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

Abstract

Background Organizational processes affect the duration of mechanical ventilation in adult and pediatric intensive care units, but surprisingly little is known about role responsibilities for mechanical ventilation and weaning and related contextual factors that may influence timely liberation from mechanical ventilation. Objective To determine the professional group and seniority of clinicians responsible for key decisions regarding ventilation and weaning; use of ventilation protocols and automated closed loop systems; and provision of education on mechanical ventilation. Methods Mailed survey to nurse managers of pediatric intensive care units in the United Kingdom. Results Response rate was 61%. In most units, nurse managers reported that physicians and nurses usually collaborated in making decisions about initializing (63%) and adjusting (94%) ventilator settings and for determining weaning readiness (88%), weaning method (59%), extubation readiness (82%), and weaning failure (100%). Protocols for mechanical ventilation were available in 35% of units, some specific to weaning (18%) and others for noninvasive ventilation (35%). Automated closed loop systems were used in 18% of units. Competency training was required before nurses could adjust ventilator settings in 35% of responding units; in the remaining units, settings were adjusted by nurses who had no specific competency training. Conclusions Key decisions were mainly collaborative, but nurses were limited in their ability to adjust ventilator settings independently. This limitation may be due to a lack of standardized competency programs and the infrequent use of non-physician-led weaning protocols and automated systems. These findings indicate some ways of improving processes to avoid delays in ventilator weaning.

How to achieve adherence to a ventilation algorithm for critically ill children?

“…This is also confirmed in two recent studies about interdisciplinary collaborative decision‐making regarding ventilation and weaning (Rose et al , ; Blackwood et al , ). Enhanced communication and collaboration between professionals could probably avoid unnecessary prolonged ventilation and weaning (Rose et al , ; Blackwood et al , ). We speculate that manipulating these specific organizational characteristics (interdisciplinary collaboration, effective communication, leadership support and organizational aspects like nurse‐to‐patient ratio and ongoing education) may be an effective strategy to improve adherence to protocols, which deserves to be explored and evaluated in further implementation projects (Sinuff et al , ).…”

Education on invasive mechanical ventilation involving intensive care nurses: a systematic review

“…Nurses who have not worked in critical care are likely to enter the ICU environment with limited knowledge on MV; therefore, comprehensive CE on MV provided by ICUs to educate nurses is essential (Blackwood et al, ; Rose et al, ). MV is taught comprehensively at the post‐graduate level as part of critical care courses; however, post‐graduate education in critical care is not mandatory prior to working in the ICU (Rose et al, ).…”

“…Management of MV is complex and dynamic, requiring extensive knowledge and skills to perform complex, accurate and timely decision‐making to provide safe, best‐practice care and reduce the risk of complications (Blackwood et al, ; Duff, ; Fenstermacher and Hong, ; Rose and Gerdtz, ). Continuing education (CE) plays a critical role in building and maintaining knowledge by developing clinical reasoning and evaluation skills, promoting self‐reflection and supporting safe practice and quality care (Al‐Majid et al, ; Cooper, ; Farnell and Dawson, ; Levett‐Jones, ; Lindner, ) given that undergraduate nursing students have limited exposure to MV.…”

Computerized Decision Support Systems for Mechanical Ventilation in Children

“…54 A recent survey of PICU staff in the United Kingdom suggested that automated or closed-loop systems were available in 18% of their ICUs. 55 Systematic reviews by Rose and Colleagues in 2012 and 2013 56 compared studies of automated and nonautomated tools for weaning. They noted that the number of studies was limited and there was substantial heterogeneity in trial designs, but that the findings suggested that such systems may reduce weaning time, duration of ventilation, and duration of ICU stay, particularly in mixed or medical ICU populations.…”