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Mechanical ventilation is used as supportive treatment for a variety of critical illnesses and usually requires admission to an intensive care unit (ICU). Once the critical illness resolves, however, many patients remain in the ICU until weaning is complete. Patients receiving long-term ventilation (LTV) account for only 3% of all admissions to medical-surgical ICUs, but account for 28% to 38% of patient days.7
The presence of LTV patients in ICUs often interferes with the day-to-day operation of the units and decreases satisfaction among staff members and patients (Table 1
). Admission and discharge decisions are, by necessity, structured around the LTV patients, meaning that more seriously ill patients who do not require mechanical ventilation may be moved out of the unit to free up ICU beds for LTV patients.
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In response to these concerns, the medical center began exploring ways to reduce the number of LTV patients in the adult ICUs. A pulmonary step-down unit (PSU) with a multidisciplinary weaning program was designed. The collaborative approach used to establish the unit and to develop the weaning program is described in this article. A case presentation illustrates how collaboration is used daily during the weaning process at the medical center.
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COLLABORATION |
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 Top COLLABORATION BACKGROUNDESTABLISHING THE UNITCONCLUSIONReferences |
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Several studies have indicated the value of nurse-physician collaboration in the achievement of good outcomes for patients. Baggs and colleagues12,13 reported a reduction in the risk of adverse outcomes for patients when nurse-physician collaboration was increased in critical care units. In other studies, Knaus et al14 and Mitchell et al15 also reported significant differences in mortality rates between institutions that had excellent communication and coordination patterns among nursing and physician staff and institutions that did not.
Several organizations, including the American Association of Critical-Care Nurses, the Society of Critical Care Medicine, the National Institutes of Health, and the Joint Commission on Accreditation of Healthcare Organizations, recommend a multidisciplinary approach for the delivery of better and more cost-effective patient care.16 They base their recommendations on the clear benefit of having groups of individuals with specialized skills work together for a common good.16–19
Successful collaboration requires considerable work on the part of all group members. They must trust and respect each other, appreciate each others’ areas of expertise, and be able to function as a team. To be effective, team members must commit to a common goal, persist in their efforts, listen to others, and speak out when necessary.17 Organizations can facilitate or hinder the process of collaboration. The process is enhanced when organizations promote structures or activities that foster collaboration and effective communication among disciplines, such as the following:
In today’s healthcare environment, shorter hospital stays, the higher levels of patients’ acuity, and the active involvement of diverse groups of healthcare providers can result in fragmentation and loss of the continuity that is essential for optimal care of patients. A multidisciplinary approach and effective collaboration are described as a way to overcome these obstacles.
An increasingly important member of the multidisciplinary team is the advanced practice nurse, who has emerged as a leader in the changing healthcare environment. Advanced practice nurses effectively coordinate care as case managers and enter into partnerships with patients and members of other healthcare disciplines to meet patients’ needs in a comprehensive manner.19
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BACKGROUND |
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TopCOLLABORATIONBACKGROUNDESTABLISHING THE UNITCONCLUSIONReferences |
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).
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Increased staff satisfaction and shorter lengths of stay for patients with respiratory failure who had tracheotomies were attributed to the weaning team’s success. These outcomes are consistent with those reported by Cohen et al,21 who compared the success of weaning efforts by a ventilator management team with the success of weaning efforts by a critical care team. In a more recent study, Henneman et al22 compared patients’ outcomes before and after the implementation of a collaborative approach to weaning, and their results suggest the effectiveness of organized, collaborative weaning efforts.
The success of the MICU weaning team prompted the hospital to consider the development of a multidisciplinary weaning unit. Through the collaborative efforts of hospital and nursing administrators, the MICU nursing managers, and the pulmonary-critical care medicine group (PCCM), a decision was made to make 6 beds in a general medical unit that focused on the care of pulmonary patients available to LTV patients. The 6 beds would be the PSU and were to be used specifically for medically stable patients who were being weaned off mechanical ventilation.
The next decision involved the determination of who would serve as the medical care providers for the weaning patients. The use of teams of medical residents was not considered an ideal choice for several reasons. First, the resident teams were overburdened. Second, they lacked experience with ventilator management and weaning. Finally, they rotated every 2 to 4 weeks, a situation that would not allow the continuity of care needed by this population of patients. Because an experienced staff nurse had successfully coordinated the MICU weaning team and because other institutions had used experienced staff nurses as case managers for chronically critically ill patients,23 the idea of hiring an advanced practice nurse, specifically a nurse practitioner, to manage the care of the patients being weaned and to coordinate the multidisciplinary team was introduced.
Discussions between members of the PCCM and the nursing administration centered on the feasibility of hiring a nurse practitioner to oversee the team. Because the nurse practitioner role was a new concept for the PCCM, the nursing administration group focused on educating the PCCM staff about the nurse practitioner’s role. Nurse administrators also shared examples of the previous successful integration of nurse practitioners into cardiology and cardiothoracic surgery services in the hospital. Ongoing discussions centered on the proposed role of the nurse practitioner in establishing the unit, assisting with staff education, developing the multidisciplinary weaning program, and providing specialized care to patients.
