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Kimura R, Hayashi N, Utsunomiya A. Effect of a Japanese Version of the Burns Wean Assessment Program e-Learning Materials on Ventilator Withdrawal for Intensive Care Unit Nurses. J Nurs Res 2023; 31:e287. [PMID: 37351563 DOI: 10.1097/jnr.0000000000000566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND No assessment tool for predicting ventilator withdrawal success is currently available in Japan. Thus, an accessible and valid assessment tool to address this issue is needed. The Burns Wean Assessment Program (BWAP) has been validated as a reliable predictor of ventilator withdrawal outcomes. However, nurses must be familiar with this tool to ensure its efficient utilization in clinical settings. PURPOSE This study was designed to examine the effect of a 26-item Japanese version of BWAP (J-BWAP) e-learning materials on ventilator withdrawal in a sample of intensive care unit nurses in Japan. METHODS The BWAP was translated into Japanese, checked, and verified as the J-BWAP. Nonrandomized intensive care unit nurses from six hospitals were assigned to three groups, including Intervention Group 1 (e-learning in one session), Intervention Group 2 (e-learning over three sessions during 1 week), and the control group. The participants underwent pretests and posttests using web-based, simulated patients. The primary outcome measure was the difference in online pretest and posttest total scores among the two intervention groups and the control group. The feasibility of the J-BWAP and its e-learning materials was evaluated using four frameworks: acceptability, demand, implementation, and adaptation. RESULTS Of the 48 participants in the study, 32 completed the posttest and were included in the analysis (dropout rate: 33.3%). The difference between pretest and posttest scores was significantly higher in the intervention groups than the control group (2 vs. -1, p = .0191) and in Intervention Group 2 than the control group (2.0 vs. -0.5, p = .049). The feasibility frameworks for the J-BWAP and its e-learning materials were mostly positive. CONCLUSIONS/IMPLICATIONS FOR PRACTICE The development of the J-BWAP and training nurses using e-learning were shown to be feasible in this study. The J-BWAP contents are appropriate for predicting the outcome of mechanical ventilation withdrawal. The J-BWAP has the potential to become a common tool among Japanese medical professionals after the contents are further simplified for daily application in clinical practice. Subsequent studies should verify the reliability and validity of this tool and test the real-world utility of the J-BWAP using randomized controlled trials in Japanese clinical settings.
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Affiliation(s)
| | - Naoko Hayashi
- PhD, RN, Professor, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Akemi Utsunomiya
- DSN, RN, CCNS, Professor, Critical Care Nursing, Graduate School of Nursing, Kansai Medical University, Osaka, Japan
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Paquette L, Kilpatrick K. L’autonomie décisionnelle d’infirmières de soins intensifs lors du sevrage de la ventilation mécanique : une analyse de concept. Rech Soins Infirm 2021:76-91. [PMID: 33485287 DOI: 10.3917/rsi.143.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Nurses have a leading role in weaning patients from mechanical ventilation (WMV) given their constant presence and their continuous monitoring. To promote proper WMV, nurses must exercise autonomy and be involved in decision-making. However, in certain care contexts, there is little involvement of nurses. The purpose of this text is to establish the characteristics of the concept of autonomous decision-making applied to nursing during WMV. An analysis of this concept was carried out according to the evolutionary method of Rodgers. The identification of the attributes, antecedents, and consequences made it possible to note ambiguity in the definition of this concept. Nurses use autonomous decision-making for the execution of assigned tasks and when they make decisions according to a pre-prescribed decision-making algorithm. Significant foundations for the decision-making autonomy of critical care nurses during WMV emerged from this analysis : scope of practice, in-depth knowledge of the patient, and commitment to the success of WMV. Participation in interdependent decision-making allows nurses to bring the patient’s perspective into decisions. Avenues of reflection have also emerged, including decisions based on evidence to provide new avenues for autonomous decision-making.
