Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation

Slow and Steady: Optimizing Intensive Care Unit Treatment Weans for Children with Chronic Critical Illness

Pediatric chronic critical illness (PCCI) is characterized by prolonged and recurrent hospitalizations, multiorgan conditions, and use of medical technology. Our prior work explored the mismatch between intensive care unit (ICU) acute care models and the chronic needs of patients with PCCI. The objective of this study was to examine whether the number and frequency of treatment weans in ICU care were associated with clinical setbacks and/or length of stay for patients with PCCI. A retrospective chart review of the electronic medical record for 300 pediatric patients with PCCI was performed at the neonatal intensive care unit, pediatric intensive care unit, and cardiac intensive care unit of two urban children's hospitals. Daily patient care data related to weans and setbacks were collected for each ICU day. Data were analyzed using multilevel mixed multiple logistic regression analysis and a multilevel mixed Poisson regression. The patient-week level adjusted regression analysis revealed a strong correlation between weans and setbacks: three or more weekly weans yielded an odds ratio of 3.35 (95% confidence interval [CI] = 2.06–5.44) of having one or more weekly setback. There was also a correlation between weans and length of stay, three or more weekly weans were associated with an incidence rate ratio of 1.09 (95% CI = 1.06–1.12). Long-stay pediatric ICU patients had more clinical setbacks and longer hospitalizations if they had more than two treatment weans per week. This suggests that patients with PCCI may benefit from a slower pace of care than is traditionally used in the ICU. Future research to explore the causative nature of the correlation is needed to improve the care of such challenging patients.

The Effect of Nursing Interventions Based on Burns Wean Assessment Program on Successful Weaning from Mechanical Ventilation: A Randomized Controlled Clinical Trial

Background:

The effective design and implementation of the nursing interventions to evaluate the patients' readiness for ventilator weaning will reduce their connection time to the ventilator and the complications of their connection to it. This study was conducted to examine the effect of nursing interventions based on the Burns Wean Assessment Program (BWAP) on successful weaning from Mechanical Ventilation (MV).

Materials and Methods:

In this clinical trial, 70 patients undergoing MV in the Intensive Care Units (ICUs) of Golestan Hospital (Ahvaz, Iran) in 2018 were randomly assigned to intervention and control groups. The nursing interventions designed based on BWAP were implemented on the patients in the intervention group, who were later weaned from the device according to this program. The recorded data included demographic information, BWAP score, vital signs, and laboratory values, which were analyzed using the Pearson correlation coefficient, Chi-Square, Fisher, and Mann-Whitney U tests.

Results:

There was a statistically significant and inverse correlation between the BWAP score and the MV duration such that a high BWAP score was associated with a shorter MV time (p = 0.041). Also, the mean number of re-intubation (p = 0.001) and the number of re-connection to the ventilator in the intervention group were significantly lower (p = 0.005).

Conclusions:

The results showed that nurses' assessment of patient's readiness for weaning from MV based on this tool and designed nursing care reduced the duration of MV, re-intubation, and re-connection.

Value of modified Burns Wean Assessment Program scores in the respiratory intensive care unit: an Egyptian study

Background

There is no consensus on the most useful predictive indicator for weaning patients from mechanical ventilation (MV). We aimed to evaluate the utility of the modified Burns Wean Assessment Program (m-BWAP) in predicting the weaning success in patients with respiratory disorders admitted to the respiratory intensive care unit (RICU).

Methods

Patients with respiratory failure requiring MV for longer than 48 hours were included. They were weaned by pressure support ventilation and spontaneous breathing trails. Patients were divided into successful and unsuccessful weaning groups according to their outcomes.

Results

A total of 91 patients were enrolled. The majority had chronic obstructive pulmonary diseases (COPD): 40%, overlap syndrome (24%), and obesity hypoventilation syndrome (OHS): 15%. The successful group had significantly higher m-BWAP scores than that in the unsuccessful group (median 65; range 35 to 80 vs. median 45; range 30 to 65; p=0.000), with area under the curve (AUC) of 0.854; 95% CI 0.766 to 0.919), p<0.001. At cut-off value of ≥55, the sensitivity and specificity of m-BWAP to predict successful weaning were 73.77% and 84.85%, respectively. The AUC for m-BWAP was significantly higher than that for rapid shallow breathing index (RSBI).

Conclusion

We conclude that m-BWAP scores represent a good predictor of weaning success among patients with chronic respiratory disorders in the RICU. The m-BWAP checklist has many factors that are closely related to the weaning outcomes of patients with chronic respiratory disorders. Further, large-scale, multicenter studies are warranted.

