Sie sind auf Seite 1von 11

Critical Care Management

lthough the literature on mechanical ventilation and weaning practices is extensive, data on the role of critical care nurses in managing these practices remain limited. Some evidence 1 suggests that trained and qualified nurses can beneficially influence the weaning process and reduce the duration of mechanical ventilation. However, most available data on the clinical application of mechanical ventilation and weaning by nonphysicians focus on the implementation of protocols.

A D

In certain contexts, such protocols implemented for the decisions made; and who implemented the by either nurses or respiratory therapists can reduce decisions by changing ventilator settings. Other 2- 4 the duration of ventilation and weaning. Protocols important aspects included methods and duration are advocated as a method of standardizing clinical of mechanical ventilation and weaning. practice and providing nurses with increased autonMethods 5, 6 omy and accountability. Conversely, protocols may be perceived as restrictive, resulting in a lack of indiSample and Setting 7 vidualized care. Furthermore, according to Lyon, During a 3-month period in 2005, all patients rather than increasing nursing autonomy, protocols admitted to the ICU of the Royal Melbourne Hospital, are a form of delegation (written rather than verbal) Victoria, Australia, who received mechanical ventilaby medical colleagues. Arguably, protocols might tion were included in the study. This ICU is a 24-bed not be required in an organizational context with adult, combined medical-surgical unit in a universityexperienced bedside clinicians and interdisciplinary affiliated teaching hospital that also serves as the collaboration, a situation common in Australian second trauma service for the state of Victoria. intensive care units (ICUs). The role of critical care Approximately 100 patients per month receive By Louise Rose, MN, Sioban Nelson, RN, PhD, Adult Ed Cert, BN, ICU Cert, nurses in mechanical ventilation and weaningLinda prac- Johnston, RN, mechanical ventilation in this ICU. PhD, and Jeffrey J. Presneill, MBBS, PhD tices in this environmental context, in the absence of formalized protocols for ventilatory support and Ethical Considerations Background Responsibilities of critical care nurses for manageweaning, requires further exploration. Approval for this observational, ment of mechanical ventilation may differ among countries. The purpose of our investigation was to describe noninterventional cohort study was Organizational interventions, including weaning protocols, may the role of critical care nurses in making decisions obtained from the institutional have a variable impact in settings that differ in nursing autonomy about mechanical ventilation and weaning in an ICU review boards of both the hospital and interdisciplinary collaboration. with a high proportion of critical care qualified nursand the University of Melbourne, Objective To characterize the role of Australian critical care ing staff (75%) and a nurse to patient ratio of 1 to 1 which waived the of need nursestogether in the management mechanical ventilation. for patients receiving ventilatory support. In particufor informed A consent from patients. cohort study was performed. Methods 3-month, prospective lar, our aim was to determine which clinicians made Informed consent to participate All clinical decisions related to mechanical ventilation in a 24the decisions; the type, frequency, and indications in data collection was obtained adult intensive care unit at the bed, combined medical-surgical from Royal all Melbourne nursing staff Hospital, involved a university-affiliated in teaching hosNotice to CE enrollees: pital in Melbourne, Victoria, Australia, were determined. A closed-book, multiple-choice examination the identification and description following this article tests your understanding of Results 474 patients admitted during the 81-day study period, of decision Of making related to About the Authors the following objectives: 319 (67%) received mechanical ventilation. Death occurred in ventilatory support. When this article was written, Louise Rose was the criti1. Describe the role of critical care nurses in the 12.5% (40/319) of patients. Median durations of mechanical ventical care course coordinator at RMIT University, Bunmanagement of mechanical ventilation. lation and intensive care stay were 0.9 and 1.9 days, respectively. doora, Melbourne, Australia, and a PhD candidate at the Data Collection 2. Discuss critical care decision-making University of Melbourne and the nurses Intensive Care Unit, A total of 3986 ventilation and weaning decisions (defined as Definitions for demographic and ventilator the Royal Melbourne Hospital, Parkville, Victoria, Ausrole in weaning mechanically ventilated any adjustment to ventilator settings, including mode change; tralia. She patients. is now an assistant professor in the Lawrence information to be collected were based on previous rate or pressure support adjustment; and titration of tidal volume, S. Bloomberg Faculty of Nursing at the University of 8 The 3. Identify advantages found in this study of international studies of ventilation practice. positive end-expiratory pressure, or fraction of inspired oxygen) Toronto, Toronto, Canada. Sioban Nelson is the dean of critical care nurses managing mechanically data collection tool was developed in consultation nursing at the University of Toronto, Toronto, Ontario, were made. Of these, 2538 decisions (64%) were made by nurses patients. Canada. ventilated Linda Johnston is the chair of Neonatal Nurswith senior nursing staff experienced in 755 managealone, 693 (17%) by medical staff, and (19%) by nurses and ing Research, School of Nursing, University of Melment staff in of collaboration. mechanical ventilation Decisions and made weaning exclusively who by nurses bourne, Childrens Hospital, and To Royal read this article and take the CEMurdoch test online, were less common for patients with predominantly were not directly involved in the study. These staff respiratory Childrens Research Institute, Parkville, Victoria, Ausvisit www.ajcconline.org and click CE Articles in disease orwere multiple organ dysfunction than for other patients. tralia. Jeffrey J. Presneill is a senior physician in the members asked to specify all clinically relevant This Issue. No CE test fee for AACN members. intensive care unit at the Royal Melbourne Hospital. Conclusions In this unit, critical care nurses indications for changes in ventilator support and have all high levels of responsibility for,that and could autonomy in, the management of Corresponding author: Louise Rose, Lawrence S. potential changes be made to ventilator Bloomberg Faculty of Nursing, University of Toronto, mechanical ventilation and weaning. Revalidation of protocols settings. The final tool was further refined in a pilot 155 College St, Room 276, Toronto, ON M5T 1P8, for ventilation practices in other clinical contexts may be study in the same ICU. Canada (email: louise.rose@utoronto). needed. ( American Journal of Critical Care. 2007;16:434-446) Evidence-Based Review on pp 445-446.

