Mechanical ventilation, weaning practices, and decision making in European PICUs

Kneyber, Martin C.J.; Tume, Lyvonne N; Blackwood, Bronagh; Rose, Louise

Abstract

Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Objectives: This survey had three key objectives: 1) To describe responsibility for key ventilation and weaning decisions in European PICUs and explore variations across Europe; 2) To describe the use of protocols, spontaneous breathing trials, noninvasive ventilation, high-flow nasal cannula use, and automated weaning systems; and 3) To describe nurse-to-patient staffing ratios and perceived nursing autonomy and influence over ventilation decision making. Design: Cross-sectional electronic survey. Setting: European PICUs. Participants: Senior ICU nurse and physician from participating PICUs. Interventions: None. Measurements and Main Results: Response rate was 64% (65/102) representing 19 European countries. Determination of weaning failure was most commonly based on collaborative decision making (81% PICUs; 95% CI, 70-89%). Compared to this decision, selection of initial ventilator settings and weaning method was least likely to be collaborative (relative risk, 0.30; 95% CI, 0.20-0.47 and relative risk, 0.45; 95% CI, 0.32-0.45). Most PICUs (> 75%) enabled physicians in registrar (fellow) positions to have responsibility for key ventilation decisions. Availability of written guidelines/protocols for ventilation (31%), weaning (22%), and noninvasive ventilation (33%) was uncommon, whereas sedation protocols (66%) and sedation assessment tools (76%) were common. Availability of protocols was similar across European regions (all p > 0.05). High-flow nasal cannula (53%), noninvasive ventilation (52%) to avoid intubation, and spontaneous breathing trials (44%) were used in approximately half the PICUs greater than 50% of the time. A nurse-to-patient ratio of 1:2 was most frequent for invasively (50%) and noninvasively (70%) ventilated patients. Perceived nursing autonomy (median [interquartile range], 4 [2-6]) and influence (median [interquartile range], 7 [5-8]) for ventilation and weaning decisions varied across Europe (p = 0.007 and p = 0.01, respectively) and were highest in Northern European countries. Conclusions: We found variability across European PICUs in interprofessional team involvement for ventilation decision making, nurse staffing, and perceived nursing autonomy and influence over decisions. Patterns of adoption of tools/adjuncts for weaning and sedation were similar.

• Journal Article Type: Review
• Acceptance Date: Oct 12, 2016
• Publication Date: Apr 1, 2017
• Deposit Date: Jul 24, 2017
• Journal: Pediatric Critical Care Medicine
• Print ISSN: 1529-7535
• Electronic ISSN: 1947-3893
• Publisher: Lippincott, Williams & Wilkins
• Peer Reviewed: Peer Reviewed
• Volume: 18
• Issue: 4
• Pages: e182-e188
• DOI: https://doi.org/10.1097/PCC.0000000000001100
• Keywords: critically ill child, intensive care, mechanical ventilation,; noninvasive ventilation, survey
• Public URL: https://uwe-repository.worktribe.com/output/889799
• Publisher URL: http://dx.doi.org/10.1097/PCC.0000000000001100
• Additional Information: Additional Information : This is the author's accepted manuscript. The final published version can be accessed via the following link: http://dx.doi.org/10.1097/PCC.0000000000001100
• Contract Date: Jul 24, 2017