Effects of Respiratory-Therapist Driven Protocols on House-Staff Knowledge and Education of Mechanical Ventilation

[The Respiratory Therapist in Neurology An Evolving Specialization in Germany]

In Germany, nurses, physiotherapists and speech and language therapists follow a qualifying training for about 1,5 years to become respiratory therapists (RTs). With respect to neurological illness, RTs diagnose and treat disorders of respiration, cough and swallowing as well as a retention of tracheobronchial secretions. There is an increasing demand for RTs in neurology, in neurointensive care and in neurological and neurosurgical early rehabilitation. The certification of specialized centers for weaning in neurological and neurosurgical early rehabilitation was introduced by the German Society for Neurorehabilitation (DGNR) in 2021. As a certification criterion it includes the employment of a respiratory therapists. In neurological organizations treating critically and severely ill patients, RTs work at an important interdisciplinary intersection of physicians, nurses and therapists. RTs are qualified to train teams, patients and family caregivers and to establish care structures for critically and severely ill neurological patients. Due to the complexity of neurological illnesses RTs working in neurological institutions need specific qualification. Specific training for RTs in neurology and neurorehabilitation might improve care for critically and severely ill neurological patients. Further professionalization of RT in Germany requires standardizing curricula, a professional society for RTs and, finally, academization.

[Impact of a continuous education program on the quality of assistance offered by intensive care physiotherapy]

Objective

To evaluate the role of quality indicators and adverse events registering in the quality assessment of intensive care physiotherapy and to evaluate the impact of implementing protocolized care and professional training in the quality improvement process.

Methods

A prospective before-after study was designed to assess 15 indicators of the quality of care. Baseline compliance and adverse events were collected before and after the implementation of treatment protocols and staff training.

Results

Eighty-nine patients admitted, being 48 in the pre-intervention period and 41 in the post-intervention period with a total of 1246 and 1191 observations respectively. Among the indicators related to the global population, there was a significant improvement in chest x-ray control, multidisciplinary rounds and shift changes as well as in compliance with these decisions. Indicators related to the population under mechanical ventilation, obtained by direct observation at bedside, showed a significant improvement in the compliance with the tidal volume of 6-8mL/Kg, plateau pressure <30cmH₂O, adequate mechanical ventilation alarm setting, mechanical ventilation humidification control, adequate humidification line exchange and orotracheal tube position. Among the mechanical ventilation indicators collected through the physiotherapy records, there was significantly improved compliance with the predicted tidal volume registry and cuff pressure registry. There was a significant reduction in the number of adverse events. There was no impact on intensive care unit mortality, length of stay, duration of mechanical ventilation and ventilator-free days.

Conclusion

It is possible to measure the quality of physiotherapy care using indicators of quality control. The implementation of care protocols and training of the professionals can improve team performance.

Default options in the ICU: widely used but insufficiently understood

PURPOSE OF REVIEW

Default options dramatically influence the behavior of decision makers and may serve as effective decision support tools in the ICU. Their use in medicine has increased in an effort to improve efficiency, reduce errors, and harness the potential of healthcare technology.

RECENT FINDINGS

Defaults often fall short of their predicted influence when employed in critical care settings as quality improvement interventions. Investigations reporting the use of defaults are often limited by variations in the relative effect across sites. Preimplementation experiments and long-term monitoring studies are lacking.

SUMMARY

Defaults in the ICU may help or harm patients and clinical efficiency depending on their format and use. When constructing and encountering defaults, providers should be aware of their powerful and complex influences on decision making. Additional evaluations of the appropriate creation of healthcare defaults and their resulting intended and unintended consequences are needed.

Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review

OBJECTIVE

Since publication of the Respiratory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) trial in 2000, use of tidal volume (VT) less than or equal to 6 mL/kg predicted body weight with corresponding plateau airway pressures (PPlat) less than or equal to 30 cm H2O has been advocated for acute lung injury. However, compliance with these recommendations is unknown. We therefore investigated VT (mL/kg predicted body weight) and PPlat (cm H2O) practices reported in studies of acute lung injury since ARMA using a systematic literature review (i.e., not a meta-analysis).

DATA SOURCES

PubMed, Scopus, and EMBASE.

STUDY SELECTION

Randomized controlled trials and nonrandomized studies enrolling patients with acute lung injury from May 2000 to June 2013 and reporting VT.

DATA EXTRACTION

Whether the study was a randomized controlled trial or a nonrandomized study and performed or not at an Acute Respiratory Distress Syndrome Network center; in randomized controlled trials, the pre- and postrandomization VT (mL/kg predicted body weight) and PPlat (cm H2O) and whether a VT protocol was used postrandomization; in nonrandomized studies, baseline VT and PPlat.

