Patients who survive experience:
 prolonged recovery and rehab overcoming hospital acquired
deficits such as decreases in mobility and energy
 substantial increase in sleep disorders and social isolation.
 Benefits of early weaning from MV include:
 Decreased mortality
 Improved outcomes
 Reduced costs
 Decreases in the body’s stress response
 Increases in the patient’s comfort level.
(Combes et al., 2003; Hamed et al., 2006)

7. Background
 Patients should be assessed daily
 To determine if they can tolerate withdrawal of MV and
sustain their own respiratory efforts.
 To determine if they can tolerate weaning or
interruption of sedation medication
 Critical care specialists remain challenged
 To deliver the ideal sedation
 Promote relaxation
 Decrease unwanted side effects.
(Institute for Clinical Systems Improvement, 2011; Jacobi et al., 2002; Kress et al., 2000;)

8. Background
 The Society of Critical Care Medicine (SCCM) guidelines for
ventilator management includes goals to decrease pain, anxiety,
ventilator days, and ICU length of stay.
 One guideline of SCCM identifies the desired level of sedation for
mechanical ventilation to be a calm and easily arousable patient.
However, less than 30% of critical care physicians report using
these sedation guidelines or achieving this level of acceptable
sedation.
 No matter who institutes the sedation protocol, it remains a nursing
responsibility and their attitudes, judgments and behavior impact
sedation practices.
(Belfort et al., 2009; Guttormson et al., 2010; Lonardo et al., 2014)

9. Problem Statements
 While mechanical ventilation is a life-saving intervention, it is
also associated with several potential complications such as
decreased cardiac output, acute lung injury, diaphragmatic
atrophy, oxygen toxicity and barotrauma.
 The cost to patients is more than financial, they have referred
to mechanical ventilation as “the most inhumane treatment
ever experienced.”
 Although a clinical practice guideline for sedation vacation was
established 11 years ago, it remains a significant practice issue
due to noncompliance by nurses to use this practice guideline.
(Belfort et al., 2009; Chlan et al., 2000; Hamed et al., 2006 Miller et al., 2012; Roberts et al., 2010)

10. Purpose
The purpose of this clinical protocol evaluation
project was to determine if the implementation
of a sedation vacation protocol in a medical
intensive care unit (MICU) reduced the
incidence of pneumonia, duration of intubation
and MICU length of stay for mechanically-
ventilated adult patients.

11. Literature Review
Databases Utilized
CINAHL
PubMed
Ovid MEDLINE
Cochrane Library
Key Search Terms
Intubation
Mechanical
Ventilation
Sedation
Sedation Vacation
Limits
Research in
English language
Research from
2000-2015
Research of
human adult
subjects
Results
190 articles
identified
30 relevant
articles included
Ranked according
to the Stetler
Evidence
Hierarchy System
Picot Question: Does the implementation of a SV protocol in a medical
ICU reduce the incidence of pneumonia, duration of intubation, and ICU
length of stay (LOS) for mechanically-ventilated adult patients?

12. Literature Review
Themes
Daily Sedation
Vacation
Ventilator
Bundle Care
Spontaneous
Breathing
Trials

13. Ventilator Bundle Care
 Adherence to bundle care
leads to a significant VAP
reduction
 Supported by CDC, AACN,
AHRQ, NIH and IHI.
(Blackwood, 2011; Griffin & Nolan, 2012;IHI, 2012; Lawrence
et al., 2011; Munroe et al., 2014; Stetler et al. 1998)
Literature Review
Ventilator
Bundle
HOB
elevated
Daily SV
Assess
readiness
to wean
Oral care with
chlorhexidine
Peptic ulcer
prophylaxis
DVT
prophylaxis

14. Literature Review
Daily Sedation Vacation
 Daily sedation vacations allow for proper assessment of
the patient’s readiness to be extubated.
 Evidence indicates that patients who receive daily
interruption of sedation have decreased number of MV
days as well as decreased LOS in the ICU.
 Associated with decreased use of sedation and lower
incidence of sedation related side effects.
(American Thoracic Society, 2005; Girard et al., 2008; Jackson et al., 2010; Kress et al., 2000;
Mendez et al., 2013)

