***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To evaluate the effect of an educational program targeted on modifiable risk factors on  ventilator-associated pneumonia ( VAP ) rates . MATERIAL AND METHOD After a preliminary study on VAP risk factors was conducted at one teaching hospital , a pre- and post-interventional study was then performed on 12 hospitals in Thail and from January 1 , 2002 to June 30 , 2003 . Each hospital r and omly selected 20 patients , who were on mechanical ventilation to be enrolled The study was divided into two phases ; 1 ) pre-intervention , 2 ) post-intervention . Data collected included patients ' demography and risk factors for VAP During pre-interventional phase , data on risk factors for VAP was analyzed and fedback to healthcare providers in the wards by an infection control nurse ( ICN ) of the individual hospital . An educational programme on the prevention of VAP was introduced by the ICN . Ventilator-associated pneumonia rates and their risk factors were continuously monitored during the post-interventionl phase . RESULTS Two hundred and forty four patients in the pre-interventional phase and 254 patients in the post-interventional phase were included . There was no significant difference in the demography between these two patient population s. After the intervetion , there was a significant improvement in h and -hygiene practice s ( p<0.001 ) among healthcare providers and increased use of sucralfate ( p=0.05 ) for stress ulcer prophylaxis . Ventilation-associated pneumonia rate ( 40.5 % vs. 24 % ; p<0.001 ) and crude mortality rate associated with VAP ( 12.3 % vs. 8.7 % ; p<0.001 ) were also reduced CONCLUSION The educational programme targeted on modifiable risk factors for prevention of VAP was effective and should be considered as an intervention to reduce VAP rates in developing countries Introduction Recent evidence suggests that early , aggressive resuscitation in patients with septic shock reduces mortality . The objective of this survey was to characterize reported resuscitation practice s of Canadian physicians caring for adult critically ill patients with early septic shock . Methods A scenario-based self-administered national survey was sent out to Canadian critical care physicians . One hypothetical scenario was developed to obtain information on several aspects of resuscitation in early septic shock , including monitoring and resuscitation end-points , fluid administration , red blood cell transfusion triggers , and use of inotropes . The sampling frame was physician members of Canadian national and provincial critical care societies . Results The survey response rate was 232 out of 355 ( 65.3 % ) . Medicine was the most common primary specialty ( 60.0 % ) , most respondents had practice d for 6 to 10 years ( 30.0 % ) , and 82.0 % were male . The following monitoring devices/parameters were reported as used/measured ' often ' or ' always ' by at least 89 % of respondents : oxygen saturation ( 100 % ) , Foley catheters ( 100 % ) , arterial blood pressure lines ( 96.6 % ) , telemetry ( 94.3 % ) , and central venous pressure ( 89.2 % ) . Continuous monitoring of central venous oxygen saturation was employed ' often ' or ' always ' by 9.8 % of respondents . The two most commonly cited resuscitation end-points were urine output ( 96.5 % ) and blood pressure ( 91.8 % ) . Over half of respondents used normal saline ( 84.5 % ) , Ringers lactate ( 52.2 % ) , and pentastarch ( 51.3 % ) ' often ' or ' always ' for early fluid resuscitation . In contrast , 5 % and 25 % albumin solutions were cited as used ' often ' or ' always ' by 3.9 % and 1.3 % of respondents , respectively . Compared with internists , surgeons and anesthesiologists ( odds ratio ( 95 % confidence interval ) : 9.8 ( 2.9 to 32.7 ) and 3.8 ( 1.7 to 8.7 ) , respectively ) reported greater use of Ringers lactate .  In the setting of a low central venous oxygen saturation , 52.5 % of respondents reported use of inotropic support ' often ' or ' always ' . Only 7.6 % of physicians stated they would use a red blood cell transfusion trigger of 100 g/l to optimize oxygen delivery further . Conclusion Our survey results suggest that there is substantial practice variation in the resuscitation of adult patients with early septic shock . More r and omized trials are needed to determine the optimal approach Reports of cluster r and omised trials require additional information to allow readers to interpret them accurately The effective reporting of r and omised controlled trials has received useful attention in recent years . Many journals