ArticleCritical care explorations2026
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.
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Abstract
objectiveTo 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.
designInternational site-level questionnaire study.
settingParticipating 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.
interventionsEach 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
resultsOf 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.
conclusionsICU 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.
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