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Sepahyar M, Molavynejad S, Adineh M, Savaie M, Maraghi E. The Effect of Nursing Interventions Based on Burns Wean Assessment Program on Successful Weaning from Mechanical Ventilation: A Randomized Controlled Clinical Trial. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2021; 26:34-41. [PMID: 33954096 PMCID: PMC8074739 DOI: 10.4103/ijnmr.ijnmr_45_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/11/2020] [Accepted: 09/26/2020] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Maryam Sepahyar
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Shahram Molavynejad
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad Adineh
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Savaie
- Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Elham Maraghi
- Department of Biostatistics and Epidemiology, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Jiang JR, Yen SY, Chien JY, Liu HC, Wu YL, Chen CH. Predicting weaning and extubation outcomes in long-term mechanically ventilated patients using the modified Burns Wean Assessment Program scores. Respirology 2014; 19:576-82. [DOI: 10.1111/resp.12266] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/23/2013] [Accepted: 01/10/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Jung-Rern Jiang
- Department of Internal Medicine; St Joseph's Hospital; Yunlin County Taiwan
| | - Shiao-Yu Yen
- Department of Medical Affairs Section; Public Health Bureau; Yunlin County Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine; Department of Health; Chest Hospital; Executive Yuan; Tainan City Taiwan
| | - Hsiao-Chien Liu
- Department of Respiratory Therapist; St Joseph's Hospital; Yunlin County Taiwan
| | - Yi-Ling Wu
- Department of Respiratory Therapist; St Joseph's Hospital; Yunlin County Taiwan
| | - Ching-Hui Chen
- Department of Respiratory Therapist; St Joseph's Hospital; Yunlin County Taiwan
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Crocker C, Scholes J. The importance of knowing the patient in weaning from mechanical ventilation. Nurs Crit Care 2011; 14:289-96. [PMID: 19840275 DOI: 10.1111/j.1478-5153.2009.00355.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The aim of the research was to understand how nurses used technology to wean patients from mechanical ventilation. BACKGROUND The literature concerned with the development of critical care centres on the role of technology with little emphasis on the nursing contribution. DESIGN An ethnographic approach was used to understand how nurses used technology to wean patients from mechanical ventilation. METHODS Data were gathered by participant observation and interviewing over a 6-month period. In total, 250 h of field notes were recorded. RESULTS Data were analysed by the content analysis method. Knowing the patient was a central theme identified. Three sub-themes were identified: ways of knowing, continuity of care and the role of the patient in the weaning trajectory. CONCLUSION 'Knowing the patient' was implied during the interviews as essential to the delivery of patient-centred care. There were two main factors that needed to be present in order for nurses to know their patients: continuity of care and expertise. 'Ways of knowing' was reliant on gaining information about the patient. The role of the patient was a passive recipient of treatment. IMPLICATIONS FOR PRACTICE Knowing the patient has been defined as a characteristic of expert nursing. To be truly patient-centred nursing needs to address the barriers that prevent nurses from getting to 'know' their patients.
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Affiliation(s)
- Cheryl Crocker
- Critical Care, Nottingham University Hospitals, Hucknall Road, Nottingham NG5 1PB, UK.
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Abstract
BACKGROUND The weaning process from mechanical ventilation is a complicated issue for patients with respiratory failure who require long-term respiratory support. Although the application of weaning protocols reduces weaning time, and enhances patient outcome, little is known about the actual approaches that clinicians use for the weaning of these patients. AIM The purpose of this paper is to explore approaches to weaning of long-term ventilated patients in a Scottish Intensive Care Unit. The findings are part of a larger study on decision-making during the weaning of long-term ventilated patients. METHOD Data were collected through participant observation and follow-up interviews with the nursing staff. Twenty-four-hour chart and medical notes review and informal conversation with the bedside nurse were also used to collect information on the weaning process. FINDINGS Nine patients were recruited to the study. Two patients were extubated and three patients were extubated but then required a tracheostomy. A further four patients had a tracheostomy performed. Thematic analysis of the data showed that weaning was individualized, and physician led, regardless of the existence of the weaning protocol. Six different weaning approaches were identified. Nurses followed a conservative approach to weaning in comparison to doctors who appeared more aggressive. CONCLUSION There are many varieties in the approaches clinicians use when weaning long-term ventilated patients, which acts on the continuity of their care. A shift of focus to identify ways of maintaining continuity of care and a combined 'wake and wean' approach needs to be considered.
