Effect of an education program on the prevention of ventilator-associated pneumonia: A multicenter study. Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. Effectiveness of an educational program to reduce ventilator-associated pneumonia in a tertiary care center in Thailand: a 4-year study. Randomized, controlled trial of the effectiveness of simulation education: A 24-month follow-up study in a clinical setting. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions International perspectives on the influence of structure and process of weaning from mechanical ventilation. Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation. Predictors of prolonged weaning and survival during ventilator weaning in a respiratory ICU Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. The impact of nurse-directed protocolised-weaning from mechanical ventilation on nursing practice: a quasi-experimental study. Decisions made by critical care nurses during mechanical ventilation and weaning in an Australian intensive care unit.
OBJECTIVE To evaluate the effect of an educational program targeted on modifiable risk factors on  ventilator-associated pneumonia ( VAP ) rates . MATERIAL AND METHOD After a preliminary study on VAP risk factors was conducted at one teaching hospital , a pre- and post-interventional study was then performed on 12 hospitals in Thail and from January 1 , 2002 to June 30 , 2003 . Each hospital r and omly selected 20 patients , who were on mechanical ventilation to be enrolled The study was divided into two phases ; 1 ) pre-intervention , 2 ) post-intervention . Data collected included patients ' demography and risk factors for VAP During pre-interventional phase , data on risk factors for VAP was analyzed and fedback to healthcare providers in the wards by an infection control nurse ( ICN ) of the individual hospital . An educational programme on the prevention of VAP was introduced by the ICN . Ventilator-associated pneumonia rates and their risk factors were continuously monitored during the post-interventionl phase . RESULTS Two hundred and forty four patients in the pre-interventional phase and 254 patients in the post-interventional phase were included . There was no significant difference in the demography between these two patient population s. After the intervetion , there was a significant improvement in h and -hygiene practice s ( p<0.001 ) among healthcare providers and increased use of sucralfate ( p=0.05 ) for stress ulcer prophylaxis . Ventilation-associated pneumonia rate ( 40.5 % vs. 24 % ; p<0.001 ) and crude mortality rate associated with VAP ( 12.3 % vs. 8.7 % ; p<0.001 ) were also reduced CONCLUSION The educational programme targeted on modifiable risk factors for prevention of VAP was effective and should be considered as an intervention to reduce VAP rates in developing countries PURPOSE Ventilator weaning protocol s can improve clinical outcomes , but their impact may vary depending on intensive care unit ( ICU ) structure , staffing , and acceptability by ICU physicians . This study was undertaken to examine their relationship . DESIGN / METHODS We prospect ively examined outcomes of 102 mechanically ventilated patients for more than 24 hours and weaned using nurse-driven protocol -directed approach ( nurse-driven group ) in an intensivist-led ICU with low respiratory therapist staffing and compared them with a historic control of 100 patients who received conventional physician-driven weaning ( physician-driven group ) .  We administered a survey to assess ICU physicians ' attitude . RESULTS Median duration s of mechanical ventilation ( MV ) in the nurse-driven and physician-driven groups were 2 and 4 days , respectively ( P = .001 ) . Median duration s of ICU length of stay ( LOS ) in the nurse-driven and physician-driven groups were 5 and 7 days , respectively ( P = .01 ) . Time of extubation was 2 hours and 13 minutes earlier in the nurse-driven group ( P < .001 ) . There was no difference in hospital LOS , hospital mortality , rates of ventilator-associated pneumonia , or reintubation rates between the 2 groups . We identified 4 independent predictors of weaning duration : nurse-driven weaning , Acute Physiology and Chronic Health Evaluation II score , vasoactive medications use , and blood transfusion . Intensive care unit physicians viewed this protocol implementation positively ( mean scores , 1.59 - 1.87 on a 5-point Likert scale ) . CONCLUSIONS A protocol for liberation from MV driven by ICU nurses decreased the duration