By Linda L. Chlan, RN, PhD, Dean’s Distinguished Professor of Symptom Management Research, The Ohio State University, College of Nursing
Dr. Chlan reports that she receives grant/research support from the National Institutes of Health.
Synopsis: Implementation of a nurse-driven protocol for weaning patients resulted in shortened duration of mechanical ventilation, shorter ICU stays, and a higher rate of successful weaning, with ICU physicians reporting a generally positive attitude toward nurses being responsible for protocol-directed weaning.
Source: Danckers M, et al. Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. J Crit Care 2012; Dec. 19. [Epub ahead of print.]
The purpose of this study was to compare the usual method of physician-directed weaning from mechanical ventilation to a weaning protocol directed and managed by bedside ICU nurses. Not all ICUs have the luxury of full-time, dedicated respiratory therapist staffing. Thus, an innovative strategy to promote timely liberation from mechanical ventilation was examined by this group of physician and nurse investigators.
The study was conducted in an intensivist-led, 13-bed, medical-surgical ICU in a teaching-affiliated hospital in the New York area. A prospective study design was used to compare retrospective data from a specific 6-month period of physician-directed weaning outcomes with patient outcomes during a 6-month prospective period of the nurse-driven ventilator weaning protocol. The hospital critical care committee developed the nurse-managed weaning protocol. Main outcomes for comparison included duration of mechanical ventilation (days), ICU length of stay, ventilator-associated pneumonia (VAP) rates, hospital mortality, and physician attitudes toward the nurse-managed protocol. The comparison and study periods were January to June to omit any seasonal variations in census. The nursing staff had an average of 15 years of ICU experience with a majority of the staff certified in critical care nursing. The nurses participated in protocol training and education sessions prior to implementation of the protocol, with a 1-month pilot period to gain familiarity with the protocol and to standardize communication with physicians. A weaning-readiness and weaning-tolerance tool was an essential component of the developed protocol. Details of this tool and criteria are available in the original article. Patients were extubated if they tolerated a spontaneous breathing trial, which was first verified by the physician.
There were 462 patients admitted to the ICU during the examination of the retrospective phase of the study, with 476 patients admitted during the prospective study phase. There were no significant differences among patients (age, gender, APACHE II scores, SOFA scores, comorbidities) during the two study phases. Results reported from this study include shorter median days for mechanically ventilated in the nurse-driven group (2 days) as compared to the physician group (4 days). Likewise, median ICU stay was less in the nurse group (5 days) when compared to the retrospective physician group data (7 days). Time to initiation of weaning trials was 2 ICU days in the nurse-driven protocol group, whereas it was 3 days in the physician group. Patients in the nurse-managed protocol period had weaning initiated more than 2 hours earlier when compared to the patients in the retrospective physician comparison group. There was no difference in sedative therapy management between the two study periods, nor were there any differences reported for hospital length of stay, VAP rates, mortality, or reintubation rates. Thus, the nurse-driven protocol was safe for ICU patients. Of the 76% of intensivists who completed the survey, their responses overall were a positive attitude toward the nurse-managed weaning protocol, including the earlier identification of patients ready to wean and the reduction in length of ventilatory support.
A majority of previous studies on weaning protocols have examined respiratory therapists taking responsibility or ICU physicians directing weaning trials. The article by Danckers and colleagues reports on an innovative protocol that utilized the expertise of the ICU nursing staff to realize positive clinical outcomes for patients weaning from mechanical ventilatory support. In addition, the investigators were wise to survey the intensivists who staff this ICU on their perceptions of the nurse-managed weaning protocol since they ultimately gave the “green light” to proceed with extubation. Luckily for the ICU patients, these physicians who responded to the survey (a full 76% of the staff) reported favorable attitudes toward the protocol. The attitudes of the non-responders is not known.
Given that the ICU participating did not have dedicated, full-time RT coverage, this study may have been conceived out of necessity. This study demonstrates that experienced ICU nurses can be trained in a weaning protocol and can achieve better outcomes than when the weaning is solely left to busy ICU physicians. An important caveat is that the nursing staff in the participating ICU were very experienced and most were certified in critical care nursing. These characteristics alone may have contributed to the strong outcomes for patients in the nurse-driven weaning protocol group. The protocol devised for this study may not be transferable to other ICUs with less experienced nursing staff or to a unit where the intensivists are not as supportive and positive about nurses managing a ventilator weaning protocol.