Decisional responsibility for mechanical ventilation and weaning: an international survey
1 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, M5T 1P8, Canada
2 Department of Respirology, Toronto East General Hospital, 825 Coxwell Ave, Toronto, M4C 3E7, Canada
3 Department of Nursing, Mt Sinai Hospital, 600 University Ave, Toronto, M5G 1X5, Canada
4 Li Ka Shing Institute, St Michael's Hospital, 30 Bond St, Toronto, M5B 1W8, Canada
5 School of Nursing and Midwifery, Queen's University, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
6 The University of Copenhagen, Faculty of Health Sciences and The University Hospitals Center for Nursing and Care Research, UCS, Copenhagen University Hospital Rigshospitalet, Department 7001, Blegdamsvej 9, DK-2100 Copenhagen O, Denmark
7 Department for Research and Development, Levanger Hospital, Nord-Trøndelag Health Trust, Kirkegt. 2, Levanger, 7600, Norway
8 Department of Intensive Care, Gelre Hospitals, Albert Schweitzerlaan 31, Apeldoorn, 7334DZ, The Netherlands
9 Deutsches Institut für angewandte Pflegeforschung, Hülchrather Str. 15 Köln, 50670, Germany
10 School of Health in Social Science Nursing Studies, The University of Edinburgh, 17/10 High Riggs, Edinburgh, EH3 9BW UK
11 Faculty of Medicine, University of Basel, Institute of Nursing Science, Bernoullistr. 28, Basel 4056, Switzerland
12 Center of Clinical Nursing Science, University Hospital Zurich, Raemistr. 100 (ZUR 44), Zurich 8091, Switzerland
13 Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, School of Nursing, Largo Francesco Vito, 1- 00168 Roma, Italy
14 Cottolengo Hospital, Little House of Divine Providence, S.C. Training and Quality, School of Nursing, via Cottolengo 13, Turin, 10100, Italy
15 Department of Intensive Care, Gelre Hospitals, Albert Schweitzerlaan 31, Apeldoorn, 7334DZ, The Netherlands
16 Department of Health and Care Sciences, Faculty of Health Sciences, University of Tromsø, Romssa universitehta, N-9037, Norway
17 Centre for Infection and Immunity, Room 01/017, Health Sciences Building, Queen's University, 97 Lisburn Road, Belfast BT9 7BL, Northern Ireland
18 Department of Intensive Care Medicine, Academic Medical Center at the University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
Critical Care 2011, 15:R295 doi:10.1186/cc10588
See related commentary by Jubran, http://ccforum.com/content/16/1/115Published: 14 December 2011
Optimal 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.
A 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.
Response 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.
Collaborative 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.