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Expanding long-term care options for persons with serious mental illness.

Remy were drawn from the instrument development study and reflect scores associated with the 7 dimensions of the instrument but not the total instrument.1 In the RESTORE trial, all physicians and nurses received training and were required to successfully complete a posttest prior to enrolling patients. We established interrater reliability checks on the SBS and monitored interrater reliability throughout the trial in both intervention and control PICUs. The overall κ score for the SBS was 0.87 (95% CI, 0.83-0.91). Any PICU falling below 80% agreement implemented a quality improvement plan and the interrater reliability was rechecked. As noted in our article and in the supplementary materials, sedation assessments were completed more frequently in the intervention compared with control PICUs, presumably because the data were used by the intervention PICUs to target sedation. Adherence to sedation assessment elements in our protocol was high; the daily SBS target was prescribed on 98% of intubation study days and achieved 95% of the time in intervention patients. We have no data on how nurse turnover or experience may have confounded the RESTORE study. As noted in our supplemental materials, the experience level of the PICU nursing workforce was good, with a median of 6.2 years (interquartile range, 5.1-8.3 years) across sites, and most nurses had bachelor’s degrees (median, 80%; interquartile range, 74%-90% across sites). In addition, we had few protocol deviations stemming from enrolled patients receiving care from a nurse who was not trained in using the RESTORE protocol. Clinical trials and observational studies2 may differ in their conclusions for the reasons that Remy cites, and there may be additional bias introduced in observational studies that may be difficult to identify, as well as the inherent differences between a toddler with acute respiratory failure and a 50-yearold adult with a medical or surgical problem.