Australasian Emergency Nursing Journal (2009) 12, 38—43

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RESEARCH PAPER

Mechanical ventilation in Australian emergencydepartments: Survey of workforce profile,nursing role responsibility, and education

L. Rose, PhD, RNa,b,c,∗, M.F. Gerdtz, PhD, RNd

a Lawrence S. Bloomberg Professor in Critical Care Nursing, Lawrence S. Bloomberg Faculty of Nursing,University of Toronto, 155 College St, Toronto, Ontario, Canadab Mount Sinai Hospital, 600 University Ave Toronto, Ontario, Canadac Li Ka Shing Institute, St Michael’s Hospital, 30 Bond St Toronto, Ontario, Canada

d School of Nursing and Social Work, The University of Melbourne, Level 5, 234 Queensberry St, Carlton, Victoria, Australia

Received 16 October 2008; received in revised form 16 December 2008; accepted 16 January 2009

KEYWORDSEmergencydepartment;Respiration;Artificial;Mechanicalventilation;Non-invasiveventilation;Decision-making

SummaryBackground: Little empirical data describes emergency nurses’ role in decision-making for ven-tilation and no Australian standards exist to guide ventilation decision-making in the emergencydepartment (ED).Methods: Self-administered questionnaire sent to nurse managers of 24 Australian EDs partici-pating in a contemporaneous prospective, observational study of ventilation management.Results: Survey responses were available from 21/24 EDs (response rate 87.5%) of which 10/21(47.6%) were categorized as a principal referral centre. All departments reported a 1:1 nurse-to-patient ratio for ventilated patients, for patients requiring non-invasive ventilation (NIV) nurse-to-patient ratios ranged from 1:1 to 1:3. Nurse managers from 10/21 (48%) EDs reported havingguidelines for the management of mechanically ventilated patients; guidelines for managementof NIV were more frequently available (13/21, 62%). Nurses independently implemented themajority of ventilator setting changes in some EDs (9/21, 43%). Competency assessment tookplace prior to un-preceptored care of ventilated patients in 13/21 (62%) EDs.Conclusions: Australian nurses participate actively in ventilation decisions but guidelines forventilation decision-making are not always available. Nurse-to-patient ratios for patients receiv-

ing invasive ventilation appear consistent; lack of uniformity in ratios for NIV was common.Further work is needed to identify safe staffing levels for patients receiving NIV in the ED.© 2009 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rightsreserved.

∗ Corresponding author at: Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, Ontario, Canada.Tel.: +1 416 978 3492; fax: +1 416 978 8222.

E-mail address: louise.rose@utoronto.ca (L. Rose).

1574-6267/$ — see front matter © 2009 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.aenj.2009.01.003

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ED Nurse manager ventilation survey

Introduction

There is little empirical data describing emergency nurses’role in decision-making related to invasive and non-invasivemechanical ventilation either in Australia or internation-ally. Only a small number of studies describe nurses’