DATA SYNTHESIS

Twenty-two randomized controlled trials and 71 nonrandomized studies were included. Since 2000 at acute respiratory distress syndrome Network centers, routine VT was similar comparing randomized controlled trials and nonrandomized studies (p = 0.25) and unchanged over time (p = 0.75) with a mean value of 6.81 (95% CI, 6.45, 7.18). At non-acute respiratory distress syndrome Network centers, routine VT was also similar when comparing randomized controlled trials and nonrandomized studies (p = 0.71), but decreased (p = 0.001); the most recent estimate for it was 6.77 (6.22, 7.32). All VT estimates were significantly greater than 6 (p ≤ 0.02). In randomized controlled trials employing VT protocols, routine VT was reduced in both acute respiratory distress syndrome Network (n = 4) and non-acute respiratory distress syndrome Network (n = 11) trials (p ≤ 0.01 for both), but even postrandomization was greater than 6 (6.47 [6.29, 6.65] and 6.80 [6.42, 7.17], respectively; p ≤ 0.0001 for both). In 59 studies providing data, routine PPlat, averaged across acute respiratory distress syndrome Network or non-acute respiratory distress syndrome Network centers, was significantly less than 30 (p ≤ 0.02).

CONCLUSIONS

For clinicians treating acute lung injury since 2000, achieving VT less than or equal to 6 mL/kg predicted body weight may not have been as attainable or important as PPlat less than or equal to 30 cm H2O. If so, there may be equipoise to test if VT less than or equal to 6 mL/kg predicted body weight are necessary to improve acute lung injury outcome.

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover

OBJECTIVE

To use a handover assessment tool for identifying patient information corruption and objectively evaluating interventions designed to reduce handover errors and improve medical decision making. The continuous monitoring, intervention, and evaluation of the patient in modern intensive care unit practice generates large quantities of information, the platform on which medical decisions are made. Information corruption, defined as errors of distortion/omission compared with the medical record, may result in medical judgment errors. Identifying these errors may lead to quality improvements in intensive care unit care delivery and safety.

DESIGN

Handover assessment instrument development study divided into two phases by the introduction of a handover intervention.

SETTING

Closed, 17-bed, university-affiliated mixed surgical/medical intensive care unit.

SUBJECTS

Senior and junior medical members of the intensive care unit team.

INTERVENTIONS

Electronic handover page.

MEASUREMENTS AND MAIN RESULTS

Study subjects were asked to recall clinical information commonly discussed at handover on individual patients. The handover score measured the percentage of information correctly retained for each individual doctor-patient interaction. The clinical intention score, a subjective measure of medical judgment, was graded (1-5) by three blinded intensive care unit experts. A total of 137 interactions were scored. Median (interquartile range) handover scores for phases 1 and 2 were 79.07% (67.44-84.50) and 83.72% (76.16-88.37), respectively. Score variance was reduced by the handover intervention (p < .05). Increasing median handover scores, 68.60 to 83.72, were associated with increases in clinical intention scores from 1 to 5 (chi-square = 23.59, df = 4, p < .0001).

CONCLUSIONS

When asked to recall clinical information discussed at handover, medical members of the intensive care unit team provide data that are significantly corrupted compared with the medical record. Low subjective clinical judgment scores are significant associated with low handover scores. The handover/clinical intention scores may, therefore, be useful screening tools for intensive care unit system vulnerability to medical error. Additionally, handover instruments can identify interventions that reduce system vulnerability to error and may be used to guide quality improvements in handover practice.

Preprinted order sets as a safety intervention in pediatric sedation

OBJECTIVES

Implement preprinted packets for pediatric procedural sedations to increase documentation compliance and decrease medication ordering errors.

STUDY DESIGN

Retrospective chart review of pediatric inpatients undergoing procedural sedation before and after implementation of a preprinted packet including an order set, consent form, and sedation monitoring form. Patient charts before and after the intervention were reviewed for completeness of medical documentation, correct medication dosages, and adverse events. Chi2 or Fisher exact test was used to determine preintervention vs postintervention differences.

RESULTS

Forty-two charts preintervention and 42 postintervention were reviewed. Documentation compliance increased on consent forms (P < .001), procedure notes (P = .113), and sedation monitoring forms (P = .003), while dating and timing of order forms decreased. Ordering of resuscitation equipment (P = .12), documentation of American Society of Anesthesiologists' (ASA) physical status classification (P < .001) and allergies (P < .001), and postsedation orders (P < .001) also increased. Medications ordered using unit/kg increased 43% (P < .05). Medication ordering errors for sedation agents decreased 64% (P < .001). Ordering of appropriate reversal agents increased 73% (P = .02).

CONCLUSIONS

Implementing preprinted physician orders, consent forms, and prepared packets increased documentation compliance and ordering of reversal agents and resuscitation equipment. Medication dosage ordering errors decreased.