Decisional responsibility for mechanical ventilation and weaning: an international survey

Introduction

Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.

Methods

A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.

Results

Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.

Conclusions

Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.     

Nurses and ventilators

In the previous issue of Critical Care, Rose and colleagues report the results of a survey on the frequency with which ICU nurses are involved in decision-making in ventilator management. About 63 to 88% of the decisions were made by nurses in collaboration with physicians, and as much as 68% of ventilator adjustments were performed by nurses independent of physicians. Nurse involvement in decision-making was twice as likely in ICUs that use weaning protocols. The ICU nurse performs many roles, the most important being the continuous observation of a patient. The diversion of a nurse's attention from constant vigilance by performing tasks of no benefit, such as the use of weaning protocols, would be a most unfortunate turn of events.     

A survey on oral care practices for ventilator‐assisted patients in intensive care units in 3A hospitals of mainland China

Oral hygiene is a critical element of patient care, particularly among patients who need ventilator‐assisted equipment. The objective of this study was to explore the current status of oral care practices, attitudes, education and knowledge among intensive care unit (ICU) nurses caring for ventilator‐assisted patients in 3A hospitals in mainland China. To achieve this aim, an 18‐item self‐assessment questionnaire was mailed to head ICU nurses in 189 Grade 3A hospitals. Additional data were collected through in‐person interviews at 38 ICUs throughout Sichuan, Shanxi, Jiangsu provinces, as well as Chongqing and Beijing. We found that most ICUs conducted oral examinations at patient admission, and that this care was largely provided by nurses. The most common oral care methods were foam swabs and mouth rinse containing antibiotics or disinfectants. Although the majority of ICUs provided continuing training for oral care, and most training was conducted by head nurses, the content and scope of training were not consistent among the hospitals in the study. The most popular sources of oral care knowledge were academic journals, Internet and professional books. Overall, it is clear that an evidence‐based oral care standard manual is urgently needed for oral practice in ICUs in mainland China.     

Nursing workforce deployment and intensive care unit strain during the COVID-19 pandemic in Victoria,Australia

BackgroundThe COVID-19 pandemic demanded intensive care units (ICUs) globally to expand to meet increasing patient numbers requiring critical care. Critical care nurses were a finite resource in this challenge to meet growing patient numbers, necessitating redeployment of nursing staff to work in ICUs.ObjectiveOur aim was to describe the extent and manner by which the increased demand for ICU care during the COVID-19 pandemic was met by ICU nursing workforce expansion in the late 2021 and early 2022 in Victoria, Australia.MethodsThis is a retrospective cohort study of Victorian ICUs who contributed nursing data to the Critical Health Information System from 1 December 2021 to 11 April 2022. Bedside nursing workforce data, in categories as defined by Safer Care Victoria’s pandemic response guidelines, were analysed. The primary outcome was ‘insufficient ICU skill mix’—whenever a site had more patients needing 1:1 critical care nursing care than the mean daily number of experienced critical care nursing staff.ResultsOverall, data from 24 of the 47 Victorian ICUs were eligible for analysis. Insufficient ICU skill mix occurred on 10.3% (280/2725) days at 66.7% (16/24) of ICUs, most commonly during the peak phase from December to mid-February. The insufficient ICU skill mix was more likely to occur when there were more additional ICU beds open over the ‘business-as-usual’ number. Counterfactual analysis suggested that had there been no redeployment of staff to the ICU, reduced nursing ratios, with inability to provide 1:1 care, would have occurred on 15.2% (415/2725) days at 91.7% (22/24) ICUs.ConclusionThe redeployment of nurses into the ICU was necessary. However, despite this, at times, some ICUs had insufficient staff to cope with the number and acuity of patients. Further research is needed to examine the impact of ICU nursing models of care on patient outcomes and on nurse outcomes.     

How nurse practitioners make decisions regarding coronary heart disease risk: a social judgment analysis

PURPOSE: Understanding how nurse practitioners use clinical decision skills in practice has the potential to guide education programs to ensure safe, competent, and high quality advanced nursing practice. This study used the lens of social judgment theory to examine the clinical decision making of 60 nurse practitioners. METHODS: A three‐group pretest–posttest comparison design was used to evaluate how much insight nurse practitioners had into their clinical decision‐making process. FINDINGS: Nurse practitioners had modest insight into their clinical decision‐making process. CONCLUSION: Self‐insight has implications for enhancing nurses' decision making, improving education, and fostering agreement among advanced practice nurses. IMPLICATIONS FOR NURSING PRACTICE: Self‐insight has implications for developing professional decision making and promoting appropriate educational opportunities for advanced practice nurses.     