MADE BY CRITICAL CARE NURSES DURING MECHANICAL V WEANING ENTILATION AND IN AN A USTRALIAN INTENSIVE CARE UNIT
ECISIONS
Although protocols enhance nurses autonomy and accountability, the presence of experienced bedside clinicians may render protocols less necessary.

2.0 Hours CE

EB R

AC C AMERICAN 434 AC C AMERICAN JOURNAL OF CRITICAL CARE, www.ajcconline.org September 2007, JOURNAL Volume OF 16, CRITICAL No. 5 www.ajcconline.org CARE, September 2007, Volume 16, J J

No. 5

435

Nurses initiated 64% of ventilator setting changes; decisions to extubate were mostly collaborative.

Before the study began, educational sessions on the aims and documentation requirements of the study were held for all staff involved in data collection. During each patients ICU admission, bedside nurses serially documented each decision episode. A decision episode was defined as any event that resulted in an adjustment to a patients ventilator settings, including a change in mode or rate; adjustment of tidal volume, pressure support, positive end-expiratory pressure, or fraction of inspired oxygen (F IO 2); alteration in inspiratory pressure or time settings; and extubation. In addition, nurses documented the primary indication for the change of settings, which settings were changed, who initiated the change, and who physically changed the ventilator settings. Indications included results of arterial blood gas analysis; observed work of breathing; values for oxygen saturation (determined by pulse oximetry), minute ventilation, and inspiratory pressures; and weaning (defined as a decision that resulted in the reduction of ventilatory support for the purposes of weaning). For analytical purposes, decisions were categorized as made exclusively by nurses, made exclusively by medical staff, or collaborative. Decisions made exclusively by nurses or exclusively by medical staff were defined as decisions that did not involve interdisciplinary communication before the decision was implemented. A collaborative decision was defined as one for which both medical and nursing staff had input and shared responsibility in the decision-making process, as opposed to verbal delegation from medical to nursing staff. During the prospective audit, twice-daily rounds were made by the primary investigator (L. R.), timed to coincide with 12-hour shift changes. The purposes of the rounds were to ensure that information on all patients receiving mechanical ventilation was included in the data set, to answer queries about data collection, and to maximize compliance with the data collection tool. Patients receiving mechanical ventilation were monitored for reintubation and the use of noninvasive ventilatory support for up to 48 hours after extubation. Likewise, follow-up of patients with a tracheostomy stopped 48 hours after the discontinuation of any form of positive-pressure ventilation. Data Analysis Continuous data, including age and severity of illness scores, as indicated by the Acute Physiology

and Chronic Health Evaluation II and the total maximum Sequential Organ Failure Assessment (SOFAmax), derived from the sum of the score for the worst finding of each of the 6 subcategories dur9 ing the patients ICU admission, were summarized as means and standard deviations. Interval or nonnormally distributed data were summarized as medians and interquartile ranges (IQRs). In several other investigations, 8, 10, 11 the duration of ventilation was described by using summary statistics for data for which the censoring process of time-to-event data was ignored. In this study, the median times to successful weaning and to ICU discharge for various categories of disease were calculated by using simple time-to-event methods (survival analysis), with deaths regarded as censored observations of the weaning process. Summary statistics for data in which censoring was ignored also are provided for selected data in order to facilitate comparisons with previously published reports. Categorical data, including sex, type of admission, clinical diagnostic category, indications for mechanical ventilation and decision episodes, changes in ventilator settings, weaning method, and weaning outcome, were expressed as proportions. Relative risk ratios were calculated to determine the probability of decisions made exclusively by nurses compared with decisions made exclusively by medical staff or as the result of collaborative discussion (a binary alternative), according to the indication for ventilation, the duration of ventilation, and the patients severity of illness (SOFAmax score). P values less than .05 were considered significant. All analyses were performed by using Minitab, Version 14 (Minitab Inc, State College, Pennsylvania), or Stata, Version 9.0 (StataCorp LP, College Station, Texas).

Results
Demographic Characteristics A total of 474 patients were admitted during the 81-day study period; of these, 319 (67%) received some form of mechanical ventilation. Most commonly, the patients who received ventilatory support were men and were admitted for surgery (Table 1). According to the categories of the Mechanical 8 Ventilation International Study Group, the most frequent indications for commencement of mechanical ventilation were postoperative respiratory failure, coma, and trauma (Figure 1). When cardiac surgery patients were excluded, the single most frequent indication for mechanical ventilation was coma caused by loss of consciousness due to

