Decisional responsibility for mechanical ventilation and weaning: an international survey

Abstract Introduction 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. Methods 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. Results 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. Conclusions 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

Three patterns of symptom communication between patients and clinicians in the intensive care unit: A fieldwork study

Aim: To describe different patterns of communication aimed at preventing, identify- ing and managing symptoms between mechanically ventilated patients and clinicians in the intensive care unit. Design: We conducted a fieldwork study with triangulation of participant observation and individual interviews. Methods: Participant observation of nine patients and 50 clinicians: nurses, physiother- apists and physicians. Subsequent individual face-to-face interviews with nine of the cli- nicians, and six of the patients after they had regained their ability to speak and breathe spontaneously, were fully alert and felt well enough to sit through the interview. Findings: Symptom communication was found to be an integral part of patient care. We identified three communication patterns: (1) proactive symptom communication, (2) reactive symptom communication and (3) lack of symptom communication. The three patterns co-existed in the cases and the first two complemented each other. The third pattern represents inadequate management of symptom distress. Conclusion: Recognition of symptoms in non-speaking intensive care patients is an important skill for clinicians. Our study uncovered three patterns of symptom commu- nication, two of which promoted symptom management. The third pattern suggested that clinicians did not always acknowledge the symptom distress. Implications for Patient Care: Proactive and reactive symptom assessment of non- speaking patients require patient verification when possible. Improved symptom prevention, identification and management require a combination of sound clinical judgement and attentiveness towards symptoms, implementation and use of relevant assessment tools, and implementation and skill building in augmentative and alterna - tive communication. Impact: This study addressed the challenges of symptom communication between mechanically ventilated patients and clinicians in the intensive care unit. Our findings may have an impact on patients and clinicians concerned with symptom management in intensive care units. Reporting Method: We used the consolidated criteria for reporting qualitative research.publishedVersio

Patient and family experiences of early cognitive rehabilitation in critical illness:A qualitative study protocol

Background: Physical, mental and cognitive impairments are known severe adverse outcomes in critically ill patients who have beenadmitted to an intensive care unit (ICU). Early rehabilitation interventions such as lighter sedation and increased mobilization have improved patient outcomes, but evidence for early cognitive rehabilitation is sparse. Aim: The study aims to describe the experiences of ICU survivors and their families regarding early cognitive stimulation as part of rehabilitation during and after ICU admission. Design: Our study has a qualitative, descriptive design using individual and dyad interviews as well as focus groups with ICU survivors and their families. Methods: Eligible participants are adult ICU survivors and families who are able to recall events during and after the ICU stay. We will use purposeful sampling in the outpatient clinic in the Department of Intensive Care at the Copenhagen University Hospital. We plan to conduct five individual patient interviews, four dyad interviews with patients and families, and two focus groups with patients. All interviews will follow a semi-structured interview guide based on the study objectives and input from a patient and public involvement (PPI) panel. We will use the framework method for analysis and invite the PPI panel to participate in the analysis process to strengthen the findings. Written informed consent will be obtained from all participants, and data will be anonymized before analyses. Relevance for Clinical Practice: This study protocol provides a methodological framework to understand early cognitive rehabilitation from the perspectives of ICU survivors and their families. This study protocol presents one of the first studies to investigate the concept of early cognitive rehabilitation during critical illness from this perspective. The findings will facilitate a tailored approach to early rehabilitation to be investigated in further studies.</p

The influence of diabetes distress on digital interventions for diabetes management in vulnerable people with type 2 diabetes:A qualitative study of patient perspectives

Background: Digital interventions for improving diabetes management in Type 2 diabetes mellitus (T2DM) are used universally. Digital interventions are defined as any intervention accessed and taking input from people with T2DM in the form of a web-based or mobile phone-based app to improve diabetes self-management. However, the current confidence in digital interventions threatens to augment social inequalities in health, also known as the “digital divide”. To counteract dissemination of the digital divide, we aimed to assess the potential of a tailored digital intervention for improving diabetes management in vulnerable people with T2DM. Methods: A qualitative design using semi-structured in-depth interviews to explore the perspectives of 12 vulnerable people with T2DM. Interviews were analyzed using inductive content analysis. Vulnerability was defined by the presence of one or more comorbidities, one or more lifestyle risk factors, poor diabetes management, low educational level and low health literacy. Results: The main themes identified were: “Dealing with diabetes distress” characterized by psychological avoidance mechanisms; “Suffering informational confusion” dealing with inconsistent information; “Experiencing digital alienation” dealing with loss of freedom when technology invades the private sphere; and “Missing the human touch” preferring human interaction over digital contact. Conclusion: Vulnerable people with T2DM are unprepared for digital interventions for disease management. Experiencing diabetes distress may be an intermediate mechanism leading to nonadherence to digital interventions and the preference for human interaction in vulnerable people with T2DM. Future interventions could include a designated caregiver and an allocated buddy to provide support and assist uptake of digital interventions for diabetes management. Keywords: Type 2 diabetes, Digital interventions, Vulnerable population, Health inequalities, Diabetes distress, Qualitative researc