15. Literature Review
Spontaneous Breathing Trials
 Allows for proper assessment of the patient’s readiness to be
extubated.
 Evidence indicates that its use decreases the length of weaning
time, number of MV days, as well as decreased LOS in the ICU.
 Used in conjunction with daily sedation vacation.
 Recommended American College of Chest Physicians &
American College of Critical Care Medicine.
(AHRQ, 2011; Girard et al., 2008 ;Kahn et al., 2014; MacIntyre, 2001; Marelich, 2000)

16. Literature Review Summary
 Introduction of guidelines and protocols, was associated with
improvements in outcomes including ICU and hospital length
of stay, duration of mechanical ventilation, costs, mortality
and reduction of nosocomial infections incidences.
 Adherence to IHI recommended bundle led to a significant
reduction of VAP.
 Nurse driven protocols were more successful with both
implementation and compliance.

17. Conceptual Framework
 Quality and safety are ultimately measured by the degree
to which health care improves significant patient outcomes.
 According to the Institute of Medicine quality in health care
is a direct correlation between the level of enhanced health
services and the individual’s and/or population’s anticipated
health outcome.
 Donabedian’s Systems model has proven to be an essential
framework for measuring both quality of care and patient
safety in healthcare.
 The model has been utilized in quality improvement
research by national and international agencies like WHO,
NIH, AHRQ.
(AHRQ, 2005; AHRQ, 2011)

18. Conceptual Framework
• Application of Donabedian’s Systems Model
Application of Systems Model for process evaluation. Adapted from “Agency for Healthcare Research and Quality U.S. Department of
Health and Human Services. (2007). Closing the quality gap: A critical analysis of quality improvement strategies Volume 7—Care
Coordination Technical Review]”. AHRQ Publication No. 04(07)-0051-7.
Structures
Intensive Care Unit,
patients, physicians,
nurses, respiratory
therapists, policies
and protocols
Processes
Delivery of sedation
vacation guided by
evidence based
protocol
Outcomes
ICU Length of stay,
Incidence of
Pneumonia,
Duration of
mechanical
ventilation

19. Aims
 Determine if the utilization of the sedation
vacation protocol in MICU was sustained in
2014
 Physicians ordering protocol
 Nurses documentation indicated use
 Determine if the implementation of the
sedation vacation protocol decreased the
incidence of pneumonia, duration of
intubation, and ICU LOS.

20. Methodology
 Design:
 Retrospective chart review.
 12-month period, January 1, 2014 - December 31, 2014.
 Setting:
 550 bed Academic Medical Center in Augusta, Georgia
 Adult in-patient, 24 bed Medical intensive Care Unit
 Sample:
 Patients selected by ICD-9 and V codes from the
Enterprise approved EMR data mining tool, I2B2

21. Methodology
Inclusion Criteria Exclusion Criteria
Patients at least 18 years of age
Diagnosis of pneumonia upon
admission to hospital
Patients admitted to the Medical
Intensive Care Unit
Diagnosis of pneumonia upon
admission to Medical Intensive Care
Unit
Patients endotracheally intubated
for ≥ 24 hours
Diagnosis of acute severe laryngeal
edema or any upper airway
obstruction
Patients requiring mechanical
ventilation
Diagnosis of severe acute
respiratory distress syndrome or
status asthmaticus
Patient receiving a continuous
infusion sedative medication

22. Results of Data Mining Search Strategy
348
123
47
33
429
EMRs during 2014 searched using ICD-9 Codes for
Respiratory–related and Mechanical Ventilation diagnoses
81 additional EMRs added with V code for
using a respirator during 2014
# EMRs matched to MICU admissions
# EMRs after excluding no ventilator (7), tracheostomies (7), outside
time frame (22), pre-existing pneumonia (14), DNR/no intubation
order (2), MICU patient in other unit (4), incomplete (7)
Final # EMRs after excluding: no ventilator (1), chronic
ventilator (1), multiple intubations, DNR (2), pre-existing
pneumonia (9)

