Organizational Factors Contribute to Adoption of ICU-Care Management Protocols

Abstract & Commentary

By Linda L. Chlan, RN, PhD, Dean’s Distinguished Professor of Symptom Management Research, The Ohio State University College of Nursing, is Associate Editor for Critical Care Alert.

Dr. Chlan reports that she receives grant/research support from the National Institutes of Health.

Synopsis: While many ICUs have protocols to guide care of complex patients, organizational, facility-specific factors such as closed units, full-time respiratory therapy coverage, and multidisciplinary rounds promote their existence and implementation based on current evidence.

Source: Ellis SM, et al. Use of mechanical ventilation protocols in intensive care units: A survey of current practice. J Crit Care 2012;27: 556-563.

The purpose of this study was to determine which protocols guiding the management of mechanical ventilation are incorporated into practice and to determine if any organizational characteristics of hospitals are associated with the adoption of protocols using evidence-based treatments. The investigators were particularly interested in protocols for low-tidal-volume ventilation (LTVV) and spontaneous breathing trials (SBTs). Other variables of interest included hospital type, open vs closed intensivist staffing, number of ICU beds, patient-to-physician ratio, 24/7 respiratory therapist coverage, and presence of daily multidisciplinary rounds. Ellis and colleagues surveyed all hospitals in Ontario, Canada, that provided both invasive and noninvasive mechanical ventilation. The survey was developed by the investigators in consultation with respiratory therapists and critical care physicians at their institution. Respiratory therapy department leadership was the target for survey completion.

Seventy of 97 potential hospitals responded to the survey (72.2%). A majority of the respondents were respiratory therapists (91%) from a community hospital (60%). Number of ICU beds ranged from 5-26 (median number of beds, 16). Most of the ICUs had open intensivist staffing (58%) with 79% having a 1:1 nurse-to-ventilated-patients staffing ratio. A majority of the ICUs reported daily multidisciplinary rounds (68%) consisting of physicians, nurses, respiratory therapists, clinical nutritionists, clinical pharmacists, physiotherapists, social workers, pastoral/spiritual/religious care, and speech language pathologists. Full-time respiratory therapist coverage was reported in 69% of the hospitals; 3% reported no respiratory therapist coverage. Written ICU care protocols existed in 97% of the hospitals, with mechanical ventilation protocols being the most common (71%). Sedation and analgesia administration was guided by protocol in 64% of the hospitals. LTVV was incorporated into 54% of the mechanical ventilation protocols. SBTs were present in 80% of the ICU protocols.

Findings from survey respondents indicate that larger ICUs with closed intensivist staffing models, daily multidisciplinary rounds, and 24/7 respiratory therapist coverage were more likely to have mechanical ventilation protocols. There was no association with type of hospital (community or academic) or the presence of mechanical ventilation protocols. There were no significant factors contributing to the presence of SBTs in the ICU care protocols in this study.

Commentary

Many articles have been published on the development of protocols to guide the care and management of complex ICU patients. This Canadian survey findings report by Ellis et al makes an additional contribution to this literature by articulating those organizational factors that favorably influence the development and implementation of protocols for LTVV and SBTs that utilize the current best available evidence. Most prominently, these factors include 24/7 respiratory therapist staffing, closed intensivist staffing models, and multidisciplinary patient-care rounds. The actual adherence to protocols to guide LTVV and SBTs was not assessed in this study. The findings from this study may not be directly applicable to all ICUs in the United States. However, the organizational factors of 24/7 respiratory therapist coverage and multidisciplinary rounds can be emulated to promote the adoption of protocols.

The authors state that upwards of 70% of the survey respondents indicated the protocols were developed by a multidisciplinary team. However, the composition of these teams was not articulated. To get support and buy-in, it is important that all voices be heard and that all constituencies be at the table, or a protocol risks being relegated to the status of just another piece of paper. As a nurse, I would be remiss if I did not comment on the fact that the authors did not involve nurses in the development of the survey nor as survey respondents. If ICU care is going to be delivered in a truly multidisciplinary model, all voices must be heard and contribute equally.