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Rose L. Clinical application of ventilator modes: Ventilatory strategies for lung protection. Aust Crit Care 2010; 23:71-80. [PMID: 20378369 DOI: 10.1016/j.aucc.2010.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 03/09/2010] [Accepted: 03/12/2010] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Identification of the mortality reducing effect of lung protective ventilation using low tidal volumes and pressure limitation is one of the biggest advances in the application of mechanical ventilation. Yet studies continue to demonstrate low adoption of this style of ventilation. Critical care nurses in Australia and New Zealand have a high level of responsibility and autonomy for mechanical ventilation and weaning practices and therefore require in-depth knowledge of ventilator technology, its clinical application and the current evidence for effective ventilation strategies. AIM To present an overview of current knowledge and research relating to lung protective ventilation. METHOD A multidatabase literature search using the terms protective ventilation, open lung, high frequency oscillatory ventilation, airway pressure release ventilation, and weaning. RESULTS Based on clinical trials and physiological evidence lung protective strategies using low tidal volumes and moderate levels of PEEP have been recommended as strategies to prevent tidal alveolar collapse and overdistension in patients with ALI/ARDS. Evidence now suggests these strategies may also be beneficial in patients with normal lungs. Lung protective ventilation may be applied with either volume or pressure-controlled ventilation. Pressure-controlled ventilation allows regulation over injurious peak inspiratory pressures; however no study has identified the superiority of pressure-controlled ventilation over low tidal volume strategies using volume-control. Other lung protective ventilation strategies include moderate to high positive-end expiratory pressure, recruitment manoeuvres, high frequency oscillatory ventilation, and airway pressure release ventilation though definitive trials identifying consistently improved patient outcomes are still needed. No ventilation strategy can be more lung protective than the timely discontinuation of mechanical ventilation. Despite the above recommendations, evidence suggests the decision to commence weaning and attempt extubation continue to be delayed. Critical care nurses play a vital role in the recognition of patients capable of spontaneous breathing and ready for extubation. Organisational interventions such as weaning protocols as well as computerised weaning systems may have less effect when nurses are able to manage weaning processes effectively. CONCLUSIONS Lung protective ventilatory strategies are not consistently applied and weaning and extubation continue to be delayed. Critical care nurses need to establish a strong knowledge base to promote effective and appropriate management of patients requiring mechanical ventilation.
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Affiliation(s)
- Louise Rose
- Lawrence S. Bloomberg Limited Term Professor in Critical Care Nursing, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
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Abstract
Weaning from mechanical ventilation has attracted a growing interest recently in the medical and nursing press. Attempts have been made to determine a patient's readiness to wean, define criteria for successful weaning and enhance the weaning process through the developments of protocols. Key to this work is the role of the critical care nurse. Transferring the role and the responsibility of weaning from the traditional perspective of the intensivist to the nurse is not without challenges. Inherent is the need for skill and expertise and the willingness to accept this level of responsibility, not questioned in the medical role, but worthy of consideration when transferred to nurses. Key to successful weaning and weaning is redefined for the purposes of this paper, is continuity of care, knowing the patient and the development of patient-centred, individualized weaning plans. Critical care nurses have an important role to play. This is particularly so when the patient experience is to be understood. There is relatively little research conducted in this area, yet this is an important consideration if we are to fully understand and embrace the role of patients in their weaning. Weaning in the context of critical care can be challenging. To wean the difficult-to-wean or the long-term-weaning patient requires great skill and expertise. Expertise in this context has not been fully explored, yet research suggests that these patients are not allocated expert nurses to care for them because they are not seen as critically ill. It may be that this group of patients would benefit from a transfer to a weaning centre as suggested by the Modernisation Agency in 2002. This would greatly challenge the way we, as critical care nurses, perceive weaning in critical care.
