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. 2025 Aug 25;6(1):91.
doi: 10.1186/s43058-025-00770-5.

Normalizing daily awakening and breathing coordination at 15 heterogenous ICUs: a multicenter post-implementation survey

Andrew J Knighton  1   2 , Jacob Kean  3 , Ithan D Peltan  4   5 , Dee Lisonbee  6 , Ashley Krueger  6 , Doug Wolfe  6 , Carrie M Winberg  7 , Corey Sillito  7 , Christopher B Jones  8 , Lori Carpenter  7 , Jason R Jacobs  4 , Lindsay Leither  4   5 , Richard Holubkov  9 , Colin K Grissom  4   5   8 , Raj Srivastava  6   10
Affiliations

Normalizing daily awakening and breathing coordination at 15 heterogenous ICUs: a multicenter post-implementation survey

Andrew J Knighton et al. Implement Sci Commun. .

Abstract

Background: Despite high post-implementation adherence, clinicians may have unresolved questions or concerns regarding use of a protocol to standardize routine daily coordination of the spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) on ventilated patients. Unresolved questions or concerns may unwittingly curtail practice normalization, impacting practice sustainment when implementation support is withdrawn. The objective of this study was to identify unresolved questions or concerns that may persist following successful implementation of a coordinated SAT/SBT (C-SAT/SBT) protocol.

Methods: We used an attributed, cross-sectional survey of physicians, advanced practice providers, nurses and respiratory therapists likely to have participated in a C-SAT/SBT in 12 hospitals (15 intensive care units) in Utah and Idaho. We evaluated clinician perceptions of acceptability, including ease of use, usefulness and confidence, along with perceived practice normalization, six months post implementation of a protocol to routinize C-SAT/SBT use.

Results: C-SAT/SBT adherence was 83.1% at the 6th month post implementation. 606 clinicians completed the survey (response rate: 50.0%). Perceived individual usefulness, ease of use, and confidence using the C-SAT/SBT protocol were high [range: 72.1%-88.1% agree/strongly agree], though individuals not performing an SAT or SBT in more than six months and respiratory therapists scored lower. Perceived practice normalization was similar with 82.0% aggregate agreement [agree/strongly agree]. However, when stratifying respondents into four categories based upon respondent percentage agreement with all statements, 71% did not agree with at least one practice normalization statement and 27% agreed with less than 80% of statements, varying by role and site. Sets of observable characteristics or phenotypes regarding the degree of practice normalization begin to emerge by subgroup.

Conclusions: Unresolved questions or concerns may persist regarding implementation of a C-SAT/SBT protocol among certain population subgroups despite current high practice adherence and high levels of perceived acceptability, including ease of use, usefulness and confidence. It is not clear what impact these unresolved questions or concerns may have on practice normalization and multi-year practice sustainment systemwide, including whether targeted late post-implementation strategies are needed to mitigate concerns and promote sustainment when implementation support is withdrawn.

Keywords: Acceptability; Normalization MeAsure Development (NoMAD) survey; Normalization process theory; Practice normalization; Practice sustainment; Spontaneous awakening trial; Spontaneous breathing trial.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The Intermountain Health Institutional Review Board reviewed this study and granted approval with a waiver of documentation of informed consent (#1052246). Consent for publication: Not applicable. Competing interests: AJK, JK, DL, AK, DW, CW, CS, CJ, LC, JRJ, LL and CG – the authors have no competing financial or non-financial interests. IP—Dr. Peltan reports funding to his institution from Bluejay Diagnostics and Novartis, both unaffiliated with this research. RH – Dr. Holubkov reports a consulting arrangement with Pfizer Inc (DSMB memberships) unaffiliated with this research. RS—Dr. Srivastava is a physician founder of the I-PASS Patient Safety Institute. His employer, Intermountain Health, owns his equity in the I-PASS Patient Safety Institute. Dr. Srivastava is supported in part by grants from the NIH, CDC, AHRQ and PCORI. Dr. Srivastava has received monetary awards, honorariums, and travel reimbursement from multiple academic and professional organizations for talks about pediatric hospitalist research networks and quality of care.

Figures

Fig. 1
Fig. 1
Clinicians’ opinions about the perceived ease of use, usefulness and confidence using and documenting the Intermountain Health coordinated spontaneous awakening and breathing trial protocol
Fig. 2
Fig. 2
Clinicians’ opinions regarding perceived practice normalization of coordinated spontaneous awakening and spontaneous breathing trials by individual construct statement
Fig. 3
Fig. 3
A grid heat map visualizing clinicians’ opinions regarding perceived practice normalization of coordinated awakening and spontaneous breath trials by individual respondent percentage agreement with practice normalization statements. Absent an existing empirical rationale, the percentage agreement was divided into four groups as follows: Group 1: 100% or complete agreement with all statements; Group 2: 80–99% agreement with statements; Group 3: 60–79% agreement with statements; Group 4: < 60% agreement with statements
See this image and copyright information in PMC

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