After considerable discussion, a decision was made to hire a critical care acute care nurse practitioner whose practice agreement would be aligned with the members of the PCCM. The PCCM would mentor the nurse practitioner in the development of expertise in ventilator management, weaning strategies, and medical management of chronically critically ill patients receiving mechanical ventilation. The PCCM physicians would rotate through the PSU every few weeks and serve as the nurse practitioner’s collaborating physicians. The nurse practitioner would serve as the constant care provider for the patients.
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ESTABLISHING THE UNIT |
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TopCOLLABORATIONBACKGROUNDESTABLISHING THE UNITCONCLUSIONReferences |
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The unit leadership team, which consisted of the medical director, nursing management, and the nurse practitioner, met regularly during the planning period to discuss equipment and personnel needs. They also worked together to define criteria for admission to the PSU. A flow chart (see Figure) was developed to clarify criteria for admission to the unit and to illustrate how LTV patients would move through the system.
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Because of the anticipated frequency with which ventilator changes would need to be made, a dedicated respiratory therapist was considered essential to the unit’s success. A respiratory therapist was hired for the day shift, and plans were made to assign a respiratory therapist to each shift. Once the unit was fully functional, the respiratory therapist was expected to help establish unit policies and to troubleshoot system problems.
Designing the Unit
The 19-bed unit selected for the PSU had 5 private rooms and 7 semiprivate rooms that were configured as a pod around a central nurses’ station. Some of the rooms were barely visible from the nurses’ station, and the rooms were not equipped to accommodate ventilators. The planning group was charged with minimizing the unit’s limitations and avoiding major renovations while facilitating optimal care.
The unit leadership team met with the respiratory therapy director and the nursing staff to begin designing the unit. The group recommended that 8 beds with high visibility from the nurses’ station be used as potential ventilator beds. Of the 8 beds, 4 were in private rooms and 4 were in semiprivate rooms. Because ventilator alarms are disruptive, hospital administrators agreed to close the second bed when an LTV patient was admitted to a semiprivate room.
Three oxygen outlets were required for each patient being weaned. Because none of the rooms had the number required, Y-adapters were used to increase the number of outlets per bed. The respiratory therapist developed a standard plan for the setup of the PSU ventilators.
Ventilator selection was considered next. Because the nurses were familiar with the LP-10 ventilator (Aequitron Medical, Inc, Minneapolis, Minn), they recommended its continued use. The unit leadership team, however, wanted the option for pressure-support ventilation, which was not available on the LP-10. As a result, the Siemens Servo 900C (Siemens Medical Systems, Inc, Danvers, Mass) was selected as the ventilator of choice. This model was selected because of its pressure-support option and its planned replacement in the ICUs. This decision eliminated the need for additional capital expenditure.
The nurse practitioner and medical director reviewed the weaning literature for best practices related to weaning. On the basis of their review, a decision was made to use a daily trial of spontaneous breathing with a tracheostomy collar, which had been tested in a prospective, randomized, multicenter study by Esteban et al.5 In this study,5 the mean duration of weaning with daily or intermittent spontaneous breathing trials was 3 days as compared with 5 days for intermittent mandatory ventilation and 4 days for pressure-support ventilation. In addition to the effectiveness of this process, daily trials with the tracheostomy collar seemed to be the least complicated weaning method to introduce to staff members. Although a daily trial with a tracheostomy collar was adopted as the primary method for weaning in the PSU, an alternative method of pressure-support ventilation was implemented for patients who were unable to tolerate a trial with the tracheostomy collar. This process involved a daily weaning trial with low-level pressure-support ventilation. Termination of weaning trials was to be based on assessment of physiological parameters suggestive of respiratory muscle fatigue24 (Table 3) and observation of patients’ comfort levels.
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Once the plans for the PSU were introduced to staff members, hiring began. The nursing staff viewed the transition as a challenge and were concerned about their ability to handle more complex cases. They were also uncertain about how a nurse practitioner would affect their practice. Staff committees and discussions with nursing management and the nurse practitioner helped allay their concerns and brought to light some educational and equipment needs.
Educational Efforts
Both the nurse manager and the nurse practitioner had extensive experience as ICU nurses working with ventilators and patients being weaned off mechanical ventilation. To prepare the staff, they presented a variety of potential patient scenarios and brainstormed with staff members to identify specific learning needs. The list of learning needs that evolved included (1) cardiac arrhythmia monitoring and the use of telemetry, (2) the care of patients being weaned off mechanical ventilation, (3) specifics about the Servo 900C ventilator, and (4) the role of a nurse practitioner on the multidisciplinary team. The nurse practitioner and the nurse manager planned the class content, the competencies expected, and the strategies most appropriate for meeting the staff’s learning needs.
The educational program consisted of lectures, poster presentations, and experiences with a preceptor working with patients receiving mechanical ventilation. By attending selected segments of the critical care course, staff members were introduced to cardiac arrhythmias and the principles of cardiac monitoring and telemetry. The content was reinforced through a series of poster presentations, handouts, and self-tests in cardiac rhythm analysis, along with validation and reinforcement from the nurse practitioner and nurse manager.
