human
***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 PURPOSE Ventilator weaning protocol s can improve clinical outcomes , but their impact may vary depending on intensive care unit ( ICU ) structure , staffing , and acceptability by ICU physicians . This study was undertaken to examine their relationship . DESIGN / METHODS We prospect ively examined outcomes of 102 mechanically ventilated patients for more than 24 hours and weaned using nurse-driven protocol -directed approach ( nurse-driven group ) in an intensivist-led ICU with low respiratory therapist staffing and compared them with a historic control of 100 patients who received conventional physician-driven weaning ( physician-driven group ) .  We administered a survey to assess ICU physicians ' attitude . RESULTS Median duration s of mechanical ventilation ( MV ) in the nurse-driven and physician-driven groups were 2 and 4 days , respectively ( P = .001 ) . Median duration s of ICU length of stay ( LOS ) in the nurse-driven and physician-driven groups were 5 and 7 days , respectively ( P = .01 ) . Time of extubation was 2 hours and 13 minutes earlier in the nurse-driven group ( P < .001 ) . There was no difference in hospital LOS , hospital mortality , rates of ventilator-associated pneumonia , or reintubation rates between the 2 groups . We identified 4 independent predictors of weaning duration : nurse-driven weaning , Acute Physiology and Chronic Health Evaluation II score , vasoactive medications use , and blood transfusion . Intensive care unit physicians viewed this protocol implementation positively ( mean scores , 1.59 - 1.87 on a 5-point Likert scale ) . CONCLUSIONS A protocol for liberation from MV driven by ICU nurses decreased the duration of MV and ICU LOS in mechanically ventilated patients for more than 24 hours without adverse effects and was well accepted by ICU physicians BACKGROUND Ventilator-associated pneumonia ( VAP ) is considered to be an important cause of infection-related death and morbidity in intensive care units ( ICUs ) . We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU ( MICU ) . METHODS A 4-year controlled , prospect i ve , quasi-experimental study was conducted in an MICU , surgical ICU ( SICU ) , and coronary care unit ( CCU ) for 1 year before the intervention ( period 1 ) , 1 year after the intervention ( period 2 ) , and 2 follow-up years ( period 3 ) . The SICU and CCU served as control ICUs . The educational program involved respiratory therapists and nurses and included a self- study module with preintervention and postintervention assessment s , lectures , fact sheets , and posters . RESULTS Before the intervention , there were 45 episodes of VAP ( 20.6 cases per 1000 ventilator-days ) in the MICU , 11 ( 5.4 cases per 1000 ventilator-days ) in the SICU , and 9 ( 4.4 cases per 1000 ventilator-days ) in the CCU . After the intervention , the rate of VAP in the MICU decreased by 59 % ( to 8.5 cases per 1000 ventilator-days ; P=.001 ) and remained stable in the SICU ( 5.6 cases per 1000 ventilator-days ; P=.22 ) and CCU ( 4.8 cases per 1000 ventilator-days ; P=.48 ) . The rate of VAP in the MICU continued to decrease in period 3 ( to 4.2 cases per 1000 ventilator-days ; P=.07 ) , and rates in the SICU and CCU remained unchanged . Compared with period 1 , the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 ( P<.001 ) and by 8.9 days in period 3 ( P<.001 ) . The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50 % ( P<.001 ) and 37%-45 % ( P<.001 ) , respectively . CONCLUSIONS A focused education intervention result ed in sustained reductions in the incidence of VAP , duration of hospital stay , cost of antibiotic therapy , and cost of hospitalization BACKGROUND Critical care nurses ' knowledge and skills in adhering to evidence -based guidelines for avoiding complications associated with intubation and mechanical ventilation are currently limited . We hypothesized that single simulation education session would lead to a long-lasting higher level of skills among critical care nurses . MATERIAL AND METHODS A r and omized controlled trial was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finl and during the period February 2012-March 2014 . Thirty out of 40 initially r and omized critical care nurses participated in a 24-month follow-up study . Behavior and cognitive development was evaluated through a vali date d Ventilator Bundle Observation Schedule and Question naire at the baseline measurement and repeated 3 times during simulation and real-life clinic setting s. RESULTS