now require that reports conform to the guidelines in the Consoli date d St and ards of Reporting Trials ( CONSORT ) statement , first published in 1996 and revised in 2001 . The statement includes a checklist of items that should be included in the trial report . These items are evidence based whenever possible and are regularly review ed . The statement also recommends including a flow diagram to show the flow of participants from group assignment through to the final analysis . The CONSORT statement focused on reporting parallel group r and omised trials in which individual participants are r and omly assigned to study groups . However , in some situations it is preferable to r and omly assign groups of individuals ( such as families or medical practice s ) rather than individuals . Reasons include the threat of contamination of some interventions ( such as dietary interventions ) if individual r and omisation is used . 5 Also , in certain setting s r and omisation by group may be the only feasible method of conducting a trial . Trials with this design are variously known as field trials , community based trials , place based trials , or ( as in this paper ) cluster r and omised trials . In an earlier discussion paper we considered the implication s of the CONSORT statement for the reporting of cluster r and omised trials . Here we present up date d guidance , based on the 2001 revision of the CONSORT statement BACKGROUND H and hygiene is a fundamental measure for the control of nosocomial infection . However , sustained compliance with h and hygiene in health care workers is poor . We attempted to enhance compliance with h and hygiene by implementing education , training , and performance feedback . We measured nosocomial infections in parallel . METHODS We monitored the overall compliance with h and hygiene during routine patient care in intensive care units ( ICUs ) ; 1 medical surgical ICU and 1 coronary ICU , of 1 hospital in Buenos Aires , Argentina , before and during implementation of a  h and hygiene education , training , and performance feedback program . Observational surveys were done twice a week from September 2000 to May 2002 . Nosocomial infections in the ICUs were identified using the National Nosocomial Infections Surveillance ( NNIS ) criteria , with prospect i ve surveillance . RESULTS We observed 4347 opportunities for h and hygiene in both ICUs .  Compliance improved progressively ( h and washing adherence , 23.1 % ( 268/1160 ) to 64.5 % ( 2056/3187 ) ( RR , 2.79 ; 95 % CI : 2.46 - 3.17 ; P < .0001 ) . During the same period , overall nosocomial infection in both ICUs decreased from 47.55 per 1000 patient-days ( 104/2187 ) to 27.93 per 1000 patient days ( 207/7409 ) RR , 0.59 ; 95 % CI : 0.46 - 0.74 , P < .0001 ) . CONCLUSION A program consisting of focused education and frequent performance feedback produced a sustained improvement in compliance with h and hygiene , coinciding with a reduction in nosocomial infection rates in the ICUs BACKGROUND Despite the evidence that enteral feeding reduces morbidity in critically ill patients and is preferred to parenteral nutrition , the delivery of enteral nutrition ( EN ) is often inadequate . The purpose of this study was to determine whether implementation of an evidence -based nutrition support ( NS ) protocol could improve EN delivery . METHODS An NS protocol incorporating available scientific evidence ; data from a retrospective survey of 30 intensive care unit ( ICU ) patients ; and input from dietitians , intensive care physicians , surgeons , nurses , and pharmacists was developed . The impact of this protocol was evaluated prospect ively in 123 consecutive adult patients admitted to a multisystem ICU who were eligible for EN . RESULTS The percentage of patients who received at least 80 % of their estimated energy requirements during their ICU stay increased from 20 % before implementation of the NS protocol to 60 % after implementation ( p < .001 ) . After adjusting for confounders , those in the postimplementation group received significantly more kcal/kg/d than the preimplementation group ( 3.71 kcal/kg/d ; 95 % confidence interval , 1.64 to 5.78 ; p = .001 ) . Parenteral nutrition use [ corrected ] was reduced in the postimplementation group ( 1.6 vs 13 % , p = .02 ) . There was no difference in time to initiation of enteral nutrition between groups ( 1.76 days pre protocol vs 1.44 days post protocol implementation , p = .9 ) . CONCLUSIONS The development and use of an evidence -based NS protocol improved the proportion of enterally fed ICU patients meeting their calculated