1 Nurses Nurses’ Role in Mechanical Role in Mechanical Ventilation: an International Ventilation: an International Perspective Perspective Louise Rose Louise Rose Lawrence S. Bloomberg Professor in Critical Care Nursing University of Toronto Adjunct Scientist Li Ka Shing Institute, St Michael's Hospital Research Scientist, Mount Sinai Hospital [email protected]Why is it important to make Why is it important to make international comparisons? international comparisons? Comparisons between countries are Comparisons between countries are no only useful but essential to no only useful but essential to….. .. identify available resources in different identify available resources in different countries countries interpret study results interpret study results study the efficacy/effectiveness of critical study the efficacy/effectiveness of critical care itself and the influence of various care itself and the influence of various organizational factors organizational factors • Wunsch Wunsch et al, 2007 et al, 2007 Curr Curr Opin Opin Crit Care Crit Care Why is Mechanical Ventilation Why is Mechanical Ventilation Important for Nurses? Important for Nurses? 24 hour bedside presence 24 hour bedside presence Nurses able to: Nurses able to: • identify changing physiological responses and initiate identify changing physiological responses and initiate interventions without delay interventions without delay • recognize weaning readiness recognize weaning readiness Availability of RTs differs Availability of RTs differs institutionally/internationally institutionally/internationally • RN lack of understanding for ventilatory/weaning RN lack of understanding for ventilatory/weaning processes may increase duration of mechanical processes may increase duration of mechanical ventilation ventilation and and result in negative patient outcomes result in negative patient outcomes Patients who undergo prolonged mechanical Patients who undergo prolonged mechanical ventilation require multidisciplinary, multi ventilation require multidisciplinary, multi-system system approach approach What What’ s Happening in s Happening in Canada Canada… With thanks to Ms Orla Smith With thanks to Ms Orla Smith St Michael St Michael’ s Hospital s Hospital ICU Profile ICU Profile Canadian ICUs admit approx 100,000 Canadian ICUs admit approx 100,000 patients each year patients each year Conservatively consume 8% of hospital Conservatively consume 8% of hospital budget budget Survey of 98 Canadian ICUs in 2003: Survey of 98 Canadian ICUs in 2003: • median number of ICU beds ~ 14 median number of ICU beds ~ 14 • median number of staff median number of staff-physicians ~ 5 physicians ~ 5 • median number admissions/ICU/yr ~ 751 median number admissions/ICU/yr ~ 751 • overnight physician coverage ~ 51% (adult overnight physician coverage ~ 51% (adult ICUs ) ICUs ) Parshuram et al (2006). Crit Care Med. 34: 1674-1678 ICU Staffing ICU Staffing MOHLTC, 2005
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NursesNurses’’ Role in Mechanical Role in Mechanical
Ventilation: an International Ventilation: an International
PerspectivePerspectiveLouise RoseLouise Rose
Lawrence S. Bloomberg Professor in Critical Care Nursing
University of Toronto
Adjunct Scientist Li Ka Shing Institute, St Michael's Hospital
Why is it important to make Why is it important to make
international comparisons?international comparisons?
�� Comparisons between countries are Comparisons between countries are
no only useful but essential tono only useful but essential to……....�� identify available resources in different identify available resources in different
countriescountries
�� interpret study resultsinterpret study results
�� study the efficacy/effectiveness of critical study the efficacy/effectiveness of critical
care itself and the influence of various care itself and the influence of various
organizational factorsorganizational factors
•• WunschWunsch et al, 2007 et al, 2007 CurrCurr OpinOpin Crit CareCrit Care
Why is Mechanical Ventilation Why is Mechanical Ventilation
�� Availability of RTs differs Availability of RTs differs institutionally/internationallyinstitutionally/internationally
•• RN lack of understanding for ventilatory/weaning RN lack of understanding for ventilatory/weaning processes may increase duration of mechanical processes may increase duration of mechanical
ventilation ventilation and and
result in negative patient outcomesresult in negative patient outcomes
�� Patients who undergo prolonged mechanical Patients who undergo prolonged mechanical ventilation require multidisciplinary, multiventilation require multidisciplinary, multi--system system approachapproach
WhatWhat’’s Happening in s Happening in
CanadaCanada……
With thanks to Ms Orla SmithWith thanks to Ms Orla Smith
St MichaelSt Michael’’s Hospitals Hospital
ICU ProfileICU Profile