436

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 www.ajcconline.org J

cerebral hemorrhage (42%), seizures (20%), intentional overdose (16%), undefined neurological cause (11%), hepatic encephalopathy (1.5%), neurological infection (1.5%), or neurological sequelae after cardiac arrest (8%). In contrast, chronic obstructive pulmonary disease (COPD) was an uncommon primary reason for ventilation; only 3 patients (1%) had this indication. Modes of Ventilation Synchronized intermittent mandatory ventilation with volume control and pressure support was the most frequently used mode on initiation of mechanical ventilation. This mode was used for 294 of 319 patients (92%). A total of 15 patients (5%) initially had pressure-support ventilation. Only 10 patients (3%) were treated with synchronized intermittent mandatory ventilation with pressure control or biphasic intermittent positive airway pressure (referred to as bilevel for the Puritan Bennett 840 ventilator; Puritan Bennett, Pleasanton, California). Of the 306 patients who underwent weaning during the study, the majority (75%) were weaned by using a rapid transition from volume- or pressurecontrolled mandatory modes to pressure-support ventilation with no other reduction in support (Figure 2). Duration of Ventilation and ICU Stay Patients were admitted to the ICU for a median duration of 1.9 days (IQR 1-4 days); when the censoring effect of mortality was ignored, median duration was 1.8 days. The duration of mechanical ventilation was 0.9 days (IQR 0.4-3 days; median without censoring 0.8 days). When cardiac surgery patients were excluded from analysis, the median duration of ICU stay increased to 3.3 days (IQR 1.7-6.1 days; median without censoring 2.8 days). For the 191 patients who did not have cardiac surgery, the median duration of ventilation was 2.1 days (IQR 0.8-4.9 days; median without censoring 1.8 days), of which 67% was taken up with the weaning process. In comparison, for the 128 cardiac surgery patients, median duration of ventilation was 0.4 days (IQR 0.2-0.8 days, median without censoring 0.4 days), of which approximately 50% was taken up with weaning. Durations of ICU stay, ventilation, and weaning differed substantially according to the indication for mechanical ventilation in patients who did not have cardiac surgery (Tables 2 and 3). Patients who had ventilatory support because of COPD, pneumonia, sepsis, heart failure, neuromuscular disorders, or acute respiratory distress syndrome tended to be treated with mechanical ventilation for durations greater than the overall median duration.

Table 1 Demographics of patients treated with mechanical ventilation (N = 319)


Characteristic Sex, No. (%) Men Women Age, y Mean (SD) Median (range) APACHE II score Mean (SD) Median (range) SOFAmax score Mean (SD) Median (range) Type of admission, No. (%) Surgical Medical Trauma Clinical diagnostic category, No. (%) Cardiovascular Cardiac surgery Other Neurological Multitrauma Respiratory Othera Value 216 103 (68) (32)

58 (18.2) 63 (18-91) 14 (6.9) 13 (2-36) 8.1 (3.8) 7 (2-22) 174 85 60 161 128 33 74 50 16 18 (54) (27) (19) (50) (40) (10) (23) (16) (5) (6)

Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; SOFAmax, total maximum Sequential Organ Failure Assessment.

a Patients with gastrointestinal, genitourinary, hematologic, or metabolic primary


disorders.

160 140 120 100 80 60 40 20 0

Indication

Figure 1 Indications for mechanical ventilation. Categories are 8 based on definitions from Esteban et al. Coma includes patients with loss of consciousness due to cerebral hemorrhage, seizures, intentional overdose, undefined neurological causes, hepatic encephalopathy, neurological infection, and neurological sequelae after cardiac arrest.
Abbreviations: ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; postop, postoperative respiratory failure.

www.ajcconline.org

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 J

437

250

200

150

100

50

Patients Outcomes Among the 319 patients, 269 (84%) were weaned during the first episode of mechanical ventilation. Reintubation occurred in 22 of the 319 patients (7%); 20 of these patients subsequently were weaned successfully. Overall, death occurred in 40 patients (12.5%): before weaning in 13 patients (4%), during weaning in 17 patients (5%), and more than 48 hours after successful extubation in 10 patients (3%). Noninvasive ventilatory support after extubation was implemented in 28 patients (9%). Only 3 patients (1%) self-extubated; of these, 2 required reintubation. Mechanical Ventilation and Weaning Decisions An overall total of 3986 decisions on mechanical ventilation and weaning were identified, a median of 6 decisions per patient per day of mechanical ventilation. A decision episode, as previously described, was defined as a decision that resulted in adjustment of ventilator settings. Among the 3986 decision episodes, 2790 (70%) occurred during the weaning phase of ventilation. Among the recorded decisions, 2538 (64%) were made exclusively by nurses, 693 (17%) were made exclusively by medical staff, and 755 (19%)

Method

Figure 2

Methods of weaning.
, change; , decrease; H/F, high-flow oxygen via tra-

Symbols and abbreviations:

cheostomy; PS, pressure support; PSV, pressure-support ventilation.

Table 2 Duration of intensive care unit stay and mechanical ventilation in patients who did not have cardiac surgery (n = 191)
Duration, d No. of patients 1 64 19 51 7 17 3 12 1 2 14 1.5 1.9 1.9 3.2 5.1 5.5 6.7 Intensive care unit Staya (1.5-1.5) (0.9-3.7) (1.0-3.8) (1.6-6.3) (0.4-5.7) (2.1-8.1) (0.3-12) Time to dischargeb 1.5 2.2 1.9 4.1 5.7 6.0 12.0 (1.5-1.5) (1.1-3.8) (1.0-3.8) (2.0-6.9) (5.5-7.1) (2.4-8.2) (0.3-12) Mechanical ventilation Durationa 1.5 1.0 0.7 2.0 2.3 4.2 4.9 (1.5-1.5) (0.5-2.6) (0.3-2.6) (1.0-4.9) (0.4-4.9) (1.2-6.4) (0.7-8.6) Time to weaningc 1.5 1.5 0.7 2.8 3.8 5.0 8.6 (1.5-1.5) (0.6-3.0) (0.3-3.6) (1.2-5.0) (2.3-5.2) (1.7-6.5) (0.7-8.6)

Indication Aspiration Coma Postoperative respiratory failure Trauma Heart failure Pneumonia Chronic obstructive pulmonary disease Sepsis Neuromuscular cause Acute respiratory distress syndromed Othere

6.7 (3.3-13.6) 11.8 (11.8-11.8) 15.1 (15.1-15.1) 3 (0.7-10.5)

7.6 (3.4-14.6) 11.8 (11.8-11.8) Not applicable 2.7 (1.5-3.8)

4.5 (1.8-12.2) 10.4 (10.4-10.4) 12.5 (12.5-12.5) 1.8 (0.5-3.9)

4.5 (2.6-13.4) 10.4 (10.4-10.4) Not applicable 1.7 (0.5-3.6)

a Values are median (interquartile range). b Values denote time to successful discharge from the intensive care unit in 50% of patients (25%-75%) according to analysis when data were treated as censored, with successful discharge as the outcome of interest and death as the censoring event. c Values denote time to successful weaning in 50% of patients (25%-75%) according to analysis when data were treated as censored, with successful weaning as the outcome of interest and death as the censoring event. d Data for both patients were censored because of death. e Other causes of respiratory failure include asthma, empyema, pulmonary emboli, anaphylaxis, and near-drowning.