23. Statistical Analysis
 Descriptive statistics
 Nonparametric Chi-square test
 Nonparametric Cochran’s Q test

24. Results (n = 33)
Caucasian 55%
African American 33%
Hispanic 3%
Other/Unknown 9%
Race

25. Gender
Measures of Central Tendency
Female 51%
Male 49%
Results (n = 33)

26. Results
Primary Hospital Admission Diagnosis
Primary (hospital admission) diagnoses grouped by similarity.
Diagnosis Frequency Percent
Respiratory Decompensation 3 9
Known Infectious Process 4 12
Altered Mental Status 15 46
Cancer 3 9
GI Bleed 1 3
Liver Failure 2 6
Cardiovascular Decompensation 3 9
Miscellaneous 2 6
Total 33 100

27. Results
Medical Intensive Care Unit Admitting Diagnosis
Diagnosis Frequency Percent
Respiratory Decompensation 14 43
Known Infectious Process 8 24
Acid-Base Imbalance 2 6
GI Bleed 3 9
Liver Failure 2 6
Cardiovascular Decompensation 3 9
Miscellaneous 1 3
Total 33 100

28. Results
Sedation Vacation Protocol Documentation

29. Sample Size
n=33
Frequency Percent p value
Statistical
Significance
Richmond
Agitation
Sedation Scale
Documented
33 100
Spontaneous
Breathing Trial
Documented
23 70 .024
Statistically
Significant
Sedation Titration
Documented
23 70 .024
Statistically
Significant
3 indirect EMR indicators investigated to determine if
the SV protocol was used but not documented.
Results
Cochran’s Q test revealed no statistical significant association was found among
these three SV protocol indicators (p = .92).

30. Results
Indicators of VAP Diagnosis Documentation
Indicators Frequency Percent
Pneumonia Diagnosis documented
Yes 5 15
No 28 85
Total 33 100
Positive Chest X-ray documented
Yes 9 27
No 24 73
Total 33 100
Positive Sputum Culture documented
Yes 12 36
No 21 64
Total 33 100

31. Discussion
 Respiratory decompensation accounted for 43% of the
MICU admission diagnoses, many of the patients were
discovered to have positive chest x-rays during the
endotracheal tube verification and therefore VAP could not
be determined.
 The duration of ventilation and MICU LOS results are
inconclusive due to the severity of illness within this patient
population, many in this sample were terminally extubated
and therefore have the same number of days for both
endotracheal intubation and MICU length of stay.

32. Discussion
 Ventilator Days and MICU LOS in this project were 1.5 and
3 days, respectively, more than that found by Kress et al.
(2000).
 Therefore, the 67% compliance shown by the MICU nurses
demonstrated the need for 100% compliance of formal SV
documentation. (If it’s not documented, it’s not done).
 Protocol Compliance
 Physicians ordering protocol: 100%
 Nurses formal documentation of protocol: 67%
 Nurses performing SV indicators, but not documenting protocol: 70%

33. Discussion
Survey by Roberts et al. (2010) and other
researchers showed that barriers to protocol
compliance included:
 Patient agitation or pain
 Nursing acceptance of practice
 Fear of patient self-extubation or harm
(Mendez et al., 2013; Miller et al., 2012; Roberts, et al., 2010; Belfort et al., 2009)

34. Limitations
Variability
in
physician
charting
ICD-9
Coding
variability
I2B2
inability to
search by
location or
procedural
code
Small
single
center
study
n=33

35. Implications for Practice:
 Educational Opportunities
 Critical Care education on sedation with sedation
vacation protocol.
 Significance of the sedation weaning and daily
interruption
 Importance of documenting rationale for patients
excluded from sedation vacation
 Importance of spontaneous breathing trials
 Importance of ventilator bundle care

36. Conclusions
 While the reviewed evidence supports the use of protocols
for MV and SV with improved outcomes, the findings
suggest that no clear conclusion could be made concerning
the effectiveness of the sedation vacation protocol in this
particular MICU.
 Research is needed to accurately determine the efficacy of
the sedation vacation protocol at this facility as well as
compare patient populations based on severity of illness
with other hospital locations across the United States.

