Decisional responsibility for mechanical ventilation and weaning: an international survey

Abstract

IntroductionOptimal 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.MethodsA 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.ResultsResponse 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.ConclusionsCollaborative 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.

Early rehabilitation in the intensive care unit: An integrative literature review

“…36 Potential implications of a lack of collaborative decision making for ventilator weaning include delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation. 37 Furthermore, nurse led ventilation weaning protocols that include spontaneous breathing trials have resulted in shorter time to extubation when compared to physician led weaning. 38,39 The literature clearly establishes that long term positive functional outcomes for the critically ill are possible with early physical exercise.…”

Role Responsibilities in Mechanical Ventilation and Weaning in Pediatric Intensive Care Units: A National Survey

“…Although adjustment of FIO 2 is important in maintaining optimal oxygenation during mechanical ventilation, weaning requires modification of additional settings such as respiratory rate, inspiratory pressure, and pressure support; in this respect, nurse involvement was minimal. The low prevalence (18%) of nurse-led weaning protocols in UK PICUs may partially explain why nurses infrequently adjusted settings, and although 18% is low compared with the prevalence in adult ICUs (54%), 20 the prevalence of nurse-led weaning protocols in UK PICUs has increased 13% since a survey in 2000. 2 Nurse managers also reported limited use of automated systems (18% of PICUs); automated systems are used in 55% of adult ICUs.…”

“…2 Nurse managers also reported limited use of automated systems (18% of PICUs); automated systems are used in 55% of adult ICUs. 20 A possible reason for the ongoing low prevalence of use of weaning protocols and automated systems in PICUs is that less evidence is available that shows beneficial effects of these strategies in children. 22 We anticipate the forthcoming findings from 2 Cochrane systematic reviews and meta-analyses of protocolized weaning in children 23 and automated closed loop systems 24 will provide clinicians with evidence-based information on the effectiveness of these interventions in optimizing clinical practice.…”

“…20 Wording was adapted and the questionnaire was validated for the UK pediatric setting by using a panel of 4 interprofessional pediatric experts who assessed clinical sensibility as recommended by Burns and colleagues. 21 In addition to demographic questions about the hospital and ICU type, the questionnaire (see Appendix) contained 18 items addressing the primary and secondary objectives:…”

Weaning From Mechanical Ventilation: A Scoping Review of Qualitative Studies

“…For example, differences exist in nurse and physician staffing models, specialty education for nurses, decision-making hierarchy, and assignment of roles and responsibilities for weaning. 56,57 Perceptions of nurses' experience and competence were key themes related to physicians' perspectives Most studies with a focus on patients were appropriately phenomenological, and the focus was lived experience of being weaned from mechanical ventilation. These studies elucidated the extreme physical and psychological challenges of weaning and underscored how horrible the experience can be for patients, regardless of how well weaning proceeds clinically.…”