�� Canadian ICUs admit approx 100,000 Canadian ICUs admit approx 100,000 patients each yearpatients each year
�� Conservatively consume 8% of hospital Conservatively consume 8% of hospital budgetbudget
�� Survey of 98 Canadian ICUs in 2003:Survey of 98 Canadian ICUs in 2003:•• median number of ICU beds ~ 14median number of ICU beds ~ 14
•• median number of staffmedian number of staff--physicians ~ 5physicians ~ 5
•• median number admissions/ICU/yr ~ 751median number admissions/ICU/yr ~ 751
Parshuram et al (2006). Crit Care Med. 34: 1674-1678
ICU StaffingICU Staffing
MOHLTC, 2005
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Mechanical Ventilation in OntarioMechanical Ventilation in Ontario
Key epidemiological trends 1992Key epidemiological trends 1992--2000:2000:�� >150,000 non>150,000 non--cardiac surgery patients received cardiac surgery patients received
mechanical ventilationmechanical ventilation
�� Incidence of mechanical ventilation increased by 9% Incidence of mechanical ventilation increased by 9%
�� 10% of all mechanically ventilated patients had >1 10% of all mechanically ventilated patients had >1
episode of mechanical ventilationepisode of mechanical ventilation
�� 30% increase in mechanical ventilation days30% increase in mechanical ventilation days
•• Mechanical ventilation days consume one of every 16 Mechanical ventilation days consume one of every 16
hospital inpatient bed dayshospital inpatient bed days
�� Mortality increased by 22%Mortality increased by 22%
Needham et al. (2004). Crit Care Med. 32:1504-1509
Needham et al. (2004). Crit Care Med. 32 1504-1509
Needham et al. (2004). Crit Care Med. 32 1504-1509
Change in patient characteristics Change in patient characteristics
from 1992 to 2000from 1992 to 2000
�� ↑↑ >80 years old>80 years old
�� ↑↑ respiratory diseaserespiratory disease
�� ↓↓ cardiovascular disease and cardiovascular disease and
neoplasmsneoplasms
�� ↑↑ inpatient and 30inpatient and 30--day mortalityday mortality
Ventilation in Ontario in 2026Ventilation in Ontario in 2026�� Number of Number of
mechanically mechanically ventilated patients ventilated patients projected to increase projected to increase by 80%by 80%•• crude increase of >30%crude increase of >30%
•• annual increase of 2.3%annual increase of 2.3%
�� Mechanical ventilation Mechanical ventilation days will consume 1 of days will consume 1 of every 9 hospital every 9 hospital inpatient bed daysinpatient bed days•• indicative of increased inindicative of increased in--
patient acuitypatient acuity
�� Worsening shortage of Worsening shortage of intensivists and critical intensivists and critical care nursescare nurses Needham et al. (2005). Crit Care Med, 33 574-579
Relevant Studies: Clinician Roles in Relevant Studies: Clinician Roles in
Weaning in CanadaWeaning in Canada
Burns et al. (Unpublished data)
Standards for Critical Care Nursing Standards for Critical Care Nursing
PracticePractice
� The critical care nurse:
� collects data using technological supports
• anticipates and/or recognizes actual or potential immediate life
threatening health crises including:� Ineffective airway clearance, breathing patterns, and impaired gas exchange
� intervenes to provide effective airway clearance by:
• positioning
• managing airway, adjunctive airways, and secretions
• administering pharmacologic agents
• managing secretions
� intervenes to correct an ineffective breathing pattern by:• administering pharmacologic agents as ordered
• troubleshooting inadequate mechanical supports
• manually ventilating
• assisting with interventions
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�� The critical care nurse: The critical care nurse:
�� interpretsinterprets diagnostic data including:diagnostic data including:
•• arterial and venous blood gases and other laboratory arterial and venous blood gases and other laboratory
resultsresults
•• ventilation informationventilation information
•• weaning parametersweaning parameters
�� intervenesintervenes to correct impaired gas exchange by managing to correct impaired gas exchange by managing
changeschanges inin::
•• oxygenationoxygenation
•• minute ventilationminute ventilation
•• modes of ventilationmodes of ventilation
�� intervenesintervenes to promote successful weaning from ventilatory to promote successful weaning from ventilatory
support by ensuring adequate nutrition, pain management, support by ensuring adequate nutrition, pain management,
rest, and alleviation from anxietyrest, and alleviation from anxiety
Standards for Critical Care Nursing Standards for Critical Care Nursing
PracticePracticeNursesNurses’’ Role in CanadaRole in Canada
�� Little empirical dataLittle empirical data
�� Not focused on manipulation of the Not focused on manipulation of the
ventilator or decisionventilator or decision--makingmaking
�� Focus directed towards care of the Focus directed towards care of the
