Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Effect of a collaborative weaning plan on patient outcome in the critical care setting Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Impact of the Hawthorne effect in a longitudinal clinical study: the case of anesthesia. Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. Protocol-directed weaning from mechanical ventilation: clinical outcome in patients randomized for a 30-min or 120-min trial with pressure support ventilation The impact of nurse-directed protocolised-weaning from mechanical ventilation on nursing practice: a quasi-experimental study.
A 2-h T-tube trial of spontaneous breathing was used in selecting patients ready for extubation and discontinuation of mechanical ventilation . However , some doubt remains as to whether it is the most appropriate method of performing a spontaneous breathing trial . We carried out a prospect i ve , r and omized , multicenter study involving patients who had received mechanical ventilation for more than 48 h and who were considered by their physicians to be ready for weaning according to clinical criteria and st and ard weaning parameters . Patients were r and omly assigned to undergo a 2-h trial of spontaneous breathing in one of two ways : with a T-tube system or with pressure support ventilation of 7 cm H2O . If a patient had signs of poor tolerance at any time during the trial , mechanical ventilation was reinstituted . Patients without these features at the end of the trial were extubated . Of the 246 patients assigned to the T-tube group , 192 successfully completed the trial and were extubated ; 36 of them required reintubation . Of the 238 patients in the group receiving pressure support ventilation  , 205 were extubated and 38 of them required reintubation . The percentage of patients who remained extubated after 48 h was not different between the two groups ( 63 % T-tube , 70 % pressure support ventilation , p = 0.14 ) . The percentage of patients falling the trial was significantly higher when the T-tube was used ( 22 versus 14 % , p = 0.03 ) . Clinical evolution during the trial was not different in patients reintubated and successfully extubated . ICU mortality among reintubated patients was significantly higher than in successfully extubated patients ( 27 versus 2.6 % , p < 0.001 ) . Spontaneous breathing trials with pressure support or T-tube are suitable methods for successful discontinuation of ventilator support in patients without problems to resume spontaneous breathing Objective The process of weaning from mechanical ventilation can be complex , requiring collaborative care planning by members of the healthcare team . Improved outcomes have been demonstrated to result from collaborative decision-making processes ( e.g. , when ventilator teams were utilized ) . The purpose of this study was to evaluate the effect of a collaborative weaning plan ( CWP ) on length of time on mechanical ventilation , length of stay in the intensive care unit ( ICU ) , and cost . Design A new , collaborative weaning plan in the form of a weaning board and flowsheet was introduced into a medical intensive care unit ( MICU ) setting . A pre- and post-quasi-experimental design using historical controls was used to test the hypotheses . Attempts to control for the effects of history were made by collecting data related to patient , staffing , and organizational variables that could independently effect outcome . Setting MICU in a west coast teaching hospital . Patients Critically ill patients receiving mechanical ventilation for 3 days or greater . InterventionImplementation of a collaborative weaning plan . Measurements Outcomes studied included length of stay in the MICU , length of time patients were mechanically ventilated in the MICU , cost per MICU stay , and the incidence of complications ( e.g. , reventilation , readmission to the ICU , and mortality rate . ) Main Results The CWP decreased length of stay in the MICU by 3.6 days ( p = .03 ) and length of ventilator time by 2.7 days ( p = .06 ) . There were no significant differences between groups related to cost or incidence of complications . Conclusions These results support the usefulness of collaborative structures ( such as weaning boards/flowsheets ) in decreasing ICU length of stay We prospect ively investigated the large-scale implementation of a respiratory-therapist-driven protocol ( TDP ) that included 117 respiratory care practitioners ( RCPs ) managing 1,067 patients with respiratory failure over 9,048 patient days of mechanical ventilation . During a 12-mo period , we reintroduced a previously vali date d protocol that included a daily screen ( DS ) coupled with spontaneous breathing trials ( SBTs ) and physician prompt , as a TDP without daily input from a physician or " weaning team . " With grade d , staged educational interventions at 2-mo intervals , RCPs had a 97 % completion rate and a 95 % correct interpretation rate for the DS . The frequency with which patients who passed the DS underwent SBTs increased throughout the implementation process ( p < 0.001 ) . As the year progressed , RCPs more often considered SBTs once patients had passed a DS ( p < 0.001 ) , and physicians ordered more SBTs ( 46 versus 65 % , p = 0.004 ) . Overall , SBTs were ordered more often on the medicine than on the surgical services ( 81 versus 63 % , p = 0.001 ) , likely reflecting medical intensivists ' prior use of this protocol . Important barriers to protocol compliance were identified through a question naire ( 89 respondents , 76 % ) , and included : Physician unfamiliarity with the protocol , RCP inconsistency in seeking an order for an SBT from the physician , specific reasons cited by the physician for not advancing the patient to a SBT , and lack of stationary unit assignments by RCPs performing the protocol . We conclude that implementation of a vali date d weaning strategy is feasible as a TDP without daily supervision from a weaning physician or team . RCPs can appropriately perform and interpret DS data more than 95 % of the time , but significant barriers to SBTs exist . Through a staged implementation process , using periodic reinforcement of all participants in ventilator management , improved compliance with this large-scale weaning protocol can be achieved Clinical research can be influenced by many factors that are capable of invalidating results , and one of these factors is known as the Hawthorne effect : the mere awareness of being under observation can alter the way in which a person behaves . In experimental research this effect can be the undesired effect of the experiments themselves , and the stronger its presence , the greater it can influence the results . In anesthesia practice , owing to the particular emotional condition of a patient facing a surgical operation , the Hawthorne