Care practices for patients requiring mechanical ventilation more than seven days in Swedish intensive care units: A national survey

ObjectiveTo identify care practices in Swedish intensive care units specific to patients requiring mechanical ventilation for >7 days.Research MethodologyWe conducted a national cross-sectional survey inviting all adult Swedish ICUs (n = 79). Nurse managers were invited by email to complete a questionnaire by telephone. The questionnaire included seven domains: ventilator weaning, mobilisation, communication, nutrition, symptom assessment, psychosocial support and organisational characteristics.ResultsWe received responses from 77 units (response rate, 97%). Weaning protocols were available in 42 (55%) units, 52 (68%) used individualised weaning strategies and 50 (65%) involved physicians and nurses in collaborative decision making. In 48 units (62%), early mobilisation was prioritised using bed cycling but only 26 (34%) units had mobilisation protocols. Most of the intensive care units (74, 96%) had nutrition protocols but only 2 (3%) had dedicated dieticians. Delirium screening tools were available in 49 (64%) ICUs, 3 (4%) assessed anxiety and none assessed dyspnoea. Nineteen (25%) units employed a primary nursing model and 11 (14%) indicated person-centred care policies. Regular case conferences, including family participation, were held by 39 (51%) units.ConclusionWe found that an individualised approach to ventilator weaning, decided by physicians and nurses in collaboration, was the predominant approach, although weaning protocols were available in some intensive care units. Most units prioritised early mobilisation, though few used protocols. Nutritional protocols were widely adopted, as few units had a dedicated dietician.     

Nurse/physician collaboration: action research and the lessons learned

OBJECTIVE: Finding time to add to nursing knowledge while solving problems in a fast-paced healthcare environment is the ultimate challenge for nurse executives. At one hospital, use of an action research model to measure collaboration in nurse/physician led interdisciplinary teams improved the intervention and the approach to outcome measurement. BACKGROUND: Many hospital nurse executives promote collaborative practice, and yet, innovations introduced to foster collaboration are rarely studied prospectively. The best-known data on collaboration is predominantly from correlational studies. Within the rapidly changing practice setting, action research may be a more legitimate strategy for studying interventions longitudinally. METHODS: An action research pretest/posttest design using Baggs' Collaboration and Satisfaction About Care Decisions measured collaboration before and after several interventions to improve nurse/physician collaboration. The sample consisted of 87 pretest and 65 posttest registered nurses working on three medical-surgical units and two intensive care units (ICU). RESULTS: Collaboration scores in the ICUs were higher than those in previous research, but the posttest indicated no significant difference in either ICU nurse or medical-surgical nurse scores. Higher ICU scores may have been related to the organizational focus on teams. A strong significant correlation between nurse report of level of collaboration and satisfaction with decision making was uncovered. CONCLUSIONS: This study contributes to the nurse/physician collaboration literature in that it was longitudinal, used a reliable and valid instrument, and surveyed nurses in medical/surgical units as well as the ICU. Some of the difficulties and benefits of research in today's practice setting are illustrated.     

Impact of staffing levels and resources of intensive care units on compliance to standard mechanical ventilator guidelines: A city-wide study in times of COVID-19 pandemic

Background

The COVID-19 pandemic has affected millions and resulted in a considerable strain on healthcare systems around the world. Intensive care units (ICUs) are reported to be affected the most because significant percentage of ICU patients requires respiratory support through mechanical ventilation (MV).

Aim

This study aims to examine the staffing levels and compliance with a ventilator care bundle in a single city in Pakistan.

Methods

A cross-sectional survey of 14 ICUs including medical and surgical ICUs was conducted through a self-structured questionnaire including a standardized ventilator care bundle. We assessed the compliance of ICU staff to ventilator care bundle and calculated the correlation between staffing patterns with compliance to this bundle.

Results

The unit response rate was 64% (7/11 hospitals). Across these seven hospitals, there were 14 functional ICUs (7 surgical and 7 medical). The Mean (SD) numbers of beds and ventilators were 8.14 (3.39) and 5.78 (3.68) while the average patient-to-nurse and patient-to-doctor ratio was 3: 1 and 5:1 respectively. The median ventilator care bundle compliance score was 26 (IQR = 21–28) out of 30, while in medical and surgical ICUs, median scores were 24 (IQR = 19–26) and 28 (IQR = 23–30) respectively. The perceived least compliant component was head elevation in ventilated patients. Correlation analysis revealed that 24 h a day, 7 days a week onsite cover of Advanced Cardiovascular Life Support certified staff was positively correlated with the ventilator care bundle score (r_s = 0.654, p value = .011). Similarly, 24-h cover of senior ICU nurses was significantly correlated with the application of chlorhexidine oral care (r_s = 0.676, p value = .008) while routine subglottic aspiration was correlated with the number of doctors (r_s = 0.636, p value = .014).