438

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 www.ajcconline.org J

were made by collaboration. In the collaborative decisions, the patients bedside nurse discussed the situation with a medical colleague and nursing input was considered and used in the decisionmaking process. Overall, the most frequent indications for a change in ventilator settings were the process of weaning itself and the results of arterial blood gas analysis. In decisions made exclusively by nurses, results of arterial blood gas analysis and weaning were the primary indicators for changes in ventilator settings (Table 4). On the basis of the 3986 decision episodes, 4638 changes in ventilator settings were made; the most frequent were alterations in F IO 2 and changes in mode (Table 5). Nurses initiated the majority of all types of changes, from changes in mode to titration of F IO 2. A notable exception was the decision to extubate, which was predominantly collaborative. Decisions for changes in F IO 2, respiratory rate, tidal volume, and pressure support were more likely to be made by a nurse than by medical staff; the decision to adjust positive end-expiratory pressure was mostly made by medical staff. A nurse initiated the onset of weaning in 249 of the 306 patients (81%) who underwent weaning. Decisions made exclusively by nurses accounted for 896 of the 1196 decisions that occurred before the commencement of weaning (75%) and 1642 of the 2790 decisions that occurred during weaning (59%). Of the 4638 physical changes to the ventilator settings, nurses made 4518 (97%) and medical staff made 120 (3%). Ventilator settings most commonly changed by medical staff were positive end-expiratory pressure and pressure support. Decisions made by nurses, both before and during weaning, often were associated with patients whose indication for ventilation was postoperative respiratory failure, aspiration, or other causes and with patients whose duration of ventilation was 7 days or less (Table 6). In patients with predominantly respiratory disease (pneumonia, acute respiratory distress syndrome, COPD) or multiple organ dysfunction (higher SOFAmax score), decisions made exclusively by nurses were less common. However, for all indications except COPD, decisions make exclusively by nurses were more common than decisions made exclusively by medical staff or in collaboration. Decision making for patients with COPD was more collaborative, and for patients with higher SOFAmax scores, more decisions were made exclusively by medical staff (Table 6).

Table 3 Duration of weaning in patients who did not have cardiac surgery (n = 177)
Duration, median (interquartile range), d Indication Postoperative respiratory failure Coma Trauma Aspiration Heart failure Pneumonia Sepsis Chronic obstructive pulmonary disease Acute respiratory distress syndromec Neuromuscular cause Otherd
8,10,11

No. of patients 18 60 48 1 5 16 11 2 2 1 14

Without censoring a 0.5 0.8 1.2 1.5 1.7 2.7 (0.1-1.5) (0.1-2.2) (0.3-3.0) (1.5-1.5) (1.6-4.1) (1.1-6.1)

With censoring b 0.5 0.9 1.3 1.5 1.7 2.9 (0.1-1.2) (0.1-2.4) (0.4-3.3) (1.5-1.5) (1.6-3.4) (1.0-6.4)

4.1 (1.6-12.0) 4.3 8.3 (4.3-4.3) (8.3-8.3)

4.1 (1.6-12.0) 0.3 (0.3-8.4)

Not applicable 10.3 (10.3-10.3) 0.8 (0.3-2.4)

10.3 (10.3-10.3) 1.2 (0.3-2.6)

a Values were calculated without censoring for death or loss to follow-up, as done in previous studies. b Values were calculated according to time-to-event analysis, with successful weaning as the outcome and death as a censored event. c Data for both patients were censored because of death. d Other causes of respiratory failure include neoplasm, empyema, pulmonary emboli, gastrointestinal bleeding or inflammatory disease, and disturbances in cardiac rhythm.

Table 4 Indications for decision episodes (N = 3986) according to professional group


No. (%) of decisions Total (N = 3986) 1348 (34) 454 (11) 138 (3) 143 (4) 41 (1) 1395 (35) 226 (6) 241 (6) Made by nurses (n = 2538) 1114 (44) 395 (16) 112 (4) 100 (4) 20 (1) 665 (26) 25 (1) 107 (4) Made by medical staff (n = 693) 130 (19) 40 (6) 18 (3) 25 (4) 11 (2) 270 (39) 103 (15) 96 (14) Collaborative (n = 755) 104 (14) 19 (3) 8 (1) 18 (2) 10 (1) 460 (61) 98 (13) 38 (5)

Indication Arterial blood gas analysis Arterial oxygen saturation Minute ventilationa Work of breathingb Peak inspiratory pressurea Weaningc Transportd Othere

a As displayed on the ventilator. b Determined by visual assessment of increased activation of respiratory muscles. c Reduction of ventilator support made for the purposes of weaning. d Changes in ventilation required for the purposes of transporting the patient. e Other indications requiring decisions about changes in ventilator settings, including apnea, chest radiography, use of increased sedation or a paralyzing agent, worsening clinical picture, increased tidal volume, positive end-expiratory pressure recruitment maneuver, ventilator-patient dysynchrony, withdrawal of treatment, and tests for brain death.