37. Plan for dissemination of
Information
 Project will be presented to MICU Leadership
 Project will be presented AUHealth Evidence Based
Practice/Performance Committee and Education
Committee.
 Project will be submitted for publication based on
committee’s recommendation.
 Future Conferences TBD

38. Acknowledgements
 Committee Chair:
 Dr. A. Schumacher, PhD, RN
 Committee Member:
 Dr. P. Hartley, DNP, RN
 Advisors:
William Todd, MSN, RN, FNP-C (DNP site preceptor)
Michelle Sweat, MSN, RN (MICU Nurse Educator)
Joy Hayman (PowerTrials and i2b2 Administrator)

39. References
• Agency for Healthcare Research and Quality. (2011). Prevention of ventilator-
associated pneumonia: Health care protocol. Retrieved from
http://www.guideline.gov/content.aspx?id=36063
• Agency for Healthcare Research and Quality. (2005). The Donabedian model of
patient safety: Medical teamwork and patient safety: The evidence-based
relation. Retrieved from http://archive.ahrq.gov/research/findings/final-
reports/medteam/medteamwork.pdf
• Agency for Healthcare Research and Quality-U.S. Department of Health and
Human Services. (2007). Closing the quality gap: A critical analysis of quality
improvement strategies Volume 7—Care Coordination [Technical Review].
Retrieved from www.ahrq.gov:
http://www.ahrq.gov/research/findings/evidence-based-reports/caregap.pdf

40. References
• Belfort, J. A. (2009, March-April). A brief report of student research: Protocol
versus nursing practice sedation vacation in a surgical intensive care unit.
Dimensions of Critical Care Nursing, 28(2), 81-82.
http://dx.doi.org/10.1097/DCC.0b013e318195d5d6
• Blamoun, J., Alfakir, M., Rella, M., Wojcik, J., Solis, R., Khan, A., & DeBari, V.
(2009). Efficacy of an expanded ventilator bundle for the reduction of ventilator-
associated pneumonia in the medical intensive care unit. American Journal of
Infection Control, 37(2), 172-175. http://dx.doi.org/10.1016/j.ajic.2008.05.010
• Blackwood, B., Alderdice, F., Burns, K., Cardwell, C., Lavery, G., & O'Hallaran, P.
(2011). Use of weaning protocols for reducing duration of mechancal ventilatoin
in critically ill adult patients: Cochran systematic review and meta-analysis. British
Medical Journal. Jan 13. http://dx.doi.org/10.1136/bmj.c7237
• Brook, A., Ahrens, T., Schaiff, R., Prentice, D., Sherman, G., Shannon, W., &
Kollef, M. (1999). Effect of a nursing-implemented sedation protocol on the
duration of mechanical ventilation. Critical Care Medicine, 27(12), 2609-2615.
http://dx.doi.org/10.1097/00003246-199912000-00001

41. References
• Combes, A., Costa, M., Trouillet, J., Baudot, J., Mokhtari, M., Gilbert, C., & Chastre, J.
(2003). Morbidity, mortality, and quality-of-life outcomes of patients requiring ≥ 14
days of mechanical ventilation. Critical Care Medicine, 31(5), 1373-1380.
http://dx.doi.org/10.1097/01.ccm.0000065188.87029.c3
• Carson, S. S. (2006). Outcomes of prolonged mechanical ventilation. Current Opinion
in Critical Care, 12(5), 405-411.
http://dx.doi.org/10.1097/01.ccx.0000244118.08753.dc
• Donabedian, A. (1966). Evaluating the quality of medical care. The Milbank
Quarterly, 83(4) 691–729. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690293
• Donabedian, A., Wheeler, J.R., & Wyszewainski, L. (1982). Quality, cost and health:
An integrative model. Medical Care, 20(10), 975-992.
• Donabedian, A. (1988). The quality of care: How can it be assessed? The Journal of
the American Medical Association, 260(12), 1743-1748. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/3045356
• Frazier, S. (1999). Neurohormonal responses during positive pressure mechanical
ventilation. Heart and Lung 28(3), 149-165.
http://www.ncbi.nlm.nih.gov/pubmed/10330211

