Mechanical Ventilation-Related Safety Incidents in General Care Wards and ICU Settings

Evaluation of the Puritan Bennett™ 980 Ventilator System Safety and Performance in the Real-World Setting

Purpose

Mechanical ventilation is a life-supporting intervention but is associated with known risks and complications. To improve the efficacy and safety profile of mechanical ventilation, manufacturers have developed advanced ventilator settings, modes, and alarm strategies to optimize ventilation for patient needs while avoiding complications. However, there is little real-world data published on the deployment of ventilator technology. The main objective of this study was to assess the clinical safety and performance of the Puritan Bennett™ 980 Ventilator System (PB980) using real-world clinical data collected from a diverse, global patient population.

Methods

This was a multi-center, post-market registry study that included nine sites: four in the United States of America, one in Europe, and four in China. Patients were enrolled into the registry if they were intended to be treated with a PB980. Data collection began at the start of ventilation and continued until extubation off the ventilator or up to seven days of ventilation, whichever occurred first. Subjects were divided by age into three categories: infants (0-365 days), pediatric (1-17 years), and adult (18 years and older). The primary outcome was device-related complication rate.

Results

Two-hundred-and-eleven subjects were enrolled (41 infants, 48 pediatric, and 122 adults). Sixteen deaths, unrelated to device deficiency, occurred during the data collection timeframe (relative frequency: 7.58, 95% CI: 4.40, 12.0). Only one device-related adverse event was reported (relative frequency: 0.47% 95% CI: 0.01%, 2.61%).

Conclusion

Ventilation by the PB980 was delivered safely in this multi-center observational study, which included a diverse sample of patients with broad ventilatory needs.

Validity and Reliability of a Short Form of the Questionnaire for the Reflective Practice of Nursing Involving Invasive Mechanical Ventilation: A Cross-Sectional Study

The number of patients on ventilators is rapidly increasing owing to the coronavirus pandemic. The previously developed Questionnaire for the Reflective Practice of Nursing Involving Invasive Mechanical Ventilation (Q-RPN-IMV) for the care of patients on ventilators includes nurses' thought processes as items. This study aims to develop a short form of the Q-RPN-IMV for immediate use in practice and to test its reliability and validity. A convenience sample of 629 participants was used to explore the factor structure using factor analysis. The test-retest reliability was assessed using the intraclass correlation coefficient (ICC). The study was a cross-sectional design instrument development study and was reported according to GRRAS guidelines. Q-RPN-IMV short form was divided into ventilator management and patient management. The ventilator management comprised 31 items organized into six factors. Cronbach's alpha ranged from 0.82 to 0.91, and the ICC ranged from 0.82 to 0.89. The patient management comprised 27 items organized into five factors. Cronbach's alpha ranged from 0.75 to 0.97, and ICC ranged from 0.75 to 0.97. The Q-RPN-IMV short form is a reliable and validated instrument for assessing care for patients on ventilators. This study was not registered.

Food choking incidents in the hospital: incidents, characteristics, effectiveness of interventions, and mortality and morbidity outcomes

AIM

Foreign body airway obstruction (FBAO) due to food can occur wherever people eat, including in hospitals. We characterized in-hospital FBAO incidents and their outcomes.

METHODS

We searched the Japan Council for Quality Health Care nationwide in-hospital adverse events database for relevant events from 1,549 institutions. We included all patients with FBAO incidents due to food in the hospital from January 2010 to June 2021 and collected data on the characteristics, interventions, and outcomes. FBAO from non-food materials were excluded. Our primary outcomes were mortality and morbidity from FBAO incidents.

RESULTS

We identified 300 patients who had a FBAO incident from food. The most common age group was 80 - 89 years old (32.3%, n = 97/300). One-half (50.0%, n = 150/300) were witnessed events. Suction was the most common first intervention (31.3%, n = 94/300) and resulted in successful removal of foreign body in 17.0% of cases (n = 16/94). Back blows (16.0%, n = 48/300) and abdominal thrusts (8.1%, n = 24/300) were less frequently performed as the first intervention and the success rates were 10.4% (n = 5/48) and 20.8% (n = 5/24), respectively. About one-third of the patients (31%, n = 93/300) died and 26.7% (n = 80/300) had a high potential of residual disability from the incidents.

CONCLUSION

FBAO from food in the hospital is an uncommon but life-threatening event. The majority of patients who suffered from the in-hospital FBAO incidents did not receive effective interventions initially and many of them died or suffered residual disability.