Discussion
This study was designed to describe the role of critical care nurses in mechanical ventilation and

www.ajcconline.org

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 J

439

Table 5 Changes in ventilator settings initiated exclusively by nurses


Decisions made exclusively by nurses Total No. of changes 1725 80 296 536 60 1238 341 307 55 % (95% confidence interval) Relative riska (95% confidence interval) 86 (84-87) 78 (67-86) 75 (70-80) 68 (64-72) 50 (37-63) 50 (47-52) 47 (41-52) 1 (0.3-3) 40 (27-54) 1 0.90 (0.80-1.02) 0.88 (0.82-0.94) 0.80 (0.75-0.85) 0.58 (0.45-0.75) 0.58 (0.54-0.61) 0.54 (0.48-0.61) 0.02 (0.01-0.04) 0.47 (0.34-0.64)

Changes made in Fraction of inspired oxygen Tidal volume Rate Pressure support Inspiratory pressure Mode Positive endexpiratory pressure Extubation Otherb

No. 1480 62 223 367 30 613 159 4 22

a Relative risk of a decision being made exclusively by a nurse. b Other changes in ventilator settings included inspiratory time, automatic tube compensation, sensitivity, apnea interval, flow rate, and reintubation.

Seventy-five percent of these nurses held critical care qualification; the unit had a nurse to patient ratio of 1 to 1 for patients receiving mechanical ventilation.

weaning practices in an Australian ICU with a closed ICU model. In this setting, clinical services were delivered by trained and experienced nursing staff practicing in collaboration with house and consultant staff assigned exclusively to this ICU. In addition, the unit had no formalized protocols for mechanical ventilation and weaning and no respiratory therapists. Our results indicate that within this context, critical care nurses had a high level of responsibility for, and autonomy in, the management of mechanical ventilation and weaning. Critical care nurses were responsible for the majority of the decision episodes that resulted in a change to ventilator settings, ranging in complexity from the simple titration of F IO 2 to a decision to commence weaning. Furthermore, on the basis 8,1 0,1 1 of international norms, this type of clinical care resulted in weaning outcomes and duration of ventilation that were generally acceptable. Traditionally, decision making associated with mechanical ventilation has been the responsibility of medical staff, with nurses involved in the process but not directly responsible for the initiation of ventilator changes. 1 2- 16 Experienced nurse clinicians are well positioned to continuously monitor a patients pathophysiological parameters and rapidly intervene with alterations in ventilatory support if required.

For ICU teams to function to the best of their ability, the skills and input of each team member must be recognized. Enabling nurses to practice with a degree of autonomy in managing mechanical ventilation and weaning, as occurred in the unit in our study, acknowledges the important contribution nurses can make. 2 ,1 7- 19 Most of the published data on the clinical management of mechanical ventilation and weaning by nonphysicians describes the implementation of weaning protocols in non-Australian ICUs. Protocols have been advocated as an effective and efficient method for providing ventilatory support and timely weaning, resulting in reductions in the dura20 tion of mechanical ventilation. According to Hess, 21 these shorter durations may be due to the early recognition of a patients ability to breathe and therefore a faster reduction in ventilatory support. However, the advantage of weaning protocols in organizational settings that favor adequate numbers of skilled and experienced staff in expediting discontinuation of mechanical ventilation has been questioned. 2 2 In studies conducted in Australia, the use of both weaning 2 3 and sedation 24 protocols resulted in a prolonged duration of mechanical ventilation rather than in the dramatic reductions found in similar studies done in North America. These findings suggest that imposing a protocol that introduces multiple steps with fixed time points may not be beneficial in existing Australian practice. The nurses in our study had marked autonomy in making decisions about mechanical ventilation and practiced in an environment in which 75% of nursing staff held a tertiary-level critical care qualification and the nurse to patient ratio was 1 to 1 for patients receiving mechanical ventilation. In many Australian ICUs, nurses administer both invasive and pharmacological treatments in the context of an overall ICU management plan 25 without the direct input of medical staff. Moreover, the proportion of nurses with a postgraduate critical care qualification in Australia is higher than in other countries. 2 6 Recommendations from both the Australian Health Workforce Advisory Committee and The Australian College of Critical Care Nurses recommend that a minimum of 50% of nursing staff employed within an individual ICU have a 25 postgraduate qualification. These characteristics, including comprehensive nursing education support, independent nursing responsibilities, and excellent nurse-physician communication, have been associated with high-performance ICUs with 27 excellent outcomes for patients. Another important feature in the workforce profile of Australian ICUs is the absence of respiratory

440

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 www.ajcconline.org J

therapists. In North America, respiratory therapists, rather than critical care nurses, play a major role in managing and making decisions about mechanical 28 ventilation and weaning. Nurse to patient ratios for patients receiving ventilatory support also differ internationally. In Australia, the nurse to patient ratio for patients receiving mechanical ventilation is 1 to 1, as recommended by the minimum standards of the Australasian Joint Faculty of Intensive Care Medicine. 2 9 In contrast, the reported nurse to patient ratio in North America is 1 to 2, and the respiratory 30 therapist to patient ratio may be 1 to 8. The results 31 -3 3 of several studies suggest that greater numbers of nursing staff improve patients outcomes within the ICU environment. Conversely, increased length of stay and rates of reintubation, pneumonia, and sepsis 31 ,3 4 are associated with reduced nurse to patient ratios. Therefore, recommendations from studies done in North America may have limited application to the Australian setting because of substantial differences in workforce profile and organizational structures. In our study, the durations of ICU stay, mechanical ventilation, and weaning compare favorably with those from international reports of ventilatory support and weaning practices and from studies of 2, 4, 8,1 0, 11 ,2 0 implementation of weaning protocols. In a study 8 ,3 5 by the Mechanical Ventilation International Study Group of 412 ICUs in North America, South America, Spain, and Portugal, the median duration of mechanical ventilation was 7 days. In randomized controlled trials 3 ,2 2, 30 ,3 6 of weaning protocols, median duration of ventilation ranged from 2.8 to 4.5 days. In our study the median duration of mechanical ventilation was 1.9 days for patients who did not have cardiac surgery. Our study sample had substantially more patients receiving mechanical ventilation because of postoperative respiratory failure and coma and fewer patients because of COPD and acute respiratory distress syndrome than reported by the Mechanical 8 Ventilation International Study Group. In our study, only a few patients received mechanical ventilation because of COPD and acute respiratory distress syndrome, a situation that may have contributed to short overall durations of mechanical ventilation and ICU stay in the study cohort. However, previously reported studies 8 ,11 do not appear to have accounted for the effect of censoring due to death on the calculation of median durations of mechanical ventilation, making direct comparison of our findings with the published literature somewhat problematic. Decisions made exclusively by nurses were less common for patients receiving ventilatory support for long periods. Arguably, the short duration of