42. References
• Girard, T., Kress, J., Fuchs, B., Thomason, J., Schweickert, W., Pun, B., . . . Ely, E.
(2008). Efficacy and safety of a paired sedation and ventilator weaning protocol
for mechanically ventilated patients in intensive care: A randomized controlled
trial. Lancet, 371, 126-134. http://dx.doi.org/10.1016/S0140-6736(08)60105-1
• Griffin, R. & Nolan, H. (2012). Using care bundles to improve health care quality.
Institute for Healthcare Improvement. Retrieved from www.IHI.org
• Guttormson, J., Chlan, L., Weinert, C., & Savik, K. (2010). Factors influencing
nurse sedation practices with mechanically ventilated patients: A U.S.
nationalsurvey. Intensive and Critical Care Nursing, 26, 44-50.
http://dx.doi.org/10.1016/j.iccn.2009.10.004
• Hamed, H., Ibrahim, H., Khater, Y., & Aziz, E. (2006). Ventilation and ventilators in
the ICU: What every intensivist must know. Current Anaesthesia & Critical Care,
17, 77-83. http://dx.doi.org/10.1016/j.cacc.2006.07.008

43. References
• Institute for Clinical Systems Improvement (2011). Health care protocol: Prevention of
ventilator-associated pneumonia. Fifth Edition. Retrieved from
https://www.icsi.org/_asset/y24ruh/VAP.pdf
• Jacobi, J., Fraser, G., Coursin, D., Riker, R., Fontaine, D., Wittbrodt, E., . . . Lumb, P.
(2002). Clinical practice guidelines for the sustained use of sedative and analgesics in
the critically ill adult. Critical Care Medicine, 30(1), 119-141.
http://dx.doi.org/10.1097/CCM.0b013e3182783b72
• Kress, J., Pohlmon, A., O’Conner, M., & Hall, J. (2000). Daily interruption of sedative
infusions in critically ill patients undergoing mechanical ventilation. New England
Journal of Medicine. 342(20), 141-147.
http://dx.doi.org/10.1056/NEJM200005183422002
• Lawrence, P., & Fulbrook, P. (2011). The ventilator care bundle and its impact on
ventilator-associated pneumonia: A review of the evidence. Nursing in Critical Care,
16(5), 222-234. http://dx.doi.org/10.1111/j.1478-153.2010.00430.x

44. References
• Lonardo, N., Mone, M., Nirula, M., Kimball, E., Ludwig, K., Zhou, X., Sauer B.,
Nechodom, K., Teng, C., & Barton, R. (2014). Propofol is Associated with Favorable
Outcomes Compared to Benzodiazepines in Ventilated ICU Patients. American
Journal of Critical Care Medicine, 10-April. http://dx.doi.org/10.1164/rccm.201312-
2291OC
• MacIntyre, N. (2001). Evidence-based guidelines for weaning and discontinuing
ventilatory support: A collective task force facilitated by American college of chest
physicians; the American association for respiratory care; American college of critical
care medicine. Chest. 120:375-396.
http://dx.doi.org/10.1378/chest.120.6_suppl.375S
• Marelich, G., Murin, S., Battistella, F., Inciardi, J., Vierra, T., Roby, M. (2000).
Protocol weaning of mechanical ventilation in medical and surgical patients by
respiratory care practitioners and nurses: Effect on weaning time and incidence of
ventilator-associated pneumonia. Chest 118(2), 459-467.
http://dx.doi.org/10.1378/chest.118.2.459
• Mehta, S., Burry, L., Martinez-Motta, J., Stewart, T., Hallett, D., McDonald, E., . . .
Cook, D. (2008). A randomized trial of daily awakening in critically ill patients
managed with a sedation protocol: A pilot trial. Critical Care Medicine, 36(7), 2092-
2099. http://dx.doi.org/10.1097/CCM.0b013e31817bff85.