After simulation education , the average skills score increased from 46.8%-58.8 % of the total score in the final postintervention measurement ( Ptime < .001 , Ptime × group = .040 , and Pgroup = .11 ) . The average knowledge scores within groups did not change significantly . The average between-group difference in skills scores was significant only at the measurement taken at 6 months ( P = .006 ) . CONCLUSIONS Critical care nurses ' skills in adhering to evidence -based guidelines improved in both groups over time , but the improvements between the study groups was significantly different only at 6 months and was no longer evident after 2 years following a single simulation education Non-r and omised studies of the effects of interventions are critical to many areas of healthcare evaluation , but their results may be biased . It is therefore important to underst and and appraise their strengths and weaknesses . We developed ROBINS-I ( “ Risk Of Bias In Non-r and omised Studies - of Interventions ” ) , a new tool for evaluating risk of bias in estimates of the comparative effectiveness ( harm or benefit ) of interventions from studies that did not use r and omisation  to allocate units ( individuals or clusters of individuals ) to comparison groups . The tool will be particularly useful to those undertaking systematic review s that include non-r and omised studies BACKGROUND Recently , clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation . One such process , use of a weaning protocol , has yielded conflicting results , arguably because of the influence of existing context and processes . OBJECTIVE To compare international data to assess differences in context and processes in intensive care units that could influence weaning . METHODS Review of existing national data on provision of care for critically ill patients , including structure , staffing , skill mix , education , roles , and responsibilities for weaning in intensive care units of selected countries . RESULTS Australia , New Zeal and , Denmark , Norway , Sweden , and the United Kingdom showed similarities in critical care provision , structure , skill mix , and staffing ratios in intensive care units . Weaning in these countries is generally a collaborative process between nurses and physicians . Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care unit 's health care team . Nurses may be excluded from direct management of ventilator weaning in some institutions , as this role is primarily assumed by respiratory therapists guided by medical directives . Availability of critical care beds was highest in the United States and lowest in the United Kingdom . CONCLUSION Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries . Further quantification of these context ual influences should be considered when translating research findings into local clinical practice and when design ing r and omized controlled trials BACKGROUND UK recommendations suggest that large neonatal intensive-care units ( NICUs ) have better outcomes than small units , although this suggestion remains unproven . We assessed whether patient volume , staffing levels , and workload are associated with risk-adjusted outcomes , and with costs or staff wellbeing . METHODS 186 UK NICUs were stratified according to volume of patients , nursing provision , and neonatal consultant provision .  Primary outcomes were hospital mortality , mortality or cerebral damage , and nosocomial bacteraemia . We studied 13515 infants of all birthweights consecutively admitted to 54 r and omly selected NICUs . Multiple logistic regression analyses were done with every primary outcome as the dependent variable . Staff wellbeing and stress were assessed by anonymous mental health index (MHI)-5 question naires . FINDINGS Data were available for 13334 ( 99 % ) infants . High-volume NICUs treated the sickest infants and had highest crude mortality . Risk-adjusted mortality and mortality or cerebral damage were unrelated to patient volume or staffing provision ; however , nosocomial bacteraemia was less frequent in NICUs with low neonatal consultant provision ( odds ratio 0.65 , 95 % CI 0.43 - 0.98 ) . Mortality was raised with increasing workload in all types of NICUs . Infants admitted at full capacity versus half capacity were about 50 % more likely to die , but there was wide uncertainty around this estimate . Most staff had MHI-5 scores that suggested good mental health . INTERPRETATION The implication s of this report for staffing policy , medicolegal risk management , and ethical