effect could be especially strong . The aim of our study was to show the impact that the knowledge of being included in a study has ( Hawthorne effect ) , by comparing the postoperative changes in psychological well-being in two groups of patients undergoing knee arthroscopy and receiving different information about the study from the anesthetist during the preoperative interview . Other signs and symptoms such as postoperative knee pain , nausea , vomiting ( the most feared occurrences ) , headache , return of spontaneous diuresis , analgesic request , anesthesia complications , as well as the intensity of anxiety were also assessed as secondary endpoints . Our results show that subjects who were aware that they were part of a study scored significantly better on postoperative measures of psychological well-being and postoperative knee pain , compared to subjects who were unaware . The size of the effect , as measured by the odds ratio , remains unchanged when controlling for potential confounding factors . The study has enabled us to demonstrate the presence of the Hawthorne effect in clinical research . Therefore , the Hawthorne effect should be acknowledged and accounted for in the design of a study and in the interpretation of results Objective To examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide , quality improvement program on clinical and economic outcomes . Design Prospect i ve , before- and -after intervention study . Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation . Patients and Setting Patients older than 18 yrs in diagnosis-related group 475 and group 483 , who were admitted to the adult medical , surgical , and cardiac intensive care units ( ICU ) in a university hospital . Interventions After the baseline year , a weaning management program was implemented throughout our institution . Primary endpoints were mortality , days on mechanical ventilation , ICU and hospital lengths of stay , hospital costs , and the percentage of patients requiring tracheostomy . Main Results The number of patients increased from 220 in the baseline year ( year 0 ) to 247 in the first year ( year 1 ) , then to 267 in the second year ( year 2 ) . The mean Acute Physiology and Chronic Health Evaluation ( APACHE ) II score increased from 22.2 to 24.4 in year 1 ( p = .006 ) and to 26.2 in year 2 ( p < .0005 ) . When year 0 was compared with year 1 , mean days on mechanical ventilation decreased from 23.9 to 21.9 days ( p = .608 ) , hospital length of stay decreased from 37.5 to 31.6 days ( p = .058 ) , ICU length of stay decreased from 30.5 to 25.9 days ( p = .133 ) , and total cost per case decreased from $ 92,933 to $ 78,624 ( p = .061 ) . When year 0 was compared with year 2 , mean days on mechanical ventilation decreased from 23.9 days to 17.5 days ( p = .004 ) , mean hospital length of stay decreased from 37.5 to 24.7 days , mean ICU length of stay decreased from 30.5 to 20.3 days , total cost per case decreased from $ 92,933 to $ 63,687 , and percentage of patients requiring tracheotomy decreased from 61 % to 41 % ( all p < .0005 ) . There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33 % to 26 % ( p = .039 ) , a total cost savings of $ 3,440,787 and a decrease in mortality between all 3 yrs from 32 % to 28 % ( p = .062 ) . Conclusions A multifaceted , multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services . This change can lead to large reductions in the duration of mechanical ventilation , length of stay , and hospital costs , even at a time when patients are sicker BACKGROUND Despite multiple reminders , education sessions , and multidisciplinary team involvement , adherence to an evidence -based mechanical ventilation weaning protocol had been less than 1 % in a general systems intensive care unit since implementation . OBJECTIVE To assess the effectiveness of using an implementation program , the Model for Accelerating Improvement , to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit . METHODS A prospect i ve comparative design , before and after implementation of the Model for Accelerating Improvement , was used with a consecutive sample of 129 patients and 112 multidisciplinary team members . Clinical outcomes were rate of unsuccessful extubations , rate of ventilator-associated pneumonia , and duration of mechanical ventilation ; practice outcomes were staff 's underst and ing of the mechanical ventilation weaning protocol , perceptions of the practice safety climate , and adherence to the weaning protocol . RESULTS After the intervention , the rate of unsuccessful extubations decreased , and staff 's underst and ing of and adherence to the weaning protocol increased significantly . The rate of ventilator-associated pneumonia , duration of mechanical ventilation , and staff 's perceptions of the practice safety climate did not change significantly . CONCLUSION Implementing the Model for Accelerating Improvement improved underst and ing of and adherence to protocol -directed weaning and reduced the rate of unsuccessful extubations Abstract Abstract Objective . To investigate the possibility of successful extubation performing a spontaneous breathing trial ( SBT ) in pressure support ventilation ( PSV ) with target duration s of 30 and 120 min . Design and setting . Prospect i ve and r and omized study in two medical-surgical adult intensive care units . Patients and participants . 98 adult patients supported by mechanical ventilation for at least 48 h and considered ready for a weaning trial . Interventions . An SBT conducted in PSV with 7 cmH2O and patients r and omly assigned to two groups with target duration s of 30- and 120-min . Measurements and results . In the 30-min group 43 patients ( 93 % ) tolerated the SBT and were extubated while 4 ( 9 % ) needed reintubation within 48 h ; in the 120-min group 46 patients ( 88 % ) successfully completed the trial and were extubated while 2 ( 4 % ) were reintubated . ICU mortality in the groups with short and long periods was 6 % and 4 % , and in-hospital mortality 20 % and 17 % , respectively . Those successful in the 30- and 120-min groups had similar length of ICU stay ( 6 and 7 days , respectively ) and in-hospital length of stay ( 20 and 25 days , respectively ) . Compared to the successfully extubated , the reintubated patients had significantly higher length of ICU stay and mortality ( 17 vs. 6 days and 33 vs. 3.6 % , respectively ) . Conclusions . An SBT with PSV of 7 cmH2O lasting 30 min is equally effective in recognizing the successfully extubated patients as a 120-min trial 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
AIM The aim of this review was to determine if ventilation-weaning protocol s developed and implemented by multidisciplinary teams ( MDTs ) reduced the duration of mechanical ventilation in adult intensive care patients compared to usual care .