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Affiliation(s)
- Cheryl Crocker
- Critical Care, Nottingham University Hospitals, Hucknall Road, Nottingham, UK.
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Abstract
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.
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Affiliation(s)
- Louise Rose
- Division of Nursing, RMIT University, Melbourne, Victoria, Australia.
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Taylor F. A comparative study examining the decision-making processes of medical and nursing staff in weaning patients from mechanical ventilation. Intensive Crit Care Nurs 2006; 22:253-63. [PMID: 16406785 DOI: 10.1016/j.iccn.2005.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Revised: 10/08/2005] [Accepted: 11/11/2005] [Indexed: 11/16/2022]
Abstract
A prolonged period of mechanical ventilation is costly for both the patient, in terms of the risk of complications such as ventilator-acquired pneumonia, and to the health service due to the high cost of maintaining a patient in intensive care. The recognition of the role nurses can play in the weaning process and the desire to try and reduce weaning times led to the introduction of nurse-managed weaning on the intensive care unit which is the focus of this study. This means that both doctors and nurses are now responsible for making decisions about weaning. Flexible guidelines for weaning were devised which still require a large element of individual, clinical decision-making during the process. At every stage in the weaning process clinicians are required to make judgments about patient responses, using these judgments as the basis for their decision-making. This study examined the ways doctors and nurses make these decisions. Semi-structured interviews were conducted with doctors and senior nurses. A grounded theory approach was used to analyse the results and the key themes of Treatment, Balance, Making Progress and The Individual were identified which were found to be linked with particular methods of decision-making.
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Affiliation(s)
- Fran Taylor
- Intensive Care Unit, Bassetlaw District General Hospital, 19 George St., Worksop, Notts S80 1QJ, UK.
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13
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Epstein CD, Peerless JR. Weaning Readiness and Fluid Balance in Older Critically Ill Surgical Patients. Am J Crit Care 2006. [DOI: 10.4037/ajcc2006.15.1.54] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
• BackgroundFew studies address predictors for successful weaning of older adults from mechanical ventilation.
• ObjectiveTo develop a clinical profile of older patients who are successfully weaned from long-term mechanical ventilation.
• MethodsForty patients in the trauma and surgical intensive care unit who were at least 60 years old were enrolled in the study after 3 days of active weaning and were monitored daily until successfully weaned or until the end of the 14-day study. Hemodynamic and gas exchange variables, fluid balance, oxygen cost of breathing, and scores on the Burns Weaning Assessment Program were analyzed.
• ResultsCompared with patients who were not weaned, successfully weaned patients required mechanical ventilation for 5.3 days, started active weaning earlier (mean 10.7 vs 14.5 days, P = .04), had lower mean negative daily fluid balances in the beginning (−0.394 vs 1.107 L, P = .004), and had lower mean net cumulative fluid balances (6.856 vs 16.212 L) at the time of enrollment. They also maintained both a lower mean net cumulative fluid balance (10.753 vs 25.049 L, P= .02) and a negative daily fluid balance (−0.389 vs 1.904 L, P = .03) throughout. Their mean central venous pressure decreased over time and was significantly lower (P<.001).
• ConclusionPersistent positive fluid balance in older surgical patients is associated with prolonged mechanical ventilation. Estimates of fluid balance might be useful in weaning older patients from long-term mechanical ventilation.