Table 6 Decisions made exclusively by nurses during mechanical ventilation


Total No. of decisions Decisions made exclusively by nurses No. % (95% confidence interval) Relative risk a (95% confidence interval)

Indication for decision Reason for ventilation Postoperative respiratory failure Aspiration Other Coma Trauma Sepsis Neuromuscular cause Pneumoniab Heart failure Acute respiratory distress syndrome Chronic obstructive pulmonary diseaseb

1009 6 214 733 986 403 63 420 66 14 72

716 5 154 475 629 228 35 233 35 7 21

71 (68-74) 83 (36-99) 72 (65-78) 65 (61-68) 64 (61-67) 56 (52-61) 56 (42-68) 55 (51-59) 53 (40-65) 50 (23-77) 29 (19-41)

1 1.17 (0.82-1.68) 1.01 (0.92-1.11) 0.91 (0.85-0.98) 0.9 (0.85-0.96) 0.8 (0.73-0.88) 0.78 (0.63-0.98) 0.78 (0.71-0.86) 0.75 (0.59-0.94) 0.70 (0.42-1.19) 0.41 (0.28-0.61)

Duration of ventilation, d 0-7 7.1-14 14.1-28 >28 SOFAmax score <12 =12c 2425 1576 1561 962 62 (60-64) 62 (59-64) 1 0.99 (0.94-1.04) 2749 1852 537 278 422 274 157 255 67 (66-69) 51 (47-55) 56 (50-62) 60 (56-65) 1 0.76 (0.69-0.83) 0.83 (0.75-0.93) 0.90 (0.83-0.97)

a Relative risk of a decision being made exclusively by a nurse. b Decision making was more collaborative (chronic obstructive pulmonary disease: relative risk 3.28, 95% confidence interval 2.58-4.18; pneumonia: relative risk 1.5, 95% confidence interval 1.21-1.85; reference (most common) category was postoperative respiratory failure). c Decisions for patients with a total maximum Sequential Organ Failure Assessment score =12 were more often made exclusively by medical staff (relative risk 1.27, 95% confidence interval 1.1-1.46).

ventilation in some patients may be in response to management practices that encourage rapid decision making and high levels of autonomous practice by clinical nursing staff. Thorens et al 1 suggest that critical care nurses help improve weaning outcomes and reduce the duration of mechanical ventilation because the nurses recognize and correct acid-base disorders, electrolyte disturbances, hypoxia, tachypnea, pain, and discomfort soon after these conditions occur. In our study, nurses use of values of

Australian nurses have significant autonomy in decision making about mechanical ventilation.

www.ajcconline.org

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 J

441

oxygen saturation and arterial blood gas analysis as a guide for changing ventilator settings supports this idea (Table 3). Of note in our study was the increase in collaborative decision making for patients who had pre18 dominantly respiratory disease. Henneman et al and Cohen et al 37 state that the most effective clinical decision making for mechanical ventilation and weaning are derived from effective communication and planning by a multidisciplinary team. The complexity of mechanical ventilation and weaning suggests that collaborative decision making by members 38 of the critical care team is advantageous. Collaborative decision making results in decisions based on more complete information, because input is obtained 39 from both nurses and physicians. Also, a collaborative team approach has been linked to improved out27 ,3 9 ,40 comes for patients in a number of studies.

management of mechanical ventilation and weaning in the absence of formalized protocols for these procedures. The generally satisfactory duration of mechanical ventilation and outcomes lend support to this Australian clinical model that promotes management of mechanical ventilation by experienced and relatively autonomous nursing clinicians in a nurse to patient ratio of 1 to 1 in collaboration with a closed ICU medical model. Further randomized controlled trials of collaborative, team-based decision making versus care based on protocols would be desirable to determine the optimal staffing and organizational structures for patients receiving mechanical ventilation in both the Australian and the international ICU setting.
ACKNOWLEDGMENTS This study was carried out in the ICU at the Royal Melbourne Hospital, Melbourne, Victoria, Australia. We thank the nursing staff of the ICU for the assistance and support they provided in this study. FINANCIAL DISCLOSURES No external financial support was provided for the study; however, research consumables and conference expenses were provided by the academic fund of the ICU of the Royal Melbourne Hospital.

Limitations
In this study we relied on bedside nursing staff to identify and categorize all ventilator decisions. Compliance with documentation of the frequency of changes in ventilator settings was checked on a twice-daily basis by inspection of the bedside clinical record and with supplementary further clarification with the bedside staff. However, the accuracy of documentation of the indication for each decision episode and the identity of the initiator and implementor of each ventilator change could not be confirmed due to the size of the ICU (24 beds) and the 24-hours-a-day nature of decision making for ventilatory support. Furthermore, the influence of the Hawthorne effect may have resulted in an increased frequency of ventilatory decisions, because ICU staff were aware that the frequency of decisions on mechanical ventilation was being documented. Another limitation of the study design was an inability to identify decisions about mechanical ventilation and weaning that did not result in a change in ventilator settings. Arguably, ventilation and weaning often require decisions that determine the current ventilatory status of a patient but do not require a change in ventilator settings. Any such decisions could not be identified in this investigation.