The Servo ventilator training plan was developed in collaboration with the respiratory therapy department. It included lectures with demonstrations about the ventilator, which were facilitated by an experienced respiratory therapist. The respiratory therapist also oversaw a half-day rotation to the MICU that facilitated nurses’ gaining first-hand experience in working with the ventilator. The nurse practitioner developed a self-learning module that reinforced information about the Servo ventilator and the expectations of nurses caring for patients receiving mechanical ventilation. Each nurse completed a ventilator competency assessment that included describing the various modes of ventilation, troubleshooting common alarms, and checking and documenting ventilator settings. The respiratory therapist, nurse manager, and nurse practitioner provided ongoing support and reinforcement of the staff’s learning at the bedside.
The nurse practitioner also taught classes on ventilator dependence, the weaning process, and the unique needs of patients being weaned off mechanical ventilation. During weaning trials, the nurse practitioner worked directly with staff members to assist with assessment of patients for signs of fatigue and to help staff members identify factors that impair or facilitate weaning. In addition, nurses without ventilator experience were trained by a nurse experienced in the care of ventilator patients.
Staff members were enthusiastic and eager to learn as they worked to enhance their skills under the guidance of the nurse practitioner and the nurse manager. Because the staff had expertise in caring for patients receiving mechanical ventilation and were beginning to incorporate the weaning process into daily practice, the nurse manager and the nurse practitioner planned a multidisciplinary teaching day. The teaching day centered on how the multidisciplinary team would facilitate the weaning process. Team members described their areas of expertise and suggested strategies to assist staff members in maximizing weaning efforts (Table 4).
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Once the protocol was developed, the respiratory therapist and the nursing staff helped define the protocol process and ensured that the protocol was presented in an easily understood format. The respiratory therapist and nurses suggested targeted starting times for weaning trials. These times were based on usual workloads in the morning and were designed to facilitate an efficient and effective process. The start times for initial trials were set for later in the morning to permit assessments to precede the trial and to minimize patients’ activity during the trial. Once a patient showed tolerance for the weaning process and required less intensive monitoring, the trials were started earlier in the day. A preprinted order form was developed to support the protocol-driven process.
The current protocol serves as a guide for the weaning trial and is modified according to patients’ needs. These needs are identified by the patient, the nurse practitioner, the weaning team physician, the nursing staff, or the respiratory therapist. Daily weaning trials are "as tolerated," but a specific goal is set with each patient.
Team members, patients, and patients’ families are considered key contributors to the success of the weaning process. Patients and their families are instructed about the protocol and are encouraged to participate in decision-making activities. Their suggestions are routinely incorporated into the weaning plan. For instance, a trial’s starting time may be changed to accommodate a patient’s sleep pattern. Patients and their families are updated daily, and a bedside progress record assists patients and their families with establishing realistic goals about the weaning process.
Daily weaning trials are only a small part of a successful weaning program. Nonrespiratory factors such as nutrition, anxiety, physical conditioning, and medical comorbid states must be considered for their potential effects on weaning outcome.27,28 The multidisciplinary team addresses each of these factors during the development of the weaning plan. Attention to these concerns maximizes the potential for achieving our mutual goals, which are (1) to liberate patients from the ventilator, (2) to return them to their preadmission functional level, and (3) to improve the quality of their hospital stay through comprehensive care.
Because involvement of patients and their families in the weaning process is so essential to the program’s success, we hold a family meeting once a patient is accepted for admission to the PSU. The focus of this meeting is to describe how the PSU differs from an ICU, how the weaning program serves as a form of rehabilitation, and how the multidisciplinary team oversees the weaning process. The goal of care in the PSU is described as supportive and directed toward having patients become strong enough to be weaned from the ventilator and return to their pre-hospital state. The meeting provides an opportunity for the patient’s family to establish a relationship with the multidisciplinary team, to receive an update about their loved one’s progress, and to establish realistic goals for weaning. The meeting also serves as a forum for allaying anxieties related to the transfer out of the ICU. It helps families explore advance directives and begin preliminary discharge planning. After the meeting, the family receives a booklet reviewing the information discussed. The booklet offers suggestions for ways in which the family can participate and contains a list of team members and their roles. It also contains a listing of the unit management team and the unit’s telephone number.
Collaboration has been a key component to the success of the weaning program. Each team member brings expertise to decision making and care planning during the weaning process, thereby maximizing the potential for favorable outcomes. A case example (shaded box) provides an indication of how the collaborative process is used throughout our program.
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CONCLUSION |
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Acknowledgment |
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References |
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This article has been cited by other articles:
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  A. Pontes-Arruda, S. DeMichele, A. Seth, and P. Singer The Use of an Inflammation-Modulating Diet in Patients With Acute Lung Injury or Acute Respiratory Distress Syndrome: A Meta-Analysis of Outcome Data JPEN J Parenter Enteral Nutr, November 1, 2008; 32(6): 596 - 605. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