ventilated patientventilated patient
•• ongoing assessment and surveillanceongoing assessment and surveillance
•• symptom managementsymptom management
•• optimizing patient for weaningoptimizing patient for weaning
WhatWhat’’s happening in the s happening in the
United StatesUnited States……
With thanks to Dr Susan Frazier With thanks to Dr Susan Frazier and Sarah Kelly and Sarah Kelly
ICU ProfileICU Profile
� Approx 5980 ICUs
• approx 55,000 pts per day
• 4245 (71%) in non-teaching community hospitals
• 3183 (53%) have no intensivist coverage
• 20% had in-house physician coverage on weekends,
12% on week nights and 10% of week end nights
• respiratory insufficiency primary reason for admission
• nurse-to-patient ratio 1:2
• RT ratios vary across institutions
� Angus et al. (2006) Crit Care Med. 34: 1016-1024� Brilli et al. (2001) Crit Care Med. 29: 2007-2019
Mechanical Ventilation in the USMechanical Ventilation in the US
�� Population adjusted incidence of Population adjusted incidence of mechanical ventilation mechanical ventilation ↑↑ 11% 11% (1996(1996--2002)*2002)*
• No corresponding increase in ICU beds
•• >64 years of age >64 years of age -- ↑↑ 4%4%
•• 1818--64 years of age 64 years of age –– ↑↑ 19%19%
•• higher burden of cohigher burden of co--morbidities (morbidities (CharlsonCharlsonindex) index)
•• proportion of patients ventilated >96 hours proportion of patients ventilated >96 hours increased from 33% to 35%increased from 33% to 35%
•• adjusted mean hospital charges rose 12%adjusted mean hospital charges rose 12%
*Data from North Carolina
Carson, et al. (2006) J Intensive Care Med. 21: 173-182
Relevant Studies in the USRelevant Studies in the US
�� Mail surveyMail survey
�� ParticipantsParticipants
•• Random sample Random sample -- American Association of Critical American Association of Critical
Audit Commission (1999) Critical to Success. Audit Commission: London
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Staffing ProfileStaffing Profile
�� 22––7 medical consultants responsible for clinical 7 medical consultants responsible for clinical
care/ICUcare/ICU
•• few fullfew full--time intensivists time intensivists –– most have anaesthetic or most have anaesthetic or
medical sessions in addition to ICU commitmentmedical sessions in addition to ICU commitment
•• junior doctor staffing levels lower in UK than Europe junior doctor staffing levels lower in UK than Europe
�� General policy in UK is 1:1 nurse patient ratioGeneral policy in UK is 1:1 nurse patient ratio
�� 45% of nurses in UK hold ENB 100: 645% of nurses in UK hold ENB 100: 6--12 month 12 month
qualification in critical care specialtyqualification in critical care specialty
�� No RTsNo RTs
Audit Commission (1999) Critical to Success. Audit Commission: London
The NurseThe Nurse’’s Roles Role
>50%
>95%
>20%
Weaning from Mechanical VentilationWeaning from Mechanical Ventilation
� Since 1997, focus on decreasing unacceptable variations in practice• White Paper: the New NHS (DoH 1997)
• A First Class Service: Quality in the new NHS (DoH 1998)
� 2000 – establishment of critical care nurse consultants, practice development teams
� NHS Survey of Weaning and Long-term ventilation (2002)
• 22% of hospitals responding to survey used weaning protocol
• 1% used weaning team
• Rest clinician-led –though professional group of ‘clinician’ not specified
�� ..
Rationales for NurseRationales for Nurse--led Protocolsled Protocols
�� Evidence from US = Evidence from US = ↓↓ ventilator daysventilator days
�� Initiatives expanding nurse role/ Initiatives expanding nurse role/ improving patient outcomesimproving patient outcomes•• Scope of Professional Practice, 1992Scope of Professional Practice, 1992
•• Comprehensive Critical Care, 2000Comprehensive Critical Care, 2000
•• Critical to Success, 2002Critical to Success, 2002
�� Weaning inefficient due to need for Weaning inefficient due to need for medical approval to progress weaningmedical approval to progress weaning
�� NonNon--uniform nursing clinical expertise to uniform nursing clinical expertise to lead weaning processlead weaning process•• Protocols standardizing practice, guiding junior Protocols standardizing practice, guiding junior
staff and optimizing patient outcomestaff and optimizing patient outcome
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Study ConclusionsStudy Conclusions
� ICU cultures & interprofessional working practices may also influence findings• Kollef protocols had least effect in unit where
weaning delegated to nurses (7.9-hours longer)
• Marelich reported no effect in unit that had a standardised multi-disciplinary approach
� Thus, while protocols may streamline practice & reduce variability where this exists, they do not affect outcomes in units where good communication & standardised practice already exists.