of MV and ICU LOS in mechanically ventilated patients for more than 24 hours without adverse effects and was well accepted by ICU physicians BACKGROUND Ventilator-associated pneumonia ( VAP ) is considered to be an important cause of infection-related death and morbidity in intensive care units ( ICUs ) . We sought to determine the long-term effect of an educational program to prevent VAP in a medical ICU ( MICU ) . METHODS A 4-year controlled , prospect i ve , quasi-experimental study was conducted in an MICU , surgical ICU ( SICU ) , and coronary care unit ( CCU ) for 1 year before the intervention ( period 1 ) , 1 year after the intervention ( period 2 ) , and 2 follow-up years ( period 3 ) . The SICU and CCU served as control ICUs . The educational program involved respiratory therapists and nurses and included a self- study module with preintervention and postintervention assessment s , lectures , fact sheets , and posters . RESULTS Before the intervention , there were 45 episodes of VAP ( 20.6 cases per 1000 ventilator-days ) in the MICU , 11 ( 5.4 cases per 1000 ventilator-days ) in the SICU , and 9 ( 4.4 cases per 1000 ventilator-days ) in the CCU . After the intervention , the rate of VAP in the MICU decreased by 59 % ( to 8.5 cases per 1000 ventilator-days ; P=.001 ) and remained stable in the SICU ( 5.6 cases per 1000 ventilator-days ; P=.22 ) and CCU ( 4.8 cases per 1000 ventilator-days ; P=.48 ) . The rate of VAP in the MICU continued to decrease in period 3 ( to 4.2 cases per 1000 ventilator-days ; P=.07 ) , and rates in the SICU and CCU remained unchanged . Compared with period 1 , the mean duration of hospital stay in the MICU was reduced by 8.5 days in period 2 ( P<.001 ) and by 8.9 days in period 3 ( P<.001 ) . The monthly hospital antibiotic costs of VAP treatment and the hospitalization cost for each patient in the MICU in periods 2 and 3 were also reduced by 45%-50 % ( P<.001 ) and 37%-45 % ( P<.001 ) , respectively . CONCLUSIONS A focused education intervention result ed in sustained reductions in the incidence of VAP , duration of hospital stay , cost of antibiotic therapy , and cost of hospitalization BACKGROUND Critical care nurses ' knowledge and skills in adhering to evidence -based guidelines for avoiding complications associated with intubation and mechanical ventilation are currently limited . We hypothesized that single simulation education session would lead to a long-lasting higher level of skills among critical care nurses . MATERIAL AND METHODS A r and omized controlled trial was conducted in a 22-bed adult mixed medical-surgical intensive care unit in Finl and during the period February 2012-March 2014 . Thirty out of 40 initially r and omized critical care nurses participated in a 24-month follow-up study . Behavior and cognitive development was evaluated through a vali date d Ventilator Bundle Observation Schedule and Question naire at the baseline measurement and repeated 3 times during simulation and real-life clinic setting s. RESULTS After simulation education , the average skills score increased from 46.8%-58.8 % of the total score in the final postintervention measurement ( Ptime < .001 , Ptime × group = .040 , and Pgroup = .11 ) . The average knowledge scores within groups did not change significantly . The average between-group difference in skills scores was significant only at the measurement taken at 6 months ( P = .006 ) . CONCLUSIONS Critical care nurses ' skills in adhering to evidence -based guidelines improved in both groups over time , but the improvements between the study groups was significantly different only at 6 months and was no longer evident after 2 years following a single simulation education Non-r and omised studies of the effects of interventions are critical to many areas of healthcare evaluation , but their results may be biased . It is therefore important to underst and and appraise their strengths and weaknesses . We developed ROBINS-I ( “ Risk Of Bias In Non-r and omised Studies - of Interventions ” ) , a new tool for evaluating risk of bias in estimates of the comparative effectiveness ( harm or benefit ) of interventions from studies that did not use r and omisation  to allocate units ( individuals or clusters of individuals ) to comparison groups . The tool will be particularly useful to those undertaking systematic review s that include non-r and omised studies BACKGROUND Recently , clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation . One such process , use of a weaning protocol , has yielded conflicting results , arguably because of the influence of existing context and processes . OBJECTIVE To compare international data to assess differences in context and processes in intensive care units that could influence weaning . METHODS Review of existing national data on provision of care for critically ill patients , including structure , staffing , skill mix , education , roles , and responsibilities for weaning in intensive care units of selected countries . RESULTS Australia , New Zeal and , Denmark , Norway , Sweden , and the United Kingdom showed similarities in critical care provision , structure , skill mix , and staffing ratios in intensive care units . Weaning in these countries is generally a collaborative process between nurses and physicians . Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care unit 's health care team . Nurses may be excluded from direct management of ventilator weaning in some institutions , as this role is primarily assumed by respiratory therapists guided by medical directives . Availability of critical care beds was highest in the United States and lowest in the United Kingdom . CONCLUSION Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries . Further quantification of these context ual influences should be considered when translating research findings into local clinical practice and when design ing r and omized controlled trials BACKGROUND UK recommendations suggest that large neonatal intensive-care units ( NICUs ) have better outcomes than small units , although this suggestion remains unproven . We assessed whether patient volume , staffing levels , and workload are associated with risk-adjusted outcomes , and with costs or staff wellbeing . METHODS 186 UK NICUs were stratified according to volume of patients , nursing provision , and neonatal consultant provision .  Primary outcomes were hospital mortality , mortality or cerebral damage , and nosocomial bacteraemia . We studied 13515 infants of all birthweights consecutively admitted to 54 r and omly selected NICUs . Multiple logistic regression analyses were done with every primary outcome as the dependent variable . Staff wellbeing and stress were assessed by anonymous mental health index (MHI)-5 question naires . FINDINGS Data were available for 13334 ( 99 % ) infants . High-volume NICUs treated the sickest infants and had highest crude mortality . Risk-adjusted mortality and mortality or cerebral damage were unrelated to patient volume or staffing provision ; however , nosocomial bacteraemia was less frequent in NICUs with low neonatal consultant provision ( odds ratio 0.65 , 95 % CI 0.43 - 0.98 ) . Mortality was raised with increasing workload in all types of NICUs . Infants admitted at full capacity versus half capacity were about 50 % more likely to die , but there was wide uncertainty around this estimate . Most staff had MHI-5 scores that suggested good mental health . INTERPRETATION The implication s of this report for staffing policy , medicolegal risk management , and ethical practice remain to be tested . Central isation of only the sickest infants could improve efficiency , provided that this does not create excessive workload for staff . Assessment of increased staffing levels that are closer to those in adult intensive care might be appropriate Purpose An International Consensus Conference proposed classifying weaning into simple , difficult , and prolonged weaning . However , the usefulness of this classification in a respiratory intensive care unit ( ICU ) is unknown . The aims of the study were : ( 1 ) to compare the clinical characteristics and outcomes of patients from the three weaning groups in a respiratory ICU ; and ( 2 ) to assess predictors for prolonged weaning and survival . Methods We prospect ively studied 181 mechanically ventilated patients ( 131 , 72 % with chronic respiratory disorders ) in whom weaning had been initiated , divided into  simple ( 78 , 43 % ) ,  difficult  ( 70 , 39 % ) , and  prolonged  ( 33 , 18 % ) weaning . We compared the characteristics and outcomes among the three groups and determined the factors associated with prolonged weaning and survival in multivariate analysis . Results Patients with simple and difficult weaning had similar characteristics and outcomes . A higher proportion of patients with prolonged weaning had chronic obstructive pulmonary disease  , and these patients also had more complications , a longer stay and lower survival . Increased heart rate ( ≥105 min−1 , p < 0.001 ) and