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Affiliation(s)
- Carol Diane Epstein
- Fairfield University School of Nursing, Fairfield, Conn (cde) and Case Western Reserve University, MetroHealth Medical Center Campus, Cleveland, Ohio (jrp)
| | - Joel R. Peerless
- Fairfield University School of Nursing, Fairfield, Conn (cde) and Case Western Reserve University, MetroHealth Medical Center Campus, Cleveland, Ohio (jrp)
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Burns SM. Mechanical Ventilation of Patients With Acute Respiratory Distress Syndrome and Patients Requiring Weaning. Crit Care Nurse 2005. [DOI: 10.4037/ccn2005.25.4.14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Suzanne M. Burns
- Suzanne M. Burns is a professor of nursing and an advanced practice nurse in the medical intensive care unit at the University of Virginia in Charlottesville
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Abstract
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.
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Affiliation(s)
- Thomas Buckley
- Acute and Specialty Care, APN2, Medicine/MICU, School of Nursing, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Earven S, Fisher C, Lewis R, Merrell P, Burns SM. The experience of four outcomes managers: an institutional approach to weaning patients from long-term mechanical ventilation. Crit Care Nurs Clin North Am 2004; 16:395-411, ix. [PMID: 15358388 DOI: 10.1016/j.ccell.2004.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Sidenia Earven
- University of Virginia Health System, Charlottesville, VA, USA
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Gelsthorpe T, Crocker C. A study exploring factors which influence the decision to commence nurse-led weaning. Nurs Crit Care 2004; 9:213-21. [PMID: 15462119 DOI: 10.1111/j.1362-1017.2004.00077.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nurse-led weaning can improve patient outcome. Exploration of the factors that influence the commencement of weaning. Themes of decision-making, pathophysiological and multidisciplinary team factors emerged. Experience was a key factor in the decision to wean. The use of protocol-led weaning may not be useful in the decision to wean.
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O'Bryan L, Von Rueden K, Malila F. Evaluating ventilator weaning best practice: a long-term acute care hospital system-wide quality initiative. AACN CLINICAL ISSUES 2002; 13:567-76. [PMID: 12473919 DOI: 10.1097/00044067-200211000-00010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Long-term acute care (LTAC) hospitals and units are becoming increasingly important to the management of patients who have serious, complex critical illnesses and require mechanical ventilation for extended periods of time. Kindred Healthcare, Inc., a nation-wide system of LTAC hospitals embarked on a quality initiative to establish a Ventilator Management and Weaning Best Practice. The process steps included: measurement of performance of all hospitals in the system using a risk-adjusted methodology to evaluate clinical outcomes, identification of facilities with superior outcomes; structured evaluation of the characteristics, practices, and protocols of these Best Practice hospitals; and utilization of the information gleaned from these hospitals to establish evidence-based LTAC best practice ventilator management guidelines. Key characteristics of the Best Practice LTAC hospitals were: hospital-wide philosophy that "everybody weans"-that is, all disciplines actively participate and all patients are expected to wean; collaborative multidisciplinary plans of care; a consistent and a 24-hour-a-day approach to ventilator management and weaning; daily communication; mutual respect for the contributions of all disciplines to the weaning process; early, aggressive nutrition support and intervention by rehabilitation services; use of 24-hour in-hospital advance practice nurses, hospitalists, or physician assistants; and intervention by physiatrists.
