Service improvement articleWeaning from ventilation: Does a care bundle approach work?
Section snippets
Background
A number of studies have estimated the incidence of prolonged ventilation in ICU to be between 5.5 and 15% (Nevins and Epstein, 2001, Ely et al., 1996, Brochard et al., 1994) with a hospital mortality of between 43 and 61% (Kurek et al., 1997, Seneff et al., 1996). The Modernisation Agency (2002) paper ‘weaning and long term ventilation’ collated data from a national survey, which indicated that 161 patients in 59% of hospitals answering the survey fulfilled the criteria for weaning delay or
A care bundle approach
The Institute for Healthcare Improvement (IHI) in the USA developed the concept of ‘bundles’ in order to help healthcare providers to deliver the best possible care for patients. The NHS Modernisation Agency's Critical Care Programme adopted this approach (MA, 2004). A bundle is a structured way of improving the processes of care and patient outcomes. It is a small, straightforward set of practices, generally three to five that, when performed together, have been proven to improve patient
Pre-weaning
Emphasis of this part of the care bundle is to maximise the potential to wean. The aim is to initiate plans for this as soon as the patient is ventilated. Concentration will be on titrating ventilatory support until such a time as weaning becomes active.
Weaning
It is essential that the patient is seen as an active partner in care and weaning plans are developed in association with the patient. Additional factors such as the assessment for anxiolytics, antidepressants, etc. may be required in order to facilitate this.
Weaning outreach service
The weaning group suggested identifying a group of healthcare professionals with an interest and experience in weaning from ventilation who would be willing to offer advice. They are called to give advice over the telephone or asked to see a patient who is weaning from ventilation. Not all networks may have an established ‘outreach’ service for weaning patients. Experience in some units has demonstrated that respiratory physicians make a valuable contribution to a patient's weaning. Where these
Use of NIV (non-invasive ventilation)
There is a wealth of evidence to support the use of NIV in weaning particularly in specific patient groups. Units with an established NIV service may exploit this at an early stage of weaning.
Criteria for weaning
Units have developed their own protocols which include criteria for weaning. The care bundle does not stipulate what these protocols should be, only that there should be one.
Audit of compliance: results
Once the care bundle was agreed and implemented one Trust agreed to audit the care bundle. The network has an agreed format for audit of compliance. This is a balance between workload and meaningful results. It was agreed that, for a pilot, 50 patients would be a suitable number for one unit. Normally all units in the network would audit compliance and these results would be aggregated. The first 50 patients in one critical care unit were audited against the bundle elements for compliance. This
Audit of pre-weaning care bundle (N = 20)
All patients who have been ventilated for over 24 h excluding patients who are deemed unlikely to survive to discharge from critical care. Patients who are deemed ventilator dependent (for 24 h) were included in the audit.
Audit of weaning care bundle (N = 32)
This bundle is executed when weaning is deemed to be active and follows on from the pre-weaning bundle.
Discussion of results
There was 100% compliance against elements 1 (daily screen) and 2 (strategies for titrating ventilatory support) but only 40% compliance against the assessment of the potential to wean against agreed criteria (element 3). Elements 1 and 2 are completed usually by the medical team but element 3 can be completed by nurses or medical staff. It may be that nurses are best placed to lead the weaning process but this is dependent on a number of factors such as skill mix, team structure, unit
Congruence with a care bundle approach
Although it appeared a sensible thing to do in order to improve the weaning process it appears that care bundles may not be the appropriate tool. Firstly a care bundle is a cohesive set of steps that must all be completed to succeed. In this bundle some of the steps are not yet developed such as the outreach service or relationship with respiratory physicians and use of non-invasive ventilation in critical care units. All the changes in a care bundle are based on level 1 evidence that is proven
Conclusion
Work continues in order to improve weaning from ventilation. It is clear that the care bundle approach cannot be utilised in weaning. Many units have simply added weaning as an element to the ventilator care bundle. Research into weaning has focused on the physical elements and little has been conducted on exploring weaning from the patient's experience. Research of this kind will greatly assist the critical care team to plan and improve weaning. May be the answer is to remove long-term weaning
Acknowledgements
The authors acknowledge the contribution made by the MTCCN, in particular the Weaning group, Clinician group, Lead Nurse group and Service Improvement group who adopted and made comments about the care bundle.
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