This is the first nationwide study conducted to understand, assess, and practice PADIS guidelines in mainland China after it was published in 2018. The mass data had a wide coverage and reflected the true situation of medical staff’s self-evaluation in adult ICU. A previous review of studies(10–12) in China presented that the medical staff had improved compliance with the guidelines, irrespective of the assessment and management of sedation, analgesia, or delirium, but there were still some shortcomings.
First, in mainland China, a satisfactory result was obtained for the education of relevant guidelines such as sedation, analgesia, and delirium. However, only about half of the people who know most of the guidelines. In a study of the barriers and enablers for implementing clinical practice guidelines in China, 27% of the Chinese medical staff reported language barriers associated with English guidelines and the impractical guidelines in the local setting (13). These observations might explain why the Chinese ICU staff was rather familiar with the Chinese guidelines. Previous studies have shown that the nurses requested additional information and training in areas such as sedation need, assessment, and management with respect to pain, delirium, and early mobilization (14, 15). The educational background and professional title of the nurses participating in the survey are lower than those of the doctors, which might be reason underlying the lack of basic knowledge. The ABCDE bundle implementation was greater in non-academic hospitals (16). However, in mainland China, the results were opposite, which might be related to the specific situation in China. According to the comprehensive ranking of hospital specialties in China released by the Hospital Management Institute of Fudan University (17), a recognized ranking board for evaluating the level of ICUs, eight out of the top ten ICUs were from University affiliated hospitals. The imbalance of the regional development in China affects the medical level in different regions. However, the PADIS content as the core treatment measure of ICU should not be limited by geographic or economic development. Owing to the heterogeneity of assessment among medical staff (18), uniform progress is necessary.
The respondents were more familiar with opioids than drug combination, data from many studies also suggested that the most preferred analgesic drugs were all opioids. The proption of clinicians assessing pain with tools was higher than previous, and interestingly, healthcare providers recommend CPOT and NRS as pain management tools. Some respondents reported using auricular therapy (AT) to relax the patients before an invasive procedure(19). Some prior reviews provided evidence from meta-analyses that ear acupuncture is effective for acute perioperative pain, but it had some limited evidence of effectiveness for acute pain as a stand-alone treatment(20–22).
Only 50% respondents who implemented DSI in tubated patients. This result was lower than the data reported before(10, 16, 17), This may due to the nouns translated into Chinese were less familiar to medical staff than spontaneous awakening trials(SATs) or spontaneous breathing trials (SBTs). Most medical staff had used tools to evaluate the efficacy of sedation, but they prefer the subjective scoring instruments to objective tools. Although it is reported that the objective sedation monitoring may reduce the total sedative use and ICU length of stay(LOS)(23), most respondents had not used BIS. Some studies suggested that the compliance were less with perceptions of high workload burden than low workload burden(24). In this survey, we did not collect data on nurse bed ratio, so whether the lower implementation rate of DSI or BIS due to fear of increasing nurse workload needs to be further explored.
Delirium is no longer a new topic in the field of critical care medicine. Numerous studies have shown that delirium is associated with the risk of mortality, ICU LOS and costs of care(25–27). The guidelines for monitoring/managing delirium have been the least utilized as previous research, but the use of assessment tools increased than before(10, 16, 17, 28). It could be concisely formulated into pamphlets or online documents so that a large number of healthcare workers could be trained with an inexpensive tool (development cost only). It is convenient to operate according to the unified process practice and conducive to ICU quality control(29). Although the guidelines did not recommend using all ICU patients and have no significant effect on key parameters (18, 30, 31), the proportion of delirium treated with drugs, especially dexmedetomidine, remains high of its reduced incidence of delirium. This phenomenon is also relevant to the specific circumstances of the patients. In this study, we did not distinguish the specific situation of patients’ self-expression. In a national multicenter cross-sectional survey currently underway, this part of the data would be collected for supplementary analysis.
The overall prevalence of physical restraint use in Chinese ICUs was higher than that reported in previous investigations(32, 33). Doctors had a low degree of implementation as the nurses were the actual operators of restraint and the core of evaluation. Restraint belts and restraint gloves were easier and cost less labor to physically restrain patients than restraint clothes, so the belts and gloves were prefered. Although physical restraint is necessary in some situations, but unintended consequences may occur,such as delirium, agitation, pressure ulcers, even death (34–37). So use of such devices has come under intense scrutiny and a systematic approach to reducing physical restraint use among critical illness patients is needed.
Most respondents had evaluated the patient’s sleep on a daily basis but lack of a regular treatment process due to the low quality of evidence provided by the available studies(38). Despite the lack of high-quality evidence to support, the respondents still preferred non-pharmacological intervention to improve patients' sleep. Similarly, a world-wide survey stated that the patients agreed that allowing uninterrupted blocks of time to sleep was the intervention with the most potential to improve patient sleep in the ICU, followed by controlling environmental noise levels(39). Despite consensus that increased family visitation is necessary, but only half of the respondents chosed to do this, the reason still need further investigation. During the COVID-19 pandemic, guidelines recommended a mitigation strategy to deliver family-centered protective material (40). Presently, a new strategy of implementing regular epidemic prevention and control measures that is in agreement with the current situation should be discussed.
Nonetheless, the limitation of this study is that it is a self-assessment report. The respondents recalled the work situation and then filled in the questionaries, such that there may be a recall bias and the medical staff may overestimate their performance in the actual work or had a wrong understanding of the concepts in the questionnaires. For these aspects, a supplementary survey was conducted in the current cross-sectional study.