13, 14 and 40 Moreover, evidence supporting the short- and long-term benefits of reducing deep sedation, including decreased delirium and ICU resource utilization, has also evolved over CAL 101 the past 30 years with the introduction and validation of sedation scales, goal-directed sedation, interruption of continuous sedative

infusions, use of bolus (rather than infusion) delivery of sedatives, and novel sedative agents.19, 21, 22, 23, 41, 42, 43 and 44 This QI project applied evidence from this body of literature and demonstrated that within a relatively short time period a large change in routine clinical practice could occur and achieve benefits similar to those demonstrated in prior research studies. As part of continuous Navitoclax molecular weight QI efforts, several steps have been taken to achieve further advances regarding early PM&R in the MICU at our hospital. Given the benefits demonstrated from this project, the hospital funded a new Critical Care Physical Medicine and Rehabilitation program, which allowed the multidisciplinary team assembled during the QI project to be sustained. This new program is seeking means of solidifying the gains from the existing QI process and investigating new ways of achieving

further improvement for early PM&R, including designing new medical devices to assist with ambulating mechanically ventilated patients and implementing or evaluating other evidence-based rehabilitation interventions, such as cycle ergometry and neuromuscular electrical stimulation therapy.33, 45, 46 and 47 Moreover, as of July 2009, the approach to sedation that

was encouraged during the QI project has been formalized as a new treatment protocol, and standardized delirium evaluation has been implemented as a routine nursing assessment throughout several ICUs at 2 of our hospitals. This QI project has limitations. First, given its design as a QI project with a before-after comparison, patients were not randomized to sedation or PM&R interventions, nor were the outcomes evaluated in a blinded manner. Hence, the results may be subject to measurement bias and temporal changes. However, the purpose of this project Racecadotril was not to test the efficacy of these interventions, because there are previously published studies demonstrating the safety, feasibility, and benefits of these activities, but to undertake a structured QI process to determine if routine clinical practice could be substantially and rapidly improved. Such a change may not be easy given that it requires a significant transformation in “culture” for the entire multidisciplinary ICU team, which can be extremely difficult to achieve in a relatively short time frame.40 Second, given the small size and duration of this QI project and its focus in a single MICU in an academic teaching hospital, the results may not be generalizable to other types of ICUs or hospitals.