Characteristics and Reported Practices of ICUs Participating in the Sedation, Analgesia and Delirium Management International Study: Variability in Site-Level Management of Mechanically Ventilated Patients

Objective: To describe site-level ICU organizational policies and implementation of pain, agitation, and delirium (PAD) best practices before the COVID-19 pandemic, and perceived changes during the pandemic. Design: International site-level questionnaire study. Setting: Participating sites completed a standardized electronic Case Report Form between January 5, 2022 and March 31, 2023. Patients/centers: Ninety-three ICUs caring for adult patients from 79 hospitals across 27 countries in North America, South America, and Europe. Interventions: Each ICU submitted data on site characteristics, staffing, implementation of PAD protocols and assessment tools prepandemic, and perceived changes during the COVID-19 pandemic. Descriptive statistics and multivariable logistic regressions were performed using R. Measurements and main results: Of 93 ICUs, 63% were university-affiliated, and 59% reported a closed physician staffing model. Most managed mixed patient populations (78%), with a nurse-to-patient ratio for ventilated patients of 1:2 (45%) or 1:1 (39%). Physiotherapists and pharmacists were available in 83% and 68% of ICUs, respectively. Over 75% reported routine use of validated PAD scales, most commonly Richmond Agitation Sedation Scale (86%), Confusion Assessment Method for ICU (59%), and Numeric Rating Scale (44%). Protocols were most available for spontaneous breathing trials (60%) and sedation (58%), followed by delirium (53%), mobilization (47%), and pain (46%). University affiliation and 1:1 nurse staffing was associated with reported use of delirium or mobilization protocols. The presence of a weaning protocol was associated with higher odds of daily sedation interruption (adjusted odds ratio [aOR] 3.80; 95% CI, 1.43-10.89; p = 0.009), and use of sedation protocols (aOR 5.95; 95% CI, 2.29-16.86; p < 0.001). Nearly one-half of ICUs reported drug shortages during the pandemic, and 62% prohibited any visitation. Conclusions: ICU organizational structures and reported PAD practices vary widely worldwide. Despite international guidelines, many ICUs lack consistent implementation of evidence-based sedation, analgesia, and delirium management strategies.