Slow and Steady: A Systematic Review of ICU Care Models Relevant to Pediatric Chronic Critical Illness

There is a growing population of children with prolonged intensive care unit (ICU) hospitalization. These children with chronic critical illness (CCI) have a high health care utilization. Emerging data suggest a mismatch between the ICU acute care models and the daily care needs of these patients. Clinicians and parents report that the frequent treatment alterations typical for ICU care may be interrupting and jeopardizing the slow recoveries typical for children with CCI. These frequent treatment titrations could therefore be prolonging ICU stays even further. The aim of this study is to evaluate and summarize existing literature regarding pace and consistency of ICU care for patients with CCI. We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (of September 2018). PubMed (biomedical and life sciences literature), Excerpta Medica database (EMBASE), and The Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for English-language studies with data about CCI, care models, and pacing of clinical management. Four unique papers were identified. Our most important finding was that quality data on chronic ICU management, particularly for children, is sparse. All papers in this review confirmed the unique needs of chronic patients, particularly related to respiratory management, which is a common driver of ICU length of stay. Taken together, the papers support the hypothesis that protocols to reduce interdisciplinary management variability and to allow for slower management pacing should be studied for their impact on patient and health system outcomes. Optimizing value in ICU care requires mapping of resources to patient needs, particularly for patients with the most intense resource utilization. For children with CCI, parents and clinicians report that rapid treatment changes undermine recovery and prolong ICU stays. This review highlights the lack of quality pediatric research in this area and supports further investigation of a "slow and steady" approach to ICU management for children with CCI.

Comparison between a nurse-led weaning protocol and weaning based on physician's clinical judgment in tracheostomized critically ill patients: a pilot randomized controlled clinical trial

Background

Weaning protocols expedite extubation in mechanically ventilated patients, yet the literature investigating the application in tracheostomized patients remains scarce. The primary objective of this parallel randomized controlled pilot trial (RCT) was to assess the feasibility and safety of a nurse-led weaning protocol (protocol) compared to weaning based on physician’s clinical judgment (control) in tracheostomized critically ill patients.

Results

We enrolled 65 patients, 27 were in the protocol group and 38 in the control group. Of 27 patients in the protocol group, 1 (3.7%) died in the ICU, 24 (88.9%) were successfully weaned from tracheostomy, and 2 (7.4%) were transferred still on the ventilator. Of 38 patients in the control group, 2 (5.3%) died in the ICU, 22 (57.9%) were successfully weaned from tracheostomy, and 14 were transferred still on the ventilator (36.8%). Risk of being discharged from the ICU on the ventilator was higher in the control group (relative risk: 1.5, IC 95% 1.14–2.01). Concerning safety and feasibility, no patients were excluded after randomization. There was no crossover between the two study arms nor missing data, and no severe adverse event related to the study protocol application was recorded by the staff. Weaning time and rate of successful weaning were not different in the protocol group compared to the control group (long-rank test, p = 0.31 for MV duration, p = 0.45 for weaning time). Based on our results and assuming a 30% reduction of the weaning time for the protocol group, 280 patients would be needed for a RCT to establish efficacy.

Conclusions

In this pilot RCT we demonstrated that a nurse-led weaning protocol from tracheostomy was feasible and safe. A larger RCT is justified to assess efficacy.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0354-1) contains supplementary material, which is available to authorized users.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

A systematic review of the experiences of adult ventilator-dependent patients

OBJECTIVES

The objective of this meta-synthesis study was to describe the nature of the experience of adult ventilator-dependent patients.

INCLUSION CRITERIA

This review considered studies utilized qualitative methods to examine the experience of adult with ventilator. The phenomena of interest were experiences of patients who were treated with ventilator for both short term and long term in ICU settings or home settings. The research was limited to studies published in Chinese or in English language.

SEARCH STRATEGY

The searching strategy sought to find both published and unpublished studies. The CINAHL, PubMed, MEDLINE, Cochrane Library, Chinese Periodicals Index and JIB website were used to search the articles. The preliminary keywords were drawn from the natural language terms of the topic, in the title, abstract and subject descriptors.

METHODOLOGICAL QUALITY

Each paper was assessed independently by two reviewers for methodological quality. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument were used to appraisal the methodological quality of the articles. Any disagreements that arose between the reviewers were resolved through discussion with a third reviewer.

DATA SYNTHESIS

Qualitative research findings were pooled and the data analysis process involved synthesizing findings to generate a set of statements that represent the nature of the experiences of ventilator-dependent adult patients. The categories and themes/meta-syntheses were emerged from the analysis process.

RESULTS

A total of 997 papers were identified from various database and hand searches. Nineteen papers were critically appraised and 15 met inclusion criteria. Four papers were excluded because they did not meet the inclusion criteria. Five themes/meta-syntheses emerged from the analysis: 1). The feelings of fear due to being dependent on ventilator and the loss of control of life, 2). Disconnection with reality, 3). Impaired embodiment (body image and body boundary), 4). Construction of coping patterns, 5). Trust and caring relationship.

CONCLUSION

The five themes/meta-syntheses derived from the review represent the patients' experiences in regarding the threatening of the integrity of self, self-other and self-environment relationships, the coping patterns and resilient resources to maintain their self-identify and the meaning of life. These findings also illustrate the resiliency factors for those patients to cope with this stressful situation.The implications to practice include enhancing the trust relationship with health professionals, as well as the nursing actions prior to suction, during the suction procedure and post suction in related to release their psychological distress and empower their resilience factors was suggested.Furthermore, the further research could focus on the development and implementation of support programs for the patients, families, and health professionals, as well as the research regarding the reduction of psychological distress and empower the coping patterns.