PaCO2 ( ≥54 mmHg , p = 0.001 ) during the spontaneous breathing trial independently predicted prolonged weaning . In addition , the need for reintubation ( p < 0.001 ) and hypercapnia during the spontaneous breathing trial ( p = 0.003 ) independently predicted a decreased 90-day survival . Conclusion Because of the similar characteristics and outcomes , the differentiation between simple and difficult weaning had no relevant clinical consequences in a respiratory ICU . Patients with prolonged weaning had the worst outcomes . For the overall population , hypercapnia at the end of spontaneous breathing predicts prolonged weaning and a worse survival , and clinicians should implement measures aim ed at improving weaning outcome RATIONALE Diaphragmatic function is a major determinant of the ability to successfully wean patients from mechanical ventilation ( MV ) .  Paradoxically , MV itself results in a rapid loss of diaphragmatic strength in animals . However , very little is known about the time course or mechanistic basis for such a phenomenon in humans . OBJECTIVES To determine in a prospect i ve fashion the time course for development of diaphragmatic weakness during MV ; and the relationship between MV duration and diaphragmatic injury or atrophy , and the status of c and i date cellular pathways implicated in these phenomena . METHODS  Airway occlusion pressure ( TwPtr ) generated by the diaphragm during phrenic nerve stimulation was measured in short-term ( 0.5 h ; n = 6 ) and long-term ( > 5 d ; n = 6 ) MV groups . Diaphragmatic biopsies obtained during thoracic surgery ( MV for 2 - 3 h ; n = 10 ) and from brain-dead organ donors ( MV for 24 - 249 h ; n = 15 ) were analyzed for ultrastructural injury , atrophy , and expression of proteolysis-related proteins ( ubiquitin , nuclear factor-κB , and calpains ) . MEASUREMENTS AND MAIN RESULTS TwPtr decreased progressively during MV , with a mean reduction of 32 ± 6 % after 6 days . Longer periods of MV were associated with significantly greater ultrastructural fiber injury ( 26.2 ± 4.8 vs. 4.7 ± 0.6 % area ) , decreased cross-sectional area of muscle fibers ( 1,904 ± 220 vs. 3,100 ± 329 μm² ) , an increase of ubiquitinated proteins ( + 19 % ) , higher expression of p65 nuclear factor-κB ( + 77 % ) , and greater levels of the calcium-activated proteases calpain-1 , -2 , and -3 ( + 104 % , + 432 % , and + 266 % , respectively ) in the diaphragm . CONCLUSIONS Diaphragmatic weakness , injury , and atrophy occur rapidly in critically ill patients  during MV  , and are significantly correlated with the duration of ventilator support CONTEXT The outcome of patients receiving mechanical ventilation for particular indications has been studied , but the outcome in a large number of unselected , heterogeneous patients has not been reported . OBJECTIVE To determine the survival of patients receiving mechanical ventilation  and the relative importance of factors influencing survival . DESIGN , SETTING , AND SUBJECTS Prospect i ve cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1 , 1998 , and March 31 , 1998 . Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days . MAIN OUTCOME MEASURE All-cause mortality during intensive care unit stay . RESULTS Of the 15 757 patients admitted , a total of 5183 ( 33 % ) received mechanical ventilation  for a mean ( SD ) duration of 5.9 ( 7.2 ) days . The mean ( SD ) length of stay in the intensive care unit was 11.2 ( 13.7 ) days . Overall mortality rate in the intensive care unit was 30.7 % ( 1590 patients ) for the entire population , 52 % ( 120 ) in patients who received ventilation because of acute respiratory distress syndrome , and 22 % ( 115 ) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease . Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69 % . The main conditions independently associated with increased mortality were ( 1 ) factors present at the start of mechanical ventilation ( odds ratio [ OR ] , 2.98 ; 95 % confidence interval [ CI ] , 2.44 - 3.63 ; P<.001 for coma ) , ( 2 ) factors related to patient management ( OR , 3.67 ; 95 % CI , 2.02 - 6.66 ; P<.001 for plateau airway pressure > 35 cm H(2)O ) , and ( 3 ) developments occurring over the course of mechanical ventilation ( OR , 8.71 ; 95 % CI , 5.44 - 13.94 ; P<.001 for ratio of PaO(2 ) to fraction of inspired oxygen < 100 ) . CONCLUSION Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation , but also on the development of complications and patient management in the intensive care unit BACKGROUND Internationally , nurse-directed protocol ised-weaning has been evaluated by measuring its impact on patient outcomes . The impact on nurses ' views and perceptions has been largely ignored . AIM To determine the change in intensive care nurses ' perceptions , satisfaction , knowledge and attitudes following the introduction of nurse-directed weaning . Additionally , views were obtained on how useful protocol ised-weaning was to practice . METHODS The sample comprised nurses working in general intensive care units in three university-affiliated hospitals .  