Conclusion

Our study suggests that ICUs in Peshawar are not well staffed in comparison with international standards and the compliance of ICUs with the ventilator care bundle is suboptimal. We found only a few aspects of ventilator care bundle compliance were related to nursing and medical staffing levels.

Relevance to clinical practice

Critical care staffs at most of the medical ICUs in Peshawar are not compliant with the standard guidelines for patients on mechanical ventilation. Moreover, the staffing levels at these ICUs are not in accordance with international standards. However, this study suggests that staffing levels may not be the only cause of non-compliance with standard mechanical ventilator guidelines. There is an urgent need to design and implement a program that can enhance and monitor the quality of nursing care provided to mechanically ventilated patients. Lastly, nurse staffing of ICUs in Pakistan must be increased to enable high quality care and more doctors should be trained in critical care.     

全国30个省市三级医院重症监护病房医护人员呼吸治疗工作现状的问卷调查

目的 调查我国三级医院重症监护病房(ICU)呼吸治疗的仪器装备、工作内容和完成人等,为规范和发展呼吸治疗工作提供依据.方法 在2006年8月国内召开的三次大规模会议上发放问卷,调查30个省264家三级医院320个ICU的491名医护人员.结果 有创、无创呼吸机数与床位数之比分别为0.52: 1(2 189/4 185)和0.16:1(672/4 185).320个ICU中,超声、喷射式以及定量雾化吸入器的配用率分别为55.9%(179/320)、33.8%(108/320)和12.1%(39/320);机械通气中呼吸机设置、撤机、拔管主要由医师完成的ICU占92.1%、93.1%、83.5%,更换管路、吸痰、雾化、湿化主要由护士完成的ICU占83.7%、93.9%、91.6%、90.2%.491名回答者中撤机前行自主呼吸试验者占40.9%,不知道或从来不做者占26.2%;有创通气时未监测气道开口端温度者占27.1%;对撤机未拔管患者应用气管内持续滴入/泵入盐水湿化者占34.4%;55.6%的人员使用前检测呼吸机;管路更换频率依次为每周1次占48.1%,1～3 d和3～5 d更换1次者为25.0%、14.7%.结论 目前国内三级医院ICU的呼吸机数量较前已大幅增加,但对其他实用装置的应用尚不足;呼吸治疗工作主要由医生和护理人员共同承担,尚缺少专业的呼吸治疗师;机械通气、气道管理和呼吸机管理等呼吸治疗工作差异较大,缺乏统一的规范.     

Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned

OBJECTIVE: To determine the effect of an institutional approach to the care of patients requiring mechanical ventilation for longer than three consecutive days in five adult intensive care units (ICU) on clinical and financial outcomes. DESIGN: A multidisciplinary team was selected from five adult ICUs to design the approach. Planning occurred from August 1999 to September 2000. The process was called outcomes management (OM) and included an evidence-based clinical pathway, protocols for weaning and sedation use, and the selection of four advanced practice nurses (called outcomes managers) to manage and monitor the program. SETTING: The project was completed in a 550-bed mid-Atlantic academic medical center. The ICUs included the following: coronary care, medical ICU, neuroscience ICU, surgical trauma ICU, and thoracic cardiovascular ICU. PATIENTS: The sample included 595 pre-OM patients and 510 post-OM patients mechanically ventilated for greater than three consecutive days. INTERVENTIONS: Full implementation of the OM approach occurred in March 2001. Retrospective baseline (18 months pre-OM) and prospective (12 months OM) clinical and financial data were compared. MEASUREMENTS AND MAIN RESULTS: Statistically significant differences in clinical outcomes were demonstrated in the managed patients compared with those managed before the institutional approach. Outcomes include ventilator duration (median days declined from ten to nine; p =.0001), ICU length of stay (median days declined from 15 to 12; p =.0008), hospital length of stay (median days declined from 22 to 20; p =.0001), and mortality rate (declined from 38% to 31%, p =.02). More than 3,000,000 US dollars cost savings were realized in the OM group. CONCLUSIONS: This institutional approach to the care of patients ventilated >3 days improved all clinical and financial outcomes of interest. To date, few similar initiatives have demonstrated similar results. The approach and lessons learned in this process improvement project may be helpful to other institutions attempting to improve outcomes in this vulnerable population.     

Factors influencing the patient during weaning from mechanical ventilation: a national survey.

Successful weaning depends on the application of skilled judgement and decision making to nursing and medical interventions. The intensive care nurse is in an unique position for adopting a holistic approach to weaning. Such an approach needs teamwork and consideration of all the factors that could influence the outcome of the weaning phase. The aim of this study was to conduct a survey, to establish the factors taken into consideration and documented during weaning at the intensive care units (ICUs) in Sweden. A questionnaire was developed and sent to all 92 ICUs. The results identified that nutrition, communication, analgesics and sedatives, psychological and metabolic factors, as well as weaning methods and measurable parameters were taken into consideration. Written instructions for weaning were used by only three ICUs and weaning protocols were not common. A holistic approach to the discontinuation of mechanical ventilation is a valuable means of improving the quality of care and merits further research.     