Mechanical Ventilation Trigger Tool Identify Errors Associated with Mechanical Ventilation in Newborn Infant

BACKGROUND: Patient safety is the core of quality of health care. Newborn infants who are admitted to NICU are liable to adverse events. Medical errors represent a serious public health problem and pose a threat to patient safety. Mechanical ventilation is a complex procedure that exposes newborn infants to adverse events and complications. AIM: The objective of this study was to identify medical errors related to mechanical ventilation (MV) in newborn infants using the newly design MV trigger tool. METHODS: Observational cohort study was conducted for 6-month duration to determine the medical errors related to mechanical ventilation. It was carried out on newborn infants who needed mechanical ventilation and admitted to the NICU. Furthermore, we used the mechanical ventilation trigger tool to estimate number, types, and risk factors for the related errors. RESULTS: There were 142 errors related to mechanical ventilation. Nearly 21.13% of the errors were related to ventilator settings, 38.39% were related to endotracheal intubation, and 40.14% of the errors were due to manipulation of the ventilators. The adverse events were diagnosed in 73.24% of the detected errors. Error of commission was seen in 53.5% of cases, and omission errors were reported in 46.5% of the cases. Mechanical ventilation trigger tool has 95.87% sensitivity and 95.24% specificity with 95.77% accuracy to detect errors. CONCLUSION: The mechanical ventilation trigger tool may be efficient and effective in identifying errors and adverse events related to mechanical ventilation; it has high sensitivity and specificity. It might increase awareness to improve MV-related care.

Critical Incident Reports Related to Ventilator Use: Analysis of the Japan Quality Council National Database

OBJECTIVE

This study aimed to assess the factors associated with medical device incidents.

METHODS

In this mixed-methods study, we used incident reporting data from the Japan Council for Quality Health Care. Of the 232 medical device-related reports that were downloaded, 34 (14.7%) were ventilator-associated incidents. Data related to patients, situations, and incidents were collected and coded.

RESULTS

The frequencies of ventilator-associated accidents were 20 (58.8%) during the daytime and 14 (41.2%) during the night/early morning. Ventilator-associated accidents occurred more frequently in the hospital room (n = 22 [64.7%]) than in the intensive care unit (n = 4 [11.8%]). Problems with ventilators occurred in only 4 cases (11.8%); in most cases, medical professionals experienced difficulty with the use or management of ventilators (n = 30 [88.2%]), and 50% of them were due to misuse/misapplication of ventilators (n = 17 [50.0%]). Ventilator-associated accidents were caused by an entanglement of complex factors-hardware, software, environment, liveware, and liveware-liveware interaction. Communication and alarm-related errors were reported to be related, as were intuitiveness or complicated specifications of the device.

CONCLUSIONS

Our study revealed that ventilator-associated accidents were caused by an entanglement of complex factors and were related to inadequate communication among caregivers and families. Moreover, alarms were overlooked owing to inattentiveness. Mistakes were generally caused by a lack of experience, insufficient training, or outright negligence. To reduce the occurrence of ventilator-associated accidents, hospital administrators should develop protocols for employment of new devices. Medical devices should be developed from the perspective of human engineering, which could be one of the systems approaches.

Comparison of the Outcomes of Patients Starting Mechanical Ventilation in the General Ward Versus the Intensive Care Unit

OBJECTIVE

Mechanical ventilation is sometimes initiated in the general ward (GW) due to the shortage of intensive care unit (ICU) beds. We investigated whether invasive mechanical ventilation (MV) started in the GW affects the patient's prognosis compared with its initiation in the ICU.

METHODS

From January 2016 to December 2018, medical records of patients who started MV in the GW or ICU were collected. The 28-day mortality, ICU mortality, ventilator-free days, and complications related to the ventilator and the ventilator-free days were analyzed as outcomes.

RESULTS

A total of 673 patients were enrolled. Among these, 268 patients (39.8%) started MV in the GW and 405 patients (60.2%) started MV within 24 hours after admittance to the ICU. There was no difference in 28-day mortality between the 2 groups (27.2% versus 27.2%, P = 0.997). In addition, there was no difference between ventilator-related complication rates, ventilator-free days, or the length of hospital stay. A high Acute Physiology and Chronic Health Evaluation II score, the presence of solid tumor, the absence of chronic kidney diseases, and low platelet count were associated with higher 28-day mortality. However, the initiation of MV in the GW was not associated with an increase in 28-day mortality compared with the initiation in the ICU.

CONCLUSIONS

Starting MV in the GW was not a risk factor for 28-day mortality. Therefore, prompt application of a ventilator if medically indicated, regardless of the patient's location, is desirable if a skilled airway team and appropriate monitoring are available.

Causes of use errors in ventilation devices - Systematic review

A systematic review according to the PRISMA reporting standard was performed to identify causes of use errors in mechanical ventilators described in the literature. The PubMed search resulted in the inclusion of 16 papers. The errors described were systematically analyzed with regard to their causes and categorized in an adapted cause-and-effect diagram. The causes of use errors were related to specific usability issues and to the general condition that medical staff often work with different ventilators. When many devices are used, the different user interfaces are a source of use errors, since, for example, the same ventilation modes have different names. In order to avoid the identified causes for use errors in the future, this work offers manufacturers of ventilation devices design recommendations and the possibility to include the results in their risk management. In addition, standardizing user interface content across all ventilators, as in ISO 19223, can help reduce use errors.