Unlike intensive care units in the United States, those in Australia do not include the respiratory therapist role.

eLetters
Now that youve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ajcconline.org and click Respond to This Article in either the full-text or .pdf view of the article.

SEE ALSO
To learn more about mechanical ventilation and weaning protocols, visit http://ccn.aacnjournals.org and read the article by Burns, Mechanical Ventilation of Patients With Acute Respiratory Distress Syndrome and Patients Requiring Weaning: The Evidence Guiding Practice ( Critical Care Nurse, August 2005).

Conclusion
Within this Australian ICU, critical care nurses played a prominent role in the day-to-day

REFERENCES 1. Thorens JB, Kaelin RM, Jolliet P, Chevrolet JC. Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. Crit Care Med. 1995;23(11):1807-1815. 2. Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med. 1999;159(2):439-446. 3. Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilatorassociated pneumonia. Chest. 2000;118(2):459-467. 4. Saura P, Blanch L, Mestre J, Valles J, Artigas A, Fernandez R. Clinical consequences of the implementation of a weaning protocol. Intensive Care Med. 1996;22:1052-1056. 5. Kingston ME, Krumberger JM, Peruzzi WT. Enhancing outcomes: guidelines, standards and protocols. AACN Clin Issues. 2000;11:363-374. 6. Beveridge M. Weaning: a nursing challenge. Aust J Holist Nurs. 1998;5(1):39-43.

442

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 www.ajcconline.org J

7. Lyon B. Getting back on track: nursings autonomous scope of practice. Clin Nurse Spec. 2005;19(1):28-33. 8. Esteban A, Anzueto A, Alia I, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med. 2000;161(5):1450-1458. 9. Moreno R, Vincent J, Matos R, et al. The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care: results of a prospective, multicentre study. Working Group on Sepsis related Problems of the ESICM. Intensive Care Med. 1999;25(7):686-696. 10. Esteban A, Alia I, Ibanez J, Benito S, Tobin MJ. Modes of mechanical ventilation and weaning: a national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group. Chest. 1994;106(4):1188-1193. 11. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA. 2002;28(3):345-355. 12. Norton L. The role of the specialist nurse in weaning patients from mechanical ventilation and the development of the nurse-led approach. Nurs Crit Care. 20 00;5(5):220-227. 13. Anderson J, OBrien M. Challenges for the future: the nurses role in weaning patients from mechanical ventilation. Intensive Crit Care Nurs. 1995;11(1):2-5. 14. Harris J. Weaning from mechanical ventilation: relating the literature to nursing practice. Nurs Crit Care. 2001;6(5):226-231. 15. Fulbrook P, Delaney N, Rigby J, et al. Developing a network protocol: nurse-led weaning from ventilation. World Crit Care Nurs. 20 03;3(2):28-37. 16. De D. Clinical skills: a care plan approach to nurse-led extubation. Br J Nurs. 2004;13(18):1086-1090. 17. Horst HM, Mouro D, Hall-Jenssens RA, Pamukov N. Decrease in ventilation time with a standardized weaning process. Arch Surg. 1998;133(5):483-489. 18. Henneman E, Dracup K, Ganz T, Molayeme O, Cooper CB. Using a collaborative weaning plan to decrease duration of mechanical ventilation and length of stay in the intensive care unit for patients receiving long-term ventilation. Am J Crit Care. 2002;11(2):132-140. 19. Burns SM. The long-term mechanically ventilated patient: an outcomes management approach. Crit Care Nurs Clin North Am. 1998;10(1):87-99. 20. Ely EW, Meade MO, Haponik EF, et al. Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines. Chest. 2001;120(6 suppl):454S-463S. 21. Hess DR. Liberation from mechanical ventilation: weaning the patient or weaning old-fashioned ideas? Crit Care Med. 2002;30(9):2154-2155. 22. Krishnan JA, Moore D, Robeson C, Rand CS, Fessler HE. A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation. Am J Respir Crit Care Med. 2004;169(6):673-678. 23. Keogh S, Courtney M, Coyer F. Weaning from ventilation in paediatric intensive care: an intervention study. Intensive Crit Care Nurs. 2003;19(4):186-197. 24. Elliot R, McKinley S, Aitken L. A sedation guideline does not reduce duration of ventilation in an Australian ICU [abstract]. Aust Crit Care. 20 05;18(4):167. 25. Australian Health Workforce Advisory Committee. The Critical Care Nurse Workforce in Australia 2001-2011. Sydney,

Australia: New South Wales Health Dept; 2002. AHWAC report 2002.1. 26. McCormick J, Blackwood B. Nursing the ARDS patient in the prone position: the experience of qualified ICU nurses. Intensive Crit Care Nurs. 20 01;17:331-334. 27. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensi ve care in major medical centers. Ann Intern Med. 1986;104(3):410-418. 28. Soo Hoo GW, Park L. Variations in the measurement of weaning parameters: a survey of respiratory therapists. Chest. 2002;121(6):1947-1955. 29. Joint Faculty of Intensive Care Medicine. Minimum standards for intensive care units. http://www.jficm.anzca.edu.au/pdfdocs /ic1_2003.pdf. Joint Faculty of Intensive Care Medicine; review IC-1. Published 2003. Accessed June 3, 2007. 30. Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med. 1997;25(4):567-574. 31. Dimick JB, Swoboda SM, Provonost PJ, Lipsett PA. Effect of nurse-to-patient ratio in the intensive care unit on pulmonary complications and resource use after hepatectomy. Am J Crit Care. 2001;10(6):376-382. 32. Tarnow-Mordi W, Hau C, Warden A, Shearer A. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet. 2000;356:185-189. 33. Dang D, Johantgen M, Provonost P, Jenckes M, Bass E. Postoperative complications: does intensive care unit staff nursing make a difference? Heart Lung. 2002;31(3):219-228. 34. Amaravadi R, Dimick J, Provonost P, Lipsett P. ICU nurse-topatient ratio is associated with complication and resource use after esophagectomy. Intensive Care Med. 2000;26:1857-1862. 35. Branson RD, Durbin CG Jr. Invasive mechanical ventilation in adults: implementation, management, weaning, and follow-up. Respir Care. 2002;47(3):247-248. 36. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335(25): 1864-1869. 37. Cohen IL, Bari N, Strosberg MA, et al. Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team. Crit Care Med. 1991;19(10):1278-1284. 38. Henneman E, Dracup K, Ganz T, Molayeme O, Cooper C. Effect of a collaborative weaning plan on patient outcome in the critical care setting. Crit Care Med. 2001;29(2):297-303. 39. Baggs J, Schmitt M, Mushlin A, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med. 1999;27:1991-1998. 40. Wheelan S, Burchill C, Tilin F. The link between teamwork and patients outcomes in intensive care units. Am J Crit Care. 2003;12:527-534.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