practice remain to be tested . Central isation of only the sickest infants could improve efficiency , provided that this does not create excessive workload for staff . Assessment of increased staffing levels that are closer to those in adult intensive care might be appropriate Purpose An International Consensus Conference proposed classifying weaning into simple , difficult , and prolonged weaning . However , the usefulness of this classification in a respiratory intensive care unit ( ICU ) is unknown . The aims of the study were : ( 1 ) to compare the clinical characteristics and outcomes of patients from the three weaning groups in a respiratory ICU ; and ( 2 ) to assess predictors for prolonged weaning and survival . Methods We prospect ively studied 181 mechanically ventilated patients ( 131 , 72 % with chronic respiratory disorders ) in whom weaning had been initiated , divided into  simple ( 78 , 43 % ) ,  difficult  ( 70 , 39 % ) , and  prolonged  ( 33 , 18 % ) weaning . We compared the characteristics and outcomes among the three groups and determined the factors associated with prolonged weaning and survival in multivariate analysis . Results Patients with simple and difficult weaning had similar characteristics and outcomes . A higher proportion of patients with prolonged weaning had chronic obstructive pulmonary disease  , and these patients also had more complications , a longer stay and lower survival . Increased heart rate ( ≥105 min−1 , p < 0.001 ) and PaCO2 ( ≥54 mmHg , p = 0.001 ) during the spontaneous breathing trial independently predicted prolonged weaning . In addition , the need for reintubation ( p < 0.001 ) and hypercapnia during the spontaneous breathing trial ( p = 0.003 ) independently predicted a decreased 90-day survival . Conclusion Because of the similar characteristics and outcomes , the differentiation between simple and difficult weaning had no relevant clinical consequences in a respiratory ICU . Patients with prolonged weaning had the worst outcomes . For the overall population , hypercapnia at the end of spontaneous breathing predicts prolonged weaning and a worse survival , and clinicians should implement measures aim ed at improving weaning outcome RATIONALE Diaphragmatic function is a major 
    Output:
    
agent
***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 PURPOSE Ventilator weaning protocol s can improve clinical outcomes , but their impact may vary depending on intensive care unit ( ICU ) structure , staffing , and acceptability by ICU physicians . This study was undertaken to examine their relationship . DESIGN / METHODS We prospect ively examined outcomes of 102 mechanically ventilated patients for more than 24 hours and weaned using nurse-driven protocol -directed approach ( nurse-driven group ) in an intensivist-led ICU with low respiratory therapist staffing and compared them with a historic control of 100 patients who received conventional physician-driven weaning ( physician-driven group ) .  We administered a survey to assess ICU physicians ' attitude . RESULTS Median duration s of mechanical ventilation ( MV ) in the nurse-driven and physician-driven groups were 2 and 4 days , respectively ( P = .001 ) . Median duration s of ICU length of stay ( LOS ) in the nurse-driven and physician-driven groups were 5 and 7 days , respectively ( P = .01 ) . Time of extubation was 2 hours and 13 minutes earlier in the nurse-driven group ( P < .001 ) . There was no difference in hospital LOS , hospital mortality , rates of ventilator-associated pneumonia , or reintubation rates between the 2 groups . We identified 4 independent predictors of weaning duration : nurse-driven weaning , Acute Physiology and Chronic Health Evaluation II score , vasoactive medications use , and blood transfusion . Intensive care unit physicians viewed this protocol implementation positively ( mean scores , 1.59 - 1.87 on a 5-point Likert scale ) . CONCLUSIONS A protocol for liberation from MV driven by ICU nurses decreased the duration of MV and ICU LOS in mechanically ventilated patients for more than 24 hours without adverse effects and was well accepted by ICU physicians BACKGROUND Ventilator-associated pneumonia ( VAP ) is considered to be an important cause of infection-related death and morbidity in intensive care units ( ICUs ) . We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU ( MICU ) . METHODS A 4-year controlled , prospect i ve , quasi-experimental study was conducted in an MICU , surgical ICU ( SICU ) , and coronary care unit ( CCU ) for 1 year