Ventilator circuit and secretion management strategies: a Franco-Canadian survey

OBJECTIVE: To determine the use of ventilator circuit and secretion management strategies in France and Canada. DESIGN: Binational cross-sectional survey. POPULATION: Intensive care unit (ICU) directors in French and Canadian university hospitals. MEASUREMENTS: We compared responses between countries regarding the use of seven circuit and secretion strategies, the rationales against their use, decisional responsibility for these strategies, whether ventilator-associated pneumonia (VAP) practice was audited, and whether VAP prevention guidelines addressing these strategies were used. RESULTS: The response rate was 72/84 (85.7%) for French and 31/32 (96.9%) for Canadian ICUs. Endotracheal intubation was predominantly oral in both countries. Changing the ventilator circuits only for every new patient was more frequent in France than in Canada (p < .0001). Heated humidifiers were used more in Canada than France (p = .0003). Closed endotracheal suctioning was used more frequently in Canada (p < .0001). In both countries, subglottic secretion drainage and kinetic beds were rarely used. Semirecumbent positioning was reported more often by French than Canadian ICUs (p = .003). Reasons for nonuse of these strategies included adverse effects (heat and moisture exchangers), cost (kinetic beds), lack of convincing benefit (subglottic secretion drainage), and nurse inconvenience (semirecumbency). Decisional responsibility for each strategy differed among institutions. VAP prevention practice was periodically reviewed in 53% of French and 68% of Canadian ICUs (p = .20). VAP prevention guidelines were used in 64% and 30% of these ICUs, respectively (p = .002). CONCLUSIONS: Our study does not support the notion that published recommendations substantially impact reported use of several ventilator circuit and secretion management strategies. Based on the use of more frequent ventilator circuit changes, closed suctioning systems, heated humidifiers, and respiratory therapists, ventilator circuit and secretion management practice appears more costly in Canada than in France.     

集束干预策略对预防呼吸机相关肺炎的临床研究

目的探讨多准则决策分析法构建的集束干预策略对呼吸机相关肺炎发生率的影响。方法选择2009年11月～2010年11月在ICU入住的患者60例,随机分为实验组和对照组,各30例。实验组实施集束干预策略,对照组实施常规护理。比较两组VAP发生率、死亡率、机械通气时间、入住ICU时间、ICU期间住院费用、护理人员依从性差异。结果实验组洗手、抬高床头依从性(96.7%,100%)显著高于对照组(57.2%,44.7%);实验组VAP发生率,机械通气时间,入住ICU时间低于对照组,差异均有显著意义(P<0.05)。结论科学构建的集束干预策略预防VAP效果较好,提高了护士依从性,能有效落实指南并改善患者预后,值得临床应用。     

TISS-28 in difficult to wean patients after long-term mechanical ventilation

PURPOSE: To compare the Therapeutic Intervention Scoring System (TISS) 28 in difficult to wean patients before and after transfer to a weaning center. PATIENTS AND METHODS: Using TISS-28, the authors investigated the difference between regular intensive care units (ICUs) and the respiratory ICU (RICU) of their hospital in difficult to wean patients after long-term mechanical ventilation (MV). Special emphasis was placed on the appropriateness of TISS-28 to cover the specific weaning activities. 63 tracheotomized patients ventilated for more than 14 days were included. RESULTS: In total, 15.9% of patients were not weaned, 20.6% of population was successfully weaned with noninvasive ventilation (NIV), and 63.5% of patients was successfully weaned without NIV. The transfer of patients from other ICUs to a weaning facility resulted in a significant reduction of total TISS-28 from 29.5 to 23.8 points (p<0.001) on average. CONCLUSION: The high weaning success rate in a specialized facility is associated with a significant reduction of TISS-28 scores. The use of TISS-28 in a weaning center for patients with prolonged MV to measure workload does not adequately mirror the efforts by physicians, nurses, physiotherapists, and other health-care personnel.     

北京市8所三级甲等医院ICU护理人力资源的调查分析

目的调查三级甲等医院ICU护理人力资源现状,为ICU护士队伍建设、ICU专科护士的培养提供依据。方法采用自制问卷调查北京市8所三级甲等医院13个ICU护理人力资源状况。结果ICU护士以大专及以上学历为主,占90．54％,职称结构不尽合理,护师及以下职称的护士占90．54％,年轻护士比例大,年龄≤30岁的占72．97％,具有ICU专科护士资质的占29．05％。结论应加强ICU护士的分层次培训和专科护士培训,充实ICU护士数量,以保障ICU护理工作质鼍。