nutrition requirements Background Evidence from recent literature shows that protocol -directed extubation is a useful approach to liberate patients from mechanical ventilation  ( MV ) . However , research evidence does not necessarily provide guidance on how to implement changes in individual intensive care units ( ICUs ) . We conducted the present study to determine whether such an evidence -based strategy can be implemented safely and effectively using a multidisciplinary team ( MDT ) approach . Method We design ed a MDT-driven extubation protocol . Multiple meetings were held to encourage constructive criticism of the design by attending physicians , nurses and respiratory care practitioners ( RCPs ) , in order to define a protocol that was evidence based and acceptable to all clinical staff involved in the process of extubation . It was subsequently implemented and evaluated in our medical/ surgical ICU . Outcomes included response of the MDT to the initiative , duration of MV and stay in the ICU , as well as reintubation rate . Results The MDT responded favourably to the design and implementation of this MDT-driven extubation protocol , because it provided greater autonomy to the staff . Outcomes reported in the literature and in the historical control group were compared with those in the protocol group , and indicated similar duration s of MV and ICU stay , as well as reintubation rates . No adverse events were documented . Conclusion An MDT approach to protocol -directed extubation can be implemented safely and effectively in a multidisciplinary ICU . Such an effort is viewed favourably by the entire team and is useful in enhancing team building Weaning protocol s can improve outcomes , but their efficacy may vary with patient and staff characteristics . In this prospect i ve , controlled trial , we compared protocol -based weaning to usual , physician-directed weaning in a closed medical intensive care unit ( ICU ) with high physician staffing levels and structured , system-based rounds . Adult patients requiring mechanical ventilation for more than 24 hours were assigned to usual care ( UC ) or protocol weaning based on their hospital identification number . Patients assigned to UC ( n=145 ) were managed at their physicians ' discretion . Patients assigned to protocol ( n=154 ) underwent daily screening and a spontaneous breathing trial by respiratory and nursing staff without physician intervention . There were no significant baseline differences in patient characteristics between groups . The proportion of patients ( protocol vs. UC ) who successfully discontinued mechanical ventilation ( 74.7 % vs. 75.2 % , p=0.92 ) , duration of mechanical ventilation ( median [ interquartile range ] : 60.4 hours [ 28.6 - 167.0 hours ] vs. 68.0 hours [ 27.1 - 169.3 hours ] , p=0.61 ) , ICU ( 25.3 % vs. 28.3 % ) and hospital mortality ( 36.4 % vs. 33.1 % ) , ICU length of stay ( 115 vs. 146 hours ) , and rates of reinstituting mechanical ventilation ( 10.3 % vs. 9.0 % ) was similar . We conclude that protocol -directed weaning may be unnecessary in a closed ICU with generous physician staffing and structured rounds OBJECTIVE To compare a practice of protocol -directed sedation during mechanical ventilation implemented by nurses with traditional non- protocol -directed sedation administration . DESIGN R and omized , controlled clinical trial . SETTING Medical intensive care unit ( 19 beds ) in an urban teaching hospital . PATIENTS Patients requiring mechanical ventilation ( n = 321 ) . INTERVENTIONS Patients were r and omly assigned to receive either protocol -directed sedation ( n = 162 ) or non- protocol -directed sedation ( n = 159 ) . MEASUREMENTS AND MAIN RESULTS The median duration of mechanical ventilation was 55.9 hrs ( 95 % confidence interval , 41.0 - 90.0 hrs ) for patients managed with protocol -directed sedation and 117.0 hrs ( 95 % confidence interval , 96.0 - 155.6 hrs ) for patients receiving non- protocol -directed sedation . Kaplan-Meier analysis demonstrated that patients in the protocol -directed sedation group had statistically shorter duration s of mechanical ventilation than patients in the non- protocol -directed sedation group ( chi-square = 7.00 , p = .008 , log rank test ; chi-square = 8.5 
    Output:
    
The exclusion of r and omized controlled trials did not change our results .
There were no associated improvements in clinical outcomes .
CONCLUSIONS Knowledge translation interventions in the ICU that include protocol s with or without education are associated with the greatest improvements in processes of critical care