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Abstract
Weaning from mechanical ventilation is challenging and requires expert knowledge and skill. Weaning can be defined as the process of assisting patients to breathe spontaneously without mechanical ventilatory support [Am. J. Crit. Care 7 (1998) 1491. Weaning from mechanical ventilation is not about the method used but more about how that method is employed [Crit. Care Med. 27 (1999) 2331]. A review of the literature revealed that there was no one method of weaning that was superior, furthermore evidence suggests that the use of a protocol was more effective in reducing the duration of weaning [Dimensions Crit. Care Nurs. 2 (1991) 398; Respir. Care Clin. North Am. 2 (1996) 105; AACN Clin. Issues Crit. Care 7 (1996) 550; Crit. Care Med. 25 (1997) 567; Arch. Surg. 133 (1998) 483; Chest 118 (2000) 459]. A retrospective audit of all patients who were ventilated for 7 or more days in one intensive care over a 1-year period, revealed 94 (of 500) patients were ventilated for an average of 16.8 days. There were no weaning guidelines or protocols in place at this time and weaning from mechanical ventilation was inconsistent and uncoordinated. A process mapping exercise revealed there was a delay in initiating the decision to wean of 96 h. Weaning protocols were put in place and nurse led weaning was initiated and supported by the nurse consultant. Monthly statistics were collated and this revealed the average ventilator time had reduced. Protocol led weaning has been effective in reducing the duration of ventilation. Problems still occur in initiating the decision to wean early. An audit of patient notes has revealed many reasons for this. These reasons include, over sedation, the use of morphine and midazolam, particularly in the elderly and those with renal impairment, is delaying weaning. Other reasons include, delay in tracheostomy placement. Staff are not initiating weaning guidelines early this may be due to lack of knowledge, lack of support or failure of the guidelines. Mechanisms are in place to support nurses at the bedside.
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Affiliation(s)
- Cheryl Crocker
- Critical Care Directorate, Nottingham City NHS Hospital, Hucknall Road, Nottingham NG5 1PB, UK.
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20
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Burns SM, Earven S. Improving outcomes for mechanically ventilated medical intensive care unit patients using advanced practice nurses: a 6-year experience. Crit Care Nurs Clin North Am 2002; 14:231-43. [PMID: 12168702 DOI: 10.1016/s0899-5885(02)00003-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Suzanne M Burns
- School of Nursing and Medical Intensive Care Unit, University of Virginia Health System, Charlottesville 22903-3395, USA.
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Epstein CD, El-Mokadem N, Peerless JR. Weaning Older Patients From Long-term Mechanical Ventilation: A Pilot Study. Am J Crit Care 2002. [DOI: 10.4037/ajcc2002.11.4.369] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background As older persons in the intensive care unit increasingly require long-term mechanical ventilation, accurate indications of readiness for weaning from ventilatory support are needed to avoid premature extubation.
• Objective To describe temporal changes in pulmonary and systemic variables in older adults receiving long-term mechanical ventilation.
• Methods After 3 days of unsuccessful attempts at weaning from ventilatory support, 10 trauma and surgical patients more than 60 years old were monitored daily. Previously reported predictors of the duration of mechanical ventilation and weaning outcome were measured, including hemodynamic and gas exchange variables, oxygen cost of breathing, and the score on the Burns Weaning Assessment Program.
• Results The 6 patients who could be weaned from ventilatory support were younger (median age, 71.5 years) than the 4 patients who could not be weaned (median age, 80 years). Patients who could be weaned were ready for weaning by day 11 of their stay in the intensive care unit and required an additional 5.5 days of mechanical ventilation; those who could not be weaned were not ready for weaning until day 17. All patients initially had increases in oxygen consumption during weaning; those who were successfully weaned had decreases before extubation. Respiratory rate, maximal inspiratory pressure, the ratio of Pao2 to fraction of inspired oxygen, and mean arterial pressure were higher in patients who could be weaned, and oxygen cost of breathing and central venous pressure were lower.
• Conclusion Further study of weaning in older adults is warranted.
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Affiliation(s)
- Carol Diane Epstein
- The Frances Payne Bolton School of Nursing (CDE, NE) and the Department of Surgery (JRP), Case Western Reserve University, Cleveland, Ohio
| | - Naglaa El-Mokadem
- The Frances Payne Bolton School of Nursing (CDE, NE) and the Department of Surgery (JRP), Case Western Reserve University, Cleveland, Ohio
| | - Joel R. Peerless
- The Frances Payne Bolton School of Nursing (CDE, NE) and the Department of Surgery (JRP), Case Western Reserve University, Cleveland, Ohio
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