www.ajcconline.org

AC C AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5 J

443

CE Test Test ID A071605: Decisions Made By Critical Ca re Nurses During Me chanical Ventilation and Wean ing in a n Australian Intensive
Care Unit. Learning objectives: 1. Describe the role of critical care nurses in the management of mechanical ventilation. 2. Discuss critical care nurses decision-making role in weaning mechanically ventilated patients. 3. Identify advantages found in this study of critical care nurses managing mechanically ventilated patients.
1. Which of the following best describes the methods used in this study? a. An 8-month concurrent study conducted in a 24-bed adult intensive care unit (ICU); all clinical decisions related to mechanical ventilation were determined b. A 3-month concurrent study in a 35-bed adult ICU; all respiratory decisions related to mechanical ventilation were determined c. A 3-month prospective cohort study in a 24-bed adult ICU; all clinical decisions related to mechanical ventilation were determined d. An 8-month prospective cohort study in a 24-bed adult ICU; all respiratory decisions related to mechanical ventilation were determined 2. Which of the following statements best describes the purpose of this study? a. To describe the role of the critical care nurse in making decisions about mechanical ventilation and weaning b. To describe a protocol for mechanical ventilation and weaning management c. To describe the development of the collaborative relationships between critical care nurses and physicians d. To describe the problems associated with critical care nurses using protocols to manage mechanically ventilated patients 3. What is a decision episode? a. A written or verbal order from the physician b. A collaborative decision made with the respiratory therapist to extubate the patient c. A point along the protocol during which the critical care nurse must document what action was taken d. Any event that resulted in an adjustment to a patients ventilator settings 4. Which of the following was not an indication for changing ventilator settings? a. Arterial blood gas analysis results b. Observed work of breathing c. Increased heart rate d. Weaning 5. Which of the following was not a decision category? a. Decision made exclusively by respiratory therapist b. Decision made exclusively by the physician c. Decision made exclusively by the nurse d. Decision made collaboratively 6. Which of the following was not pa rt of the categorica l data set? a. Sex b. Physician c. Diagnostic category d. Weaning methods 7. Which of the following best describes the demographic characteristics? a. 474 patients admitted during a 106-day study period with 87% receiving mechanical ventilation b. 346 patients admitted during an 81-day study period with 67% receiving mechanical ventilation c. 346 patients admitted during a 106-day study period with 87% receiving mechanical ventilation d. 474 patients admitted during an 81-day study period with 67% receiving mechanical ventilation 8. What were the most frequent indications for starting mecha nical ventilation? a. Surgery, respiratory failure, and trauma b. Respiratory failure, coma, and trauma c. Coma, trauma, and stroke d. Surgery, stroke, and trauma 9. What wa s the median duration of ventilation for the noncardiac surgery patients? a. 1.9 days b. 1.8 days c. 2.1 days d. 2.8 days 10. What percent age of decision episodes occurred during the weaning phase of mechanica l vent ilation? a. 47% b. 70% c. 17% d. 64% 11. What is the recommended nurse to patient ratio by the Australian and New Zealand Joint Faculty of Intensive Care? a. 1 to 3 b. 1 to 1 c. 1 to 4 d. 1 to 2 12. Which statement best describes why collaborative decisions are linked to improved outcomes for patients? a. They are based on more complete information. b. They are required by the Australian Hospital Authority. c. Those that lead to disagreements should be mediated by the nursing supervisor. d. They also should include the familys input.

Test ID: A0716042 Contact hours: 2.0 Form expires: September 1, 2009. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

1. K a Kb Kc Kd

2. K a Kb Kc Kd

3. K a Kb Kc Kd

4. K a Kb Kc Kd

5. K a Kb Kc Kd

6. K a Kb Kc Kd

7. K a Kb Kc Kd
Name

8. K a Kb Kc Kd

9. K a Kb Kc Kd

10. K a Kb Kc Kd

11. K a Kb Kc Kd

12. K a Kb Kc Kd

Fee: AACN members, $0; nonmembers, $12 Passing score: 9 correct (75%) Category: A, Synergy CERP A Test writer: Diane Byrum, RN ,

MS N, C CR N, C CNS , F C CM

Program evaluation
Yes No Objective 1 was met KK Objective 2 was met KK Objective 3 was met KK Content was relevant to my nursing practice KK My expectations were met KK This method of CE is effective for this content KK The level of difficulty of this test was: K easy K medium Kdifficult To complete this program, it took me hours/minutes.

Member #

Address City Country RN License #1 RN License #2 Payment by: Card # Signature K Visa KM/C KAMEX K Check Expiration Date Phone E-mail address State State State ZIP

For faster processing, take this CE test online at www.ajcconline.org (CE Articles in This Issue) or mail this entire page to: AACN, 101 Columbia, Aliso Viejo, CA 92656.

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

Das könnte Ihnen auch gefallen