before the intervention ( period 1 ) , 1 year after the intervention ( period 2 ) , and 2 follow-up years ( period 3 ) . The SICU and CCU served as control ICUs . The educational program involved respiratory therapists and nurses and included a self- study module with preintervention and postintervention assessment s , lectures , fact sheets , and posters . RESULTS Before the intervention , there were 45 episodes of VAP ( 20.6 cases per 1000 ventilator-days ) in the MICU , 11 ( 5.4 cases per 1000 ventilator-days ) in the SICU , and 9 ( 4.4 cases per 1000 ventilator-days ) in the CCU . After the intervention , the rate of VAP in the MICU decreased by 59 % ( to 8.5 cases per 1000 ventilator-days ; P=.001 ) and remained stable in the SICU ( 5.6 cases per 1000 ventilator-days ; P=.22 ) and CCU ( 4.8 cases per 1000 ventilator-days ; P=.48 ) . The rate of VAP in the MICU continued to decrease in period 3 ( to 4.2 cases per 1000 ventilator-days ; P=.07 ) , and rates in the SICU and CCU remained unchanged . Compared with period 1 , the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 ( P<.001 ) and by 8.9 days in period 3 ( P<.001 ) . The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50 % ( P<.001 ) and 37%-45 % ( P<.001 ) , respectively . CONCLUSIONS A focused education intervention result ed in sustained reductions in the incidence of VAP , duration of hospital stay , cost of antibiotic therapy , and cost of hospitalization BACKGROUND Critical care nurses ' knowledge and skills in adhering to evidence -based guidelines for avoiding complications associated with intubation and mechanical ventilation are currently limited . We hypothesized that single simulation education session would lead to a long-lasting higher level of skills among critical care nurses . MATERIAL AND METHODS A r and omized controlled trial was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finl and during the period February 2012-March 2014 . Thirty out of 40 initially r and omized critical care nurses participated in a 24-month follow-up study . Behavior and cognitive development was evaluated through a vali date d Ventilator Bundle Observation Schedule and Question naire at the baseline measurement and repeated 3 times during simulation and real-life clinic setting s. RESULTS After simulation education , the average skills score increased from 46.8%-58.8 % of the total score in the final postintervention measurement ( Ptime < .001 , Ptime × group = .040 , and Pgroup = .11 ) . The average knowledge scores within groups did not change significantly . The average between-group difference in skills scores was significant only at the measurement taken at 6 months ( P = .006 ) . CONCLUSIONS Critical care nurses ' skills in adhering to evidence -based guidelines improved in both groups over time , but the improvements between the study groups was significantly different only at 6 months and was no longer evident after 2 years following a single simulation education Non-r and omised studies of the effects of interventions are critical to many areas of healthcare evaluation , but their results may be biased . It is therefore important to underst and and appraise their strengths and weaknesses . We developed ROBINS-I ( “ Risk Of Bias In Non-r and omised Studies - of Interventions ” ) , a new tool for evaluating risk of bias in estimates of the comparative effectiveness ( harm or benefit ) of interventions from studies that did not use r and omisation  to allocate units ( individuals or clusters of individuals ) to comparison groups . The tool will be particularly useful to those undertaking systematic review s that include non-r and omised studies BACKGROUND Recently , clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation . One such process , use of a weaning protocol , has yielded conflicting results , arguably because of the influence of existing context and processes . OBJECTIVE To compare international data to assess differences in context and processes in intensive care units that could influence weaning . METHODS Review of existing national data on provision of care for critically ill patients , including structure , staffing , skill mix , education , roles , and responsibilities for weaning in intensive care units of selected countries . RESULTS Australia , New Zeal and , Denmark , Norway , Sweden , and the United Kingdom showed similarities in critical care provision , structure , skill mix , and staffing ratios in intensive care units . Weaning in these countries is generally a collaborative process between nurses and physicians . Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care unit 's health care team . Nurses may be excluded from direct management of ventilator weaning in some institutions , as this role is primarily assumed by respiratory therapists guided by medical directives . Availability of critical care beds was highest in the United States and lowest in the United Kingdom . CONCLUSION Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries . Further quantification of these context ual influences should be considered when translating research findings into local clinical practice and when design ing r and omized controlled trials BACKGROUND UK recommendations suggest that large neonatal intensive-care units ( NICUs ) have better outcomes than small units , although this suggestion remains unproven . We assessed whether patient volume , staffing levels , and workload are associated with risk-adjusted outcomes , and with costs or staff wellbeing . METHODS 186 UK NICUs were stratified according to volume of patients , nursing provision , and neonatal consultant provision .  Primary outcomes were hospital mortality , mortality or cerebral damage , and nosocomial bacteraemia . We studied 13515 infants of all birthweights consecutively admitted to 54 r and omly selected NICUs . Multiple logistic regression analyses were done with every primary outcome as the dependent variable . Staff wellbeing and stress were assessed by anonymous mental health index (MHI)-5 question naires . FINDINGS Data were available for 13334 ( 99 % ) infants . High-volume NICUs treated the sickest infants and had highest crude mortality . Risk-adjusted mortality and mortality or cerebral damage were unrelated to patient volume or staffing provision ; however , nosocomial bacteraemia was less frequent in NICUs with low neonatal consultant provision ( odds ratio 0.65 , 95 % CI 0.43 - 0.98 ) . Mortality was raised with increasing workload in all types of NICUs . Infants admitted at full capacity versus half capacity were about 50 % more likely to die , but there was wide uncertainty around this estimate . Most staff had MHI-5 scores that suggested good mental health . INTERPRETATION The implication s of this report for staffing policy , medicolegal risk management , and ethical practice remain to be tested . Central isation of only the sickest infants could improve efficiency , provided that this does not create excessive workload for staff . Assessment of increased staffing levels that are closer to those in adult intensive care might be appropriate Purpose An International Consensus Conference proposed classifying weaning into simple , difficult , and prolonged weaning . However , the usefulness of this classification in a respiratory intensive care unit ( ICU ) is unknown . The aims of the study were : ( 1 ) to compare the clinical characteristics and outcomes of patients from the three weaning groups in a respiratory ICU ; and ( 2 ) to assess predictors for prolonged weaning and survival . Methods We prospect ively studied 181 mechanically ventilated patients ( 131 , 72 % with chronic respiratory disorders ) in whom weaning had been initiated , divided into  simple ( 78 , 43 % ) ,  difficult  ( 70 , 39 % ) , and  prolonged  ( 33 , 18 % ) weaning . We compared the characteristics and outcomes among the three groups and determined the factors associated with prolonged weaning and survival in multivariate analysis . Results Patients with simple and difficult weaning had similar characteristics and outcomes . A higher proportion of patients with prolonged weaning had chronic obstructive pulmonary disease  , and these patients also had more complications , a longer stay and lower survival . Increased heart rate ( ≥105 min−1 , p < 0.001 ) and PaCO2 ( ≥54 mmHg , p = 0.001 ) during the spontaneous breathing trial independently predicted prolonged weaning . In addition , the need for reintubation ( p < 0.001 ) and hypercapnia during the spontaneous breathing trial ( p = 0.003 ) independently predicted a decreased 90-day survival . Conclusion Because of the similar characteristics and outcomes , the differentiation between simple and difficult weaning had no relevant clinical consequences in a respiratory ICU . Patients with prolonged weaning had the worst outcomes . For the overall population , hypercapnia at the end of spontaneous breathing predicts prolonged weaning and a worse survival , and clinicians should implement measures aim ed at improving weaning outcome RATIONALE Diaphragmatic function is a major 
    Output:
    