Survival of mechanically ventilated ward patients and association with organisational factors: a multicentre prospective study

OBJECTIVES

Determine 90-day mortality of mechanically ventilated ward patients outside the intensive care unit (ICU) and its association with organisational factors.

DESIGN

Multicentre prospective observational study of mechanically ventilated ward patients. Modified Poisson regression was used to assess association between nurse to patient ratio (NPR) and 90-day mortality, adjusted for designated medical team, Society of Critical Care Medicine (SCCM) triage priority and centre effect. NPR was divided into low (1:9.6 to 1:10), medium (1:6 to 1:8) and high (1:2.6). Sensitivity analysis was conducted for pneumonia with or without acute respiratory distress syndrome (ARDS) to assess magnitude of association.

SETTING

7 acute public hospitals in Hong Kong.

PARTICIPANTS

All 485 mechanically ventilated patients in wards from participating hospitals between 18 January 2016 and 17 April 2016 were recruited. Three hundred patients were included after excluding patients with limitation of therapy within 24 hours of intubation.

MAIN OUTCOMES

90-day mortality, Mortality Prediction Model III Standardised mortality ratio (MPMIII₀ SMR).

RESULTS

201 patients died within 90 days after intubation (67.0%, 95% CI 61.5% to 72.1%), with MPMIII₀ SMR 1.88, 95% CI 1.63 to 2.17. Compared with high NPR, medium and low NPRs were associated with higher risk of 90-day mortality (adjusted relative risk (RR_adj) 1.84, 95% CI 1.70 to 1.99 and 1.64, 95% CI 1.47 to 1.83, respectively). For 114 patients with pneumonia with or without ARDS, low to medium NPR, too sick to benefit from ICU (SCCM priority 4b), no ICU consultation and designated medical team were associated with risk of 90-day mortality (RR_adj 1.49, 95% CI 1.40 to 1.58; RR_adj 1.60, 95% CI 1.49 to 1.72; RR_adj 1.34, 95% CI 1.27 to 1.40; RR_adj 0.85, 95% CI 0.78 to 0.93, respectively).

CONCLUSION

The 90-day mortality rates of mechanically ventilated ward patients were high. NPR was an independent predictor of survival for mechanically ventilated ward patients.

The Effect of a Non-Invasive Positive Pressure Ventilation Simulation Program on General Ward Nurses' Knowledge and Self-Efficacy

The purpose of this study is to develop a simulation-based ventilator training program for general ward nurses and identify its effects. Quantitative data were collected from 29 nurses (intervention group: 15, control group: 14), of which seven were interviewed with focus groups to collect qualitative data. The quantitative results revealed significant differences in ventilator-related knowledge (p = 0.029) and self-efficacy (p = 0.026) between the intervention and control groups. Moreover, three themes were derived from meaningful statements in the qualitative data: understanding psychophysical discomfort of the patient while applying the ventilator; helping in ventilator care; and establishing a future ventilator training strategy. The findings confirmed that the non-invasive positive pressure ventilation (NPPV) simulation program is an effective method for improving the knowledge of ventilator nursing and self-efficacy and will be helpful in developing educational methods and strategies related to ventilator nursing for general ward nurses.

Epidemiology and outcomes of invasive mechanical ventilation without ICU admission in acute care hospitals in Texas: A population-based cohort study

PURPOSE

The high ICU bed capacity in the United States (US) allows ICU care of patients requiring invasive mechanical ventilation (IMV), absent public health crisis. The use of IMV without ICU admission (non-ICU) in acute care hospitals in the US and its impact on patients' outcomes were not examined.

METHODS

A retrospective cohort study was performed using statewide inpatient data in Texas to identify hospitalizations aged ≥18 years receiving IMV in acute care hospitals with ICU care capability during January 2014 through September 2015. Use of non-ICU IMV, patient characteristics, and hospital mortality were examined.

RESULTS

Among 136,728 IMV hospitalizations, 4531 (3.3%) were non-ICU. As compared to ICU admissions, non-ICU IMV hospitalizations were younger (age 18-44 years: 24.9% vs. 17.2%), with lower burden of major comorbidities (no major comorbidity: 24.7% vs. 14.5%), and lower occurrence of non-respiratory organ failures (no non-respiratory organ failure: 32.7% vs. 19.8%). Risk-adjusted hospital mortality of non-ICU vs. ICU IMV hospitalizations was 48.7% (95% CI 48.1-49.4) and 29.9% (95% CI 29.8-30.0), respectively.

CONCLUSIONS

Non-ICU IMV was provided in 1 in 30 IMV hospitalizations in acute care hospitals. Although non-ICU IMV hospitalizations were younger and healthier than those admitted to ICU, their hospital mortality was markedly higher.