Are Doctors and Nurses Sharing the Responsibility for Timely and Safe Weaning of Mechanically Ventilated Pediatric Patients?

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In this issue of Pediatric Critical Care Medicine, Tume et al (1) report their results of a cross-sectional electronic survey of decision-making, doctor-nurse collaboration, and perceived nursing autonomy in mechanical ventilation weaning practices from 65 PICUs in 19 European countries.
These are important factors in critical care medicine as the complexities of mechanical ventilation management, sedation administration, and ventilator weaning practices require strong interprofessional collaboration and communication to promote timely extubation and targeted safety outcomes. Literature demonstrates these practice areas may be highly variable across pediatric ICUs (2–4). Even within a specific ICU, variation in patient outcomes may be affected by the presence and adherence to weaning and sedation protocols (5). Further variation may be influenced by organizational culture, clinician staffing, nursing-to-patient ratio, case-mix, healthcare professional educational training, confidence, and experience (6–9). Variability in practice and poor communication has been linked to poor patient safety outcomes in unintended extubations, healthcare acquired infection rates, and prolonged length of ventilation (10–13). Although adult literature in mechanical ventilation and daily interruption of sedative infusions has led to reduced duration of mechanical ventilation and reduced morbidity, we do not have universally adopted protocols for weaning or sedation in the mechanically ventilated pediatric patient (4, 13).
Tume et al (1) survey current practice in European countries to benchmark areas for quality improvement and to describe the collaborative decision-making in usual care. They received a 64% response rate (65/102 PICUs). Of PICUs, 92% were university affiliated, 97% intensivist-led in mixed medical-surgical units, and 25 units additionally provide cardiac surgery. The median PICU size was 12 beds (range, 4–52) and median annual admissions 550 (range, 100–1,700) with median of 320 (range, 30–1,218) admissions for children being ventilated. The authors report eight key ventilation and weaning decision as being collaborative: 1) initiation of noninvasive ventilation (NIV); 2) wean/discontinue NIV; 3) select initial ventilator settings; 4) assessing weaning readiness; 5) titration of ventilator settings; 6) determining weaning method; 7) identify weaning failure (defined as need to reinstate ventilatory support or reintubate); and 8) identify extubation readiness.
Of 63 PICUs reporting decision-making responsibility, seven PICUs (11%) reported all eight decisions were made by physician only and a further seven (11%) reported all eight decisions were based on interprofessional collaborative discussion. They found collaborative decision-making and perceived nurse autonomy varied across ICUs in Europe and were highest in Northern Europe. Most PICUs enabled the physicians in registrar (fellow) positions to have responsibility for key vent decisions. Few PICUs reported nurse autonomy in titrating ventilator settings except FIO2.
The decision most likely to be based on interprofessional collaboration (51/63 [81%]) was the determination of weaning failure, whereas selection of the weaning method and initial ventilator settings were the least likely to involve collaborative decision-making. The authors found European ICUs rarely had written guidelines and protocols for ventilation (31%), weaning (22%), and NIV (33%), whereas protocols for weaning sedation (66%) and sedation assessment tools (76%) were common.
We can put these findings of 19 European countries in perspective with large recent international and U.S.-based multicenter studies. The International Group for Mechanical Ventilation in Children, the Pediatric Acute Lung Injury and Sepsis Investigators, and the Randomized Evaluation of Sedation Titration for Respiratory Failure Investigators showed that children receiving mechanical ventilation for greater than 24 hours are a median of 1 year old and ventilated for 6–7 days and are frequently exposed to multiple sedative medications and more than one ventilator mode (4, 14, 15). Extubation failure rates are between 4% and 15%. Longer length of ventilation and extubation failure events are associated with increased morbidity and mortality for pediatric patients (10).

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