WhatWhat’’s Happening s Happening
DownunderDownunder……
ICU ProfileICU Profile
�� 195 ICUs in Aus and NZ195 ICUs in Aus and NZ�� Majority are combined units, very few Majority are combined units, very few
specializedspecialized�� All All closed closed intensivistintensivist--led led unitsunits
�� Aus: 1233 available beds/20325,926 Aus: 1233 available beds/20325,926 populationpopulation
�� Mean beds 13/ICUMean beds 13/ICU�� ICU admission 2.24% of overall hospital ICU admission 2.24% of overall hospital
admissionsadmissions
�� Median LOS: 43 hoursMedian LOS: 43 hours�� Median APACHE II 15.57Median APACHE II 15.57
Intensive Care Resources & Activity: Australia and New Zealand 2003-2005
ICU WorkforceICU Workforce
�� 3.9 beds/intensivist3.9 beds/intensivist
�� ICUs also staffed by senior ICUs also staffed by senior
registrars/registrars and residentsregistrars/registrars and residents
�� 1:1 nurse1:1 nurse--toto--patient ratiopatient ratio
�� 56% of RNs hold postgraduate 56% of RNs hold postgraduate
specialty qualificationspecialty qualification
�� No RTsNo RTs
�� Interdisciplinary team focusInterdisciplinary team focus
Intensive Care Resources & Activity: Australia and New Zealand 2003-2005
Bellomo et al. (2007) Curr Opin Anaesth, 20:100-105
Nursing Input Medical Input Only
n % (95% CI) n % (95% CI)
Readiness to wean 46 85 (73-93) 8 15 (7-27)
Weaning method 39 72 (58-84) 15 28 (16-42)
Readiness to extubate 36 67 (53-79) 18 33 (21-47)
Weaning failure 51 94 (85-99) 3 6 (1-15)
Nursing input defined as either independent or collaborative
Ventilation Decisions made by Ventilation Decisions made by
�� ExclusivelyExclusively nursingnursing decisions, prior to and during decisions, prior to and during weaning, associated withweaning, associated with::
•• post operative respiratory failurepost operative respiratory failure oror coma coma
•• duration of ventilation duration of ventilation ≤≤ seven daysseven days
�� NursingNursing decisions were less common decisions were less common
Multivariate Cox proportional hazards model adjusted for all othMultivariate Cox proportional hazards model adjusted for all other variables.er variables.
Test of proportional hazards assumption: P = 0.97 (Test of proportional hazards assumption: P = 0.97 (SchoenfeldSchoenfeld residuals)residuals)
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All 1All 1°° and 2and 2°° OutcomesOutcomes**
* Estimated median durations (Kaplan* Estimated median durations (Kaplan--Meier)Meier)
Separation
Wean
Ventilation
ICU Stay
0
2 4
4 8
7 2
9 6
1 2 0
1 4 4
1 6 8
1 9 2 S m a r tC a r e /P S
C o n tr o l
P = 0 .3
P = 0 .6
P = 0 .9
P = 0 .7
Duration (h)
ComplicationsComplications
Characteristic n (%) SmartCare/PS Usual weaning P value*
Reintubation
Within 48 hours 5 (10) 6 (12) 1.0
NIV post extubation 8 (16) 6 (12) 0.8
Self extubation 0 0 1.0
Tracheostomy 6 (12) 8 (16) 0.8
Duration of ventilation >21 days 2 (4) 3 (6) 1.0
Death
On protocol 2 (4) 1 (2) 0.4
In ICU 7 (14) 1 (2) 0.06
* Fisher exact tests* Fisher exact tests
ConclusionsConclusions
�� Weaning with SmartCare/PSWeaning with SmartCare/PS
comparable tocomparable to
weaning by weaning by qualified and ventilationqualified and ventilation--
experienced ICU nursesexperienced ICU nurses working with working with
trained intensiviststrained intensivists
�� Advantages of SmartCare/PS may vary Advantages of SmartCare/PS may vary
according to ICU clinical organisationaccording to ICU clinical organisation
Final WordsFinal Words�� Nursing role in mechanical ventilation and Nursing role in mechanical ventilation and