Nurse-directed protocol ised-weaning was implemented in one unit ( intervention group ) ; two ICUs continued with usual doctor-led practice ( control group ) . Nurses ' perceptions , satisfaction , knowledge and attitudes were measured by self-completed question naires before ( Phase I ) and after the implementation of nurse-directed weaning ( Phase II ) in all units . RESULTS Response rates were 79 % ( n=140 ) for Phase 1 and 62 % ( n=132 ) for Phase II . Regression-based analyses showed that changes from Phase I to Phase II were not significantly different between the intervention and control groups . Sixty-nine nurses responded to both Phase I and II question naires . In the intervention group , these nurses scored their mean perceived level of knowledge higher in Phase II ( 6.39 vs 7.17 , p=0.01 ) . In the control group , role perception ( 4.41 vs 4.22 , p=0.01 ) was lower and , perceived knowledge ( 6.03 vs 6.63 , p=0.04 ) , awareness of weaning plans ( 6.09 vs 7.06 , p=0.01 ) and satisfaction with communication ( 5.28 vs 6.19 , p=0.01 ) were higher in Phase II . The intervention group found protocol ised weaning useful in their practice ( 75 % ) : this was scored significantly higher by junior and senior nurses than middle grade nurses ( p=0.02 ) . CONCLUSION We conclude that nurse-directed protocol ised-weaning had no effect on nurses ' views and perceptions due to the high level of satisfaction which encouraged nurses ' participation in weaning throughout . Control group changes are attributed to a ' reactive effect ' from being study participants . Weaning protocol s provide a uniform method of weaning practice and are particularly beneficial in providing safe guidance for junior staff BACKGROUND Responsibilities of critical care nurses for management of mechanical ventilation may differ among countries . Organizational interventions , including weaning protocol s , may have a variable impact in setting s that differ in nursing autonomy and interdisciplinary collaboration . OBJECTIVE To characterize the role of Australian critical care nurses in the management of mechanical ventilation . METHODS A 3-month , prospect i ve cohort study was performed . All clinical decisions related to mechanical ventilation in a 24-bed , combined medical-surgical adult intensive care unit at the Royal Melbourne Hospital , a university-affiliated teaching hospital in Melbourne , Victoria , Australia , were determined . RESULTS Of 474 patients admitted during the 81-day study period , 319 ( 67 % ) received mechanical ventilation .  Death occurred in 12.5 % ( 40/319 ) of patients . Median duration s of mechanical ventilation and intensive care stay were 0.9 and 1.9 days , respectively . A total of 3986  ventilation and weaning  decisions ( defined as any adjustment to ventilator setting s , including mode change ; rate or pressure support adjustment ; and titration of tidal volume , positive end-expiratory pressure , or fraction of inspired oxygen ) were made . Of these , 2538 decisions ( 64 % ) were made by nurses alone , 693 ( 17 % ) by medical staff , and 755 ( 19 % ) by nurses and staff in collaboration . Decisions made exclusively by nurses were less common for patients with predominantly respiratory disease or multiple organ dysfunction than for other patients . CONCLUSIONS In this unit , critical care nurses have high levels of responsibility for , and autonomy in , the management of  mechanical ventilation  and weaning  . Revalidation of protocol s for ventilation practice s in other clinical context s may be needed
BACKGROUND Intensive care unit nurses are critical for managing mechanical ventilation .
Continuing education is essential in building and maintaining nurses ' knowledge and skills , potentially improving patient outcomes .
AIMS The aim of this study was to determine whether continuing education programmes on invasive mechanical ventilation involving intensive care unit nurses are effective in improving patient outcomes .