45. References
• Mehta, S., Burry, L., Cook, D., Fergusson, D., Steinberg, M., Granton, J., . . . Meade,
M. (2012). Daily sedation interruption in mechanically ventilated critically ill patients
cared for with a sedation protocol. Journal of the American Medical Association,
308(19), E1-E8. http://.dx.doi.org/10.1001/jama.2012.13872.
• Mendel, P., Weissbein, D., Weinberg, D., Farley, D., Baker, D., & Kahn, K. (2011).
Agency for Healthcare Research and Quality Center for Quality Improvement and
Patient Safety. Longitudinal Program Evaluation of the HHS Action Plan to Prevent
Healthcare‐Associated Infections Year 1 Report. September, 1. Retrieved from
http://health.gov/hcq/pdfs/hhs-action-plan-eval-report.pdf
• Mendez, M., Lazar, M., DiGiovine, B., Schuldt, S., Behrendt, R., Peters, M., &
Jennings, J. (2013). Dedicated multidisciplinary ventilator bundle team with
compliance and sedation vacation. American Journal of Critical Care, 22(1), 54-59.
http://dx.doi.org/10.4037/ajcc2013873
• Miller, A., Bosk, E., Iwashyna, T., & Krein, S. (2012). Implementation challenges in
the intensive care unit: The why, who and how of daily interruption of sedation.
Journal of Critical Care, 27, 218e1-218e7. doi:10.1016/j.jcrc.2011.11.007
• Munro, N., Ruggiero, M. (2014). Ventilator-associated pneumonia bundle:
Reconstruction for best care. Advanced Critical Care 25 (1), 163-175.
http://dx.doi.org/10.1097/NCI.0000000000000019

46. References
• Quenot J, Ladoire S, Devoucoux F, Doise, J-M., Cailliod, R., Cunin, N., Aube, H.,
Blettery, B., Cahrles, E. (2007) Effect of a nurse-implemented sedation
protocol on the incidence of ventilator associated pneumonia. Critical Care
Medicine. 35(9):2031-9.
http://dx.doi.org/10.1097/01.ccm.0000282733.83089.4d
• Roberts, R., deWitt, M., Epstein, S., Didomenico, D., & Delvin, J. (2010).
Predictors for daily interruption of sedation therapy: A nursing prospective,
multicenter study. Journal of Critical Care, 25, 660e1-660e7.
doi:10.1016/j.jcrc.2010.03.007
• Sessler, C., Gosnell, M., Grap, M., Brophy, G., O’Neal, P., & Keane, K. (2002).
The Richmond agitation–sedation scale validity and reliability in adult intensive
care unit patients. American Journal of Respiratory and Critical Care Medicine,
166, 1338–1344. http://dx.doi.org/10.1164/rccm.2107138
• Stetler, C., Brunell, M., Giuliano, K., Morsi, D., Prince, L., & Newell-Stokes, V.
(1998). Evidence based practice and the role of nursing leadership. Journal of
Nursing Administration, 28(7/8), 45-53.

47. References
• Tablan, O., Anderson, L. J., Besser, R., Bridges, C., & Hajjeh, R. (2003). Guidelines
for preventing health-care associated pneumonia, 2003. Recommendations of CDC
and the Healthcare Infection Control Practices Advisory Committee. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
• U. S. Department of Health and Human Services Health Resources and Services
Administration (HRSA). (2011). Quality Improvement. Retrieved from
http://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf
• Ventilation (2013). In A. D. Venes (Ed.), Tabers’s cyclopedic medical dictionary
(22nd ed., pp 2319-2321). Philadelphia, PA: F.A. Davis.
• Zilbergerg, M., De Wit, M., &, Shorr, A. (2012). Accuracy of previous estimates for
adult prolonged acute mechanical ventilation volume in 2020: Update using 2000-
2008 data. Critical Care Medicine, 40(1), 18-20.
http://dx.doi.org/10.1097/CCM.0b013e31822e9ffd
• Zilberberg, M., Luippold, R., Sulsky, S., & Shorr, A. (2008). Prolonged acute
mechanical ventilation, hospital resource utilization, and mortality in the United
States. Critical Care Medicine, 36(3), 724-730.
http://dx.doi.org/10.1097/CCM.0B013E31816536F7