Ventilatory weaning: a case study of protracted weaning

BACKGROUND

Dysfunctional ventilatory weaning response (DVWR) is characterized by interrupted and prolonged weaning. This reflective analysis presents how using nursing diagnoses in critical care can raise awareness of, and provide strategies for, managing problems related to ventilatory weaning.

AIM

To examine and reflect upon why one patient took so long to wean from the ventilator using the structured approach of instrumental case study and nursing diagnosis to explain aspects of the weaning process.

ANALYSIS

This case study examines one patient's experiences around ventilatory weaning using selected nursing diagnoses, exploring the implications that physiological, social, emotional and psychological factors have on both weaning and healing processes in critical care. By using dialogue, an explicit texture is presented of how one patient felt, with particular resonance to the relationships she had and the impact they made. Various nursing diagnoses proved useful in determining why this patient had an extended weaning trajectory and included DVWR, ineffective breathing pattern, impaired spontaneous ventilation, anxiety and impaired verbal communication. There were specific points of interest, in particular her anxiety, which proved a major factor, and her significantly improved functional status after the critical care episode. A DVWR may be minimized by nursing presence, reassurance and respect for patient autonomy. Complex anatomy and physiology contributes to protracted weaning and a DVWR and is compounded by anxiety. Furthermore, there is a significant element of nursing care, timely reassurance and presence, which can have a positive impact on patient well-being.

CONCLUSIONS

This reflective analysis highlights the benefits and importance of the nurse-patient relationship during what was a very protracted ventilatory wean. This shared trajectory enabled significant patient empowerment, and this case study gives the patient the voice she temporarily lost.

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

AIM AND OBJECTIVE

To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP).

METHOD

Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge SM. We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications.

RESULTS

The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested.

CONCLUSION

Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes.

[Septic shock: from recommendations to bedside]

Management of septic shock requires complex and multiple diagnostic as well as therapeutic procedures in a limited time-frame. This issue is a major source of medical errors. The author presents a critical analysis of tools (guidelines, clinical path, algorithm, check-lists) to help physicians for the management of patients with septic shock.

Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care

AIMS

To describe the actual clinical activities undertaken by a critical care nurse consultant in an eight-bedded adult surgical high dependency unit within a large NHS Teaching Hospitals NHS Trust.

BACKGROUND

In the United Kingdom, the first critical care nurse consultants were approved in 2000 following the Department of Health's (1999) revised career structure for nurses. Expert practice is a core function of the role although the nature of expert practice in the context of critical care is unclear. Expert practice is often deemed to be a feature of advanced practice and although a number of studies have investigated this in context of critical care, there is little insight into the nature of advanced practitioners' clinical practice and how it might influence patient outcome.

DESIGN METHODS

A diary was used by a critical care nurse consultant to record activity during scheduled clinical sessions. Data were collected for four months: 39 sessions were evaluated. Qualitative data were content analysed and coded into categories. Clinical activities were coded, categorized and analysed using SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA).

FINDINGS

Clinical activities included direct care activities, clinical leadership, education and training. Two main themes emerged from the qualitative data and were categorized as clinical reasoning and clinical instruction. Clinical activities arising from clinical reasoning and clinical instruction were aimed at minimizing risk and the provision of quality care. In doing this, one of the outcomes was the detection and resolution of untoward clinical occurrences.

CONCLUSION

The level of achievement--or end point--of clinical activities was that the patient was established in 'a state free from risk or harm that optimises rehabilitation'. 'A state free from risk or harm that optimizes rehabilitation' might be one outcome reflecting the needs of individual critically ill patients that is sensitive to individual nursing contribution.

RELEVANCE TO CLINICAL PRACTICE

There is increasing pressure on health-care professionals to identify and measure their individual impact on the outcome of patients. This study adds further insight into the complexities associated with evaluating the influence of individual contribution on patient outcome, especially when it is characterized by complex processes involving clinical judgement and decision-making.

Issues in weaning from mechanical ventilation: literature review

AIM

The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation.

BACKGROUND

Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process.

METHOD

In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations.

DISCUSSION

Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level.

CONCLUSION

Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.

Long-term mechanical ventilation in a critical care unit: existing in an uneveryday world

AIM

This paper reports a study to describe and interpret the meaning of being on long-term mechanical ventilation.

BACKGROUND

Patients who require mechanical ventilation in a critical care unit for prolonged periods of time are typically sicker than those who are ventilated for shorter periods. Despite advances in treatment modalities for critically ill patients, many still require long-term mechanical ventilation for 7 days or more. Therefore, caring for a long-term ventilated patient is often an everyday occurrence for critical care nurses; however, there is insufficient evidence of the meaning of this experience from a patient perspective.

METHOD

We used an ontological phenomenological approach informed by the ideas of Heidegger. Data were collected using unstructured audio-taped interviews with nine former patients from critical care units unit in Queensland, Australia. The data were collected between January 2000 and December 2001 and analysed thematically using the method developed by van Manen.

FINDINGS

Thematic analysis revealed four themes. This paper presents the findings from the theme titled 'existing in an uneveryday world', which revealed what it meant for participants to exist, live through and survive the many physiological and psychological effects arising from their critical illness episode. For the most part, this was an unpleasant and frightening experience that involved bizarre nightmares and inability to distinguish time, place and the familiar body; disagreeable effects from the technology used and patient care activities; and reliance on external agents for survival. In addition, participants reported how they questioned their chances of surviving the critical illness ordeal.

CONCLUSION

There is a need for further research in the areas of sedative and analgesic management in critically ill patients, methods of communicating with intubated and mechanically ventilated patients, and debriefing and follow-up support services for survivors.

Methodological issues in evaluating complex healthcare interventions

AIM

This paper outlines the difficulties in defining and evaluating a complex intervention and a number of currently available models for assisting this process are discussed.

BACKGROUND

Interventions aimed at producing change in the delivery and organization of healthcare services require rigorous evaluation to demonstrate their effectiveness. Evaluation poses difficulties, however, because these interventions are usually very complex.

METHODS

A framework developed by the United Kingdom Medical Research Council to evaluate complex interventions is described. The use of this framework in designing and evaluating a nurse-led intervention in intensive care for weaning patients from mechanical ventilation is discussed. Semi-structured interviews, a questionnaire survey and observational work were undertaken to define the components of the intervention, which was subsequently evaluated in an exploratory trial using a quasi-experimental design.

CONCLUSION

The framework was a useful tool and can be easily applied in developing and evaluating complex nursing interventions. Three key challenges emerge from this experience: (i) relevant research evidence should be used systematically in developing the components of the intervention, (ii) the definition and measurement of complex intervention outcomes needs to be improved and (iii) appropriate research designs must be used when evaluating complex interventions.

Improving Adherence to a Mechanical Ventilation Weaning Protocol for Critically Ill Adults: Outcomes After an Implementation Program

• Background Despite multiple reminders, education sessions, and multidisciplinary team involvement, adherence to an evidence-based mechanical ventilation weaning protocol had been less than 1% in a general systems intensive care unit since implementation.

• Objective To assess the effectiveness of using an implementation program, the Model for Accelerating Improvement, to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit.

• Methods A prospective comparative design, before and after implementation of the Model for Accelerating Improvement, was used with a consecutive sample of 129 patients and 112 multidisciplinary team members. Clinical outcomes were rate of unsuccessful extubations, rate of ventilator-associated pneumonia, and duration of mechanical ventilation; practice outcomes were staff’s understanding of the mechanical ventilation weaning protocol, perceptions of the practice safety climate, and adherence to the weaning protocol.

• Results After the intervention, the rate of unsuccessful extubations decreased, and staff’s understanding of and adherence to the weaning protocol increased significantly. The rate of ventilator-associated pneumonia, duration of mechanical ventilation, and staff’s perceptions of the practice safety climate did not change significantly.

• Conclusion Implementing the Model for Accelerating Improvement improved understanding of and adherence to protocol-directed weaning and reduced the rate of unsuccessful extubations.

The impact of nurse-directed protocolised-weaning from mechanical ventilation on nursing practice: a quasi-experimental study

BACKGROUND

Internationally, nurse-directed protocolised-weaning has been evaluated by measuring its impact on patient outcomes. The impact on nurses' views and perceptions has been largely ignored.

AIM

To determine the change in intensive care nurses' perceptions, satisfaction, knowledge and attitudes following the introduction of nurse-directed weaning. Additionally, views were obtained on how useful protocolised-weaning was to practice.

METHODS

The sample comprised nurses working in general intensive care units in three university-affiliated hospitals. Nurse-directed protocolised-weaning was implemented in one unit (intervention group); two ICUs continued with usual doctor-led practice (control group). Nurses' perceptions, satisfaction, knowledge and attitudes were measured by self-completed questionnaires before (Phase I) and after the implementation of nurse-directed weaning (Phase II) in all units.

RESULTS

Response rates were 79% (n=140) for Phase 1 and 62% (n=132) for Phase II. Regression-based analyses showed that changes from Phase I to Phase II were not significantly different between the intervention and control groups. Sixty-nine nurses responded to both Phase I and II questionnaires. In the intervention group, these nurses scored their mean perceived level of knowledge higher in Phase II (6.39 vs 7.17, p=0.01). In the control group, role perception (4.41 vs 4.22, p=0.01) was lower and, perceived knowledge (6.03 vs 6.63, p=0.04), awareness of weaning plans (6.09 vs 7.06, p=0.01) and satisfaction with communication (5.28 vs 6.19, p=0.01) were higher in Phase II. The intervention group found protocolised weaning useful in their practice (75%): this was scored significantly higher by junior and senior nurses than middle grade nurses (p=0.02).

CONCLUSION

We conclude that nurse-directed protocolised-weaning had no effect on nurses' views and perceptions due to the high level of satisfaction which encouraged nurses' participation in weaning throughout. Control group changes are attributed to a 'reactive effect' from being study participants. Weaning protocols provide a uniform method of weaning practice and are particularly beneficial in providing safe guidance for junior staff.

Outcomes of Care Managed by an Acute Care Nurse Practitioner/Attending Physician Team in a Subacute Medical Intensive Care Unit

• Background Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff.

• Objective To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows.

• Methods During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes.

• Results Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02).

• Conclusions In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

A process improvement project: achieving quality outcomes

The University of Virginia Health System designed a systematic approach to the care of the long-term, mechanically ventilated, adult patient population to improve patient outcomes and use institutional resources more efficiently. The authors discuss their process improvement strategies, barriers to implementation, and project outcomes.

Protocolized weaning from mechanical ventilation: ICU physicians' views

BACKGROUND

The use of protocols during weaning from mechanical ventilation is uncommon in the UK, despite research pointing to their potential benefits. This may be because the research evidence is considered not to apply in different settings. Intensive care unit consultant physicians are the major decision-makers in weaning in the UK and any attempt to introduce protocolized weaning will require consideration of their views.

AIM

The aim of this paper is to report a study exploring intensive care physicians' views on (i) weaning from mechanical ventilation, (ii) the utility of weaning protocols and (iii) nurses' roles in the weaning process. A specific goal was to identify potential aids and barriers to developing weaning protocols and their introduction into clinical practice.

METHODS

Qualitative interviews were conducted with a purposive sample of 10 consultant physicians in two intensive care units in Northern Ireland and subjected to content analysis.

FINDINGS

The primary themes identified were (i) information required for weaning decisions and clinical judgement, (ii) professional boundaries, (iii) protocol issues and (iv) timing of weaning. Three types of information were deemed to be required for weaning decisions - empirical objective, empirical subjective and abstract - and interviewees considered that it would be challenging to incorporate all into a protocol. They were divided on whether protocols were useful when nursing experience was limited. Some groups of patients were thought more suitable than others for protocolized weaning.

CONCLUSIONS

Although local physicians were supportive in theory, introduction of protocolized weaning is likely to be difficult because of the breadth of information required for successful decision-making. Consultant views in this study were not consistent with American findings that physicians' caution may unnecessarily prolong weaning.

Weaning of the neurologically impaired patient

Many studies have been published on weaning patients from mechanical ventilation, but few have addressed the unique needs of patients with neurologic impairment. Typically, neuroscience patients remain intubated because of concerns over airway protection or neuromuscular weakness. This article discusses special weaning considerations for this patient population. Neurologic-specific weaning trends from a comprehensive ventilator weaning program are also presented.

Perceptions of Physicians, Nurses, and Respiratory Therapists About the Role of Acute Care Nurse Practitioners

• Background Information about the contributions of acute care nurse practitioners to medical management teams in critical care settings is limited.

• Objective To examine contributions of acute care nurse practitioners to medical management of critically ill patients from the perspectives of 3 disciplines: medicine, respiratory care, and nursing.

• Methods Attending physicians, respiratory therapists, and nurses in 2 intensive care units were asked to list 3 advantages and 3 disadvantages of collaborative care provided by acute care nurse practitioners. Qualitative methods (coding/constant comparative analysis) were used to identify common themes and subthemes. Overall response rate was 35% (from 69% for attending physicians to 26% for nurses).

• Results Responses were grouped into 4 main themes: accessibility, competence/knowledge, care coordination/communication, and system issues. Acute care nurse practitioners were valued for their accessibility, expertise in routine daily management of patients, and ability to meet patient/family needs, especially for “long-stay” patients. Also, they were respected for their commitment to providing quality care and for their communication skills, exemplified through teaching of nursing staff, patient/family involvement, and fluency in weaning protocols. Physicians valued acute care nurse practitioners’ continuity of care, patient/family focus, and commitment. Nurses valued their accessibility, commitment, and patient/family focus. Respiratory therapists valued their accessibility, commitment, and consistency in implementing weaning protocols.

• Conclusion Responses reflected unique advantages of acute care nurse practitioners as members of medical management teams in critical care settings. Despite perceptions of the acute care nurse practitioner’s role as medically oriented, the themes reflect a clear nursing focus.

The experience of four outcomes managers: an institutional approach to weaning patients from long-term mechanical ventilation

Care of patients requiring long-term mechanical ventilation (LTMV) is the focus of many hospitals nationwide. Because the care of patients who require LTMV is complex and morbidity and mortality are high, associated costs often exceed reimbursement. This article describes a successful institutional program for the care of the patient population requiring LTMV using advanced practice nurses (APNs) in the role of outcomes managers (OMs). So that others may benefit from the experiences of the clinicians, this article describes the historical background, the selection and qualifications of APNs, the process APNs use to manage and monitor the patients, role challenges, and associated outcomes.

The science of weaning: when and how?

Weaning patients from long-term mechanical ventilation continues to be a goal of clinicians and scientists and the hospitals charged with their care. This article describes the science of the "wean" and the "how" of weaning. A goal of scientists has been to develop predictors that determine accurately the optimal time to initiate weaning. Unfortunately to date none has emerged as superior. Quite simply, predictors do not predict. In contrast, methods that decrease variation in care practices have demonstrated positive outcomes. The methods include protocols for weaning trials and sedation and other system initiatives inclusive of a multidisciplinary plan of care or clinical pathway.

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.

Collaborative Practice: Development, Implementation, and Evaluation of a Weaning Protocol for Patients Receiving Mechanical Ventilation

• Background Use of protocols to reduce weaning time for patients receiving mechanical ventilation helps reduce cost and length of stay. However, implementation of this type of protocol is not easy and requires a consistent collaborative effort.

• Objective To provide a systematic approach to the weaning process by developing, implementing, and evaluating a protocol for weaning patients from mechanical ventilation in a medical respiratory intensive care unit.

• Methods The weaning protocol used was a modification of a protocol developed by Ely et al. Modifications included a more aggressive approach in proceeding to the spontaneous breathing trial, inclusion of the Richmond Agitation-Sedation Scale, and documentation of the production of secretions.

• Results Implementation of the protocol significantly reduced the duration of mechanical ventilation as measured by 8-hour shifts and ventilator days. Although length of stay in the intensive care unit was not significantly reduced (P = .29), a continuing downward trend occurred, from a mean of 8.6 days before the protocol was implemented to 7.9 days during the last 6 months of data collection (P = .07).

• Conclusions The need to provide efficient care requires the collaboration of all disciplines involved in providing patients’ care. The weaning protocol introduced in this study demonstrates the benefits of using a collaborative team to identify best practices and implement them in a practice setting.

Weaning from ventilation in paediatric intensive care: an intervention study

OBJECTIVE

To standardise the paediatric intensive care unit (PICU) team's approach to weaning paediatric patients from mechanical ventilation.

METHOD

The study employed a time series design over 2 years. A total of 220 patients (pre-intervention n=107 and post-intervention n=113) were studied. Independent variables measured in both the pre- and post-intervention groups included total ventilation time (TVT), weaning duration (WD), and length of stay (LOS), as well as quality indicators (weaning failure and reintubation rates).

RESULTS

The pre-intervention analysis demonstrated an existing fluctuation between outcome variables. When outcome indicators were compared between the pre- and post-intervention groups, both TVT and LOS were longer post-intervention (median difference: TVT -15.8 hours, P<0.068; and LOS -23.75 hours, P<0.088). WD was comparable between groups (median difference: WD -1.5 hours, P<0.427). Quality indicators were better post-intervention. Kaplan-Meier survival analysis demonstrated that long-term ventilated patients post-intervention had a reduced probability of remaining ventilated.

CONCLUSION

Weaning children from mechanical ventilation can be performed safely and effectively with the aid of collaborative guidelines. Although times were prolonged, the quality indicators were slightly improved, indicating that quicker was not always better. Long-term ventilated patients, in particular, would appear to benefit from weaning guidelines.

Can protocolised-weaning developed in the United States transfer to the United Kingdom context: a discussion

Weaning patients from mechanical ventilation using standardised protocols has been demonstrated to be safe and effective in reducing mechanical ventilation time, intensive care unit (ICU) stay and costs. Studies supporting this have all been conducted in the United States of America and weaning protocols are not widely used in the United Kingdom. With such a strong scientific evidence-base for protocolised-weaning, it is unclear why the introduction of evidence-based practice in this area is so low in the UK. There may be a number of reasons for this. First, it may be that the evidence is considered not to apply to different settings, particularly between the USA and UK where there are many differences in health care cultures. Second, it is suggested that the strength of evidence is not the only factor to account for when trying to introduce research evidence into practice [Qual. Health Care 7 (1998) 149]. The context or environment into which the research is to be implemented and how the implementation process is facilitated are equally important factors to be considered. Kitson et al. [Qual. Health Care 7 (1998) 149] argue that the interplay between the three factors of evidence, context and facilitation, enable the successful implementation of evidence-based practice. This discussion paper explores the factors that influence the introduction of weaning protocols. The discussion is structured around the three core elements from Kitson et al.'s conceptual framework and it draws upon examples of UK and USA contextual differences from Northern Ireland (NI) and Virginia (VA).

Subjective Perceptions and Physiological Variables During Weaning From Mechanical Ventilation

• Background As costs related to mechanical ventilation increase, clear indicators of patients’ readiness to be weaned are needed. Research has not yet yielded a consensus on physiological variables that are consistent correlates of weaning outcomes. Subjective perceptions rarely have been examined for their contribution to successful weaning.

• Objective To explore the subjective perceptions of dyspnea, fatigue, and self-efficacy and selected physiological variables in patients being weaned from mechanical ventilation.

• Methods Data were collected prospectively on 68 patients being weaned from mechanical ventilation. Subjective perceptions were measured by using 3 visual analog scales; physiological variables were measured by using the Burns Weaning Assessment Program and a patient profile. Weaning outcomes were recorded 24 hours after data collection.

• Results Participants were primarily white women and required mechanical ventilation for a mean of less than 4 days. Participants reported mild dyspnea, moderate fatigue, and high weaning self-efficacy. High Pao2, low Paco2, stable hemodynamic status, adequate cough and swallow reflexes, no metabolic changes, and no abdominal problems were associated with complete weaning (P = .05). Subjective perceptions were associated with physiological variables but not with weaning outcomes.

• Conclusions Multidimensional assessment of both primary and secondary indicators of readiness to be weaned is necessary for timely, efficient weaning from mechanical ventilation. Primary assessments include physiological variables related to gas exchange, hemodynamic status, diaphragmatic expansion, and airway clearance. Secondary assessments include perceptions related to key physiological variables. Additional research is needed to determine the predictive value of physiological variables and perceptions of dyspnea, fatigue, and self-efficacy.

Effect of Tracheal Gas Insufflation During Weaning From Prolonged Mechanical Ventilation: A Preliminary Study

• Background Tracheal gas insufflation reduces inspired tidal volume and minute ventilation in spontaneously breathing patients and may facilitate weaning from mechanical ventilation.

• Objective To determine if tracheal gas insufflation can reduce ventilatory demand during weaning trials in patients who require prolonged mechanical ventilation.

• Methods A reduction in ventilatory demand was defined as a relative decrease in tidal volume, minute ventilation, and mean inspiratory flow during trials with tracheal gas insufflation compared with the values during trials without this therapy. A total of 14 subjects underwent T-piece trials with and without insufflation (flow rate 6 L/min) on 2 consecutive days; the order of insufflation was randomized. Tidal volume, minute ventilation, and mean inspiratory flow were measured at baseline (without insufflation) and 2 hours later.

• Results Differences in ventilatory demand were not significant when comparisons were made for condition (tracheal gas insufflation vs no flow) or time (baseline vs 2 hours) for the total group (P = .48). Subjects were classified post hoc as responders (n = 9) or nonresponders (n = 5). Comparisons between responders and nonresponders indicated a significant (P = .02) 3-way multivariate interaction for group (responder vs nonresponder), condition (tracheal gas insufflation vs no flow), and time (baseline vs 2 hours) for ventilatory demand variables.

• Conclusion Tracheal gas insufflation can reduce ventilatory demand during weaning trials in some patients who require mechanical ventilation.

Improving outcomes for mechanically ventilated medical intensive care unit patients using advanced practice nurses: a 6-year experience

The value of an APN in a role such as for the management of patients requiring LTMV is easily recognized. There are few healthcare providers who are as uniquely qualified to ensure the successful resolution of the many complex clinical and system issues that affect these patients' outcomes. Similar models of care using APNs in similar roles have been used successfully in other populations of patients at our institution. We hope that other hospitals will implement models using the APN to manage and monitor complex patient populations and continue to report the results so that the true value of the APN is recognized.

What advanced practice nursing outcomes research is out there?

With a traditional focus on primary care or selected patient populations, advanced practice nurses (APNs) are forging new roles in a variety of practice settings, including acute and critical care. APNs have become important members of the critical care team, yet the impact of their care on acute and critically ill patients has not been well studied. This article presents an overview of the research currently available on outcomes of APN practice for acute and critically ill patients. The findings from these studies are discussed and implications for the future of APN outcomes research are provided.

Outcomes of and Resource Consumption by High-Cost Patients in the Intensive Care Unit

• Background Care of patients in an intensive care unit is among the most costly in hospitals. Little is known about high-cost patients within the intensive care unit or their outcomes of care.

• Objectives To examine outcomes of and resource consumption by high-cost adult patients who received care in an intensive care unit at an academic medical center.

• Methods Data on patients admitted during the period January 1, 1995, through June 30, 1999, were analyzed retrospectively. An intensive care unit database, the hospital discharge data set, and a cost-accounting data set were used to determine the total intensive care unit cost for the hospitalization. Patients were then stratified into cost deciles. Hospital and intensive care unit outcomes for patients in the top decile were compared with those of patients in the other deciles.

• Results Cost data were available on 10606 of the 11244 patients who received care in an intensive care unit. Patients in the top decile accounted for 48.7% of all intensive care unit costs, and 67.6% of this group survived to discharge despite prolonged care. Patients transferred from an outside hospital were more likely to be in the top decile, have a longer stay in the intensive care unit, or die than were the other patients.

• Conclusions A small group of patients accounts for a disproportionately higher amount of intensive care unit resources but has a relatively high survival rate. This cohort should be treated as an intact group that is not amenable to traditional cost-cutting measures.

Effect of an Outcomes-Managed Approach to Care of Neuroscience Patients by Acute Care Nurse Practitioners

• Objective To improve clinical and financial outcomes for neuroscience patients by using an “outcomes-managed” model of care delivery and 2 acute care nurse practitioners as outcomes managers.

• Methods Baseline data from the year before implementation of the care model were compared with data from the first 6 months of implementation. A random list of 122 adult patients admitted to the neuroscience intensive care unit or the acute care neurosurgery unit of a university teaching hospital between January and December 1998 was generated to provide the baseline data. The prospective sample included 402 patients admitted to either unit during the first 6 months of the project (January through June 1999). The acute care nurse practitioners used an evidence-based multidisciplinary plan of care to manage all patients.

• ResultsNo differences were found in age, sex, or ethnicity between groups. Patients managed by acute care nurse practitioners had significantly shorter overall length of stay (P = .03), shorter mean length of stay in the intensive care unit (P&lt;.001), lower rates of urinary tract infection and skin breakdown (P&lt;.05), and shorter time to discontinuation of the Foley catheter and mobilization (P &lt; .05). The outcomes-managed group was hospitalized 2306 fewer days than the baseline group, at a total cost savings of $2 467 328.

• Conclusions Clinical and financial outcomes are improved significantly by identifying patients at risk, monitoring for complications, and having acute care nurse practitioners manage the patients.

Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines

Health-care professionals (HCPs) can provide protocol-based care that has a measurable impact on critically ill patients beyond their liberation from mechanical ventilation (MV). Randomized controlled trials have demonstrated that protocols for liberating patients from MV driven by nonphysician HCPs can reduce the duration of MV. The structure and features of protocols should be adapted from published protocols to incorporate patient-specific needs, clinician preferences, and institutional resources. As a general approach, shortly after patients demonstrate that their condition has been stabilized on the ventilator, a spontaneous breathing trial (SBT) is safe to perform and is indicated. Ventilator management strategies for patients who fail a trial of spontaneous breathing include the following: (1) consideration of all remediable factors (such as electrolyte derangements, bronchospasm, malnutrition, patient positioning, and excess secretions) to enhance the prospects of successful liberation from MV; (2) use of a comfortable, safe, and well-monitored mode of MV (such as pressure support ventilation); and (3) repeating a trial of spontaneous breathing on the following day. For patients who pass the SBT, the decision to extubate must be guided by clinical judgment and objective data to minimize the risk of unnecessary reintubations and self-extubations. Protocols should not represent rigid rules but, rather, guides to patient care. Moreover, the protocols may evolve over time as clinical and institutional experience with them increases. Useful protocols aim to safely and efficiently liberate patients from MV, reducing unnecessary or harmful variations in approach.

Long-term ventilator management strategies: experiences of two hospitals

Historically, negative clinical and economic outcomes have been associated with patients who need long-term mechanical ventilation. Institutions and clinicians charged with the care of these patients are understandably interested in exploring clinical strategies that assure positive outcomes. This article describes the evidence base for clinical pathways, weaning teams, protocols, and care-managed approaches. In addition, the article describes how different elements of system initiatives designed for a university teaching hospital and a community hospital were implemented and evaluated. The systematic approaches encourage multidisciplinary input and decrease variation, thus improving both quality and cost.

The weaning continuum use of Acute Physiology and Chronic Health Evaluation III, Burns Wean Assessment Program, Therapeutic Intervention Scoring System, and Wean Index scores to establish stages of weaning

OBJECTIVE

To determine whether four stages of weaning (acute, prewean, wean, and outcome) could be identified by using clinical instruments designed to quantify severity of illness, patient stability, or weaning readiness. The instruments used were the Acute Physiology and Chronic Health Evaluation (APACHE III), the Therapeutic Intervention Scoring System (TISS), the Burns Wean Assessment Program (BWAP), and the Wean Index (WI). The stages were adapted from those proposed by the American Association of Critical Care Nurses Third National Study Group's Weaning Continuum Model.

DESIGN

Prospective, convenience cohort. This study was part of a larger study designed to test an outcomes managed approach to weaning by using an outcomes manager and a clinical pathway.

SETTING

University medical intensive care unit.

PATIENTS

Adult patients requiring mechanical ventilation >3 days admitted to the medical intensive care unit between November 1994 and May 1995.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Scores for the APACHE III, TISS, BWAP, and WI were collected on 97 patients every other day until they weaned, were transferred, or died. Outcomes described for each stage of weaning were dated on the clinical pathway when achieved. Comments about patient stability and ventilator progress also were recorded along with a subjective determination of the stage of weaning. We used decision rules to identify time intervals for each stage of weaning and outcomes attained by stage. Finally, APACHE III, TISS, BWAP, and WI scores were placed in each stage by date for analysis. The APACHE III, TISS, and BWAP scores were able to differentiate the acute, prewean, and wean stages but not the outcome stage.

CONCLUSIONS

By identifying distinct scores for each stage, we may be able to better explore appropriate interventions for the stages as well as predict weaning outcomes. Indices that include physiologic and respiratory factors can differentiate weaning stages, but respiratory factors alone cannot.

Strategies to improve compliance with evidence-based clinical management guidelines

BACKGROUND

Clinical management guidelines (CMGs) have been developed to standardize physician practices and ensure safe and cost-effective patient care. In June 1996, evidence-based CMGs were initiated at our urban Level I trauma center. This study compares physician compliance with two such CMGs before (PRE) and after (POST) the institution of continuous surveillance by a clinical resource manager.

STUDY DESIGN

For 2 months PRE resource manager surveillance hospital records were reviewed retrospectively for compliance with two CMGs. POST data were collected prospectively for 2 months by the resource manager, who alerted practitioners to deviance from CMGs to justify or document therapy alternatives. The CMGs studied addressed deep venous thrombosis and stress ulcer prophylaxis. "Under" or "over" therapy described that which fell short of or exceeded guidelines. Data were analyzed by chi-square; p < 0.05 defined statistical significance.

RESULTS

Compliance with the CMGs was 48% PRE and 74% POST (p=0.001). All noncompliant instances POST (and none PRE) were altered or justified. Deep venous thrombosis and ulcer "over" therapy was significantly higher PRE (19% versus 2%, p=0.003; 49% versus 19%, p=0.001), resulting in $22,760.35 in costs. There was no difference in pulmonary embolism or gastrointestinal bleed rate (1%) PRE to POST.

CONCLUSIONS

The use of a clinical resource manager empowered to monitor and coordinate physician behavior improves compliance with CMGs. Further study is warranted to validate resultant outcomes benefit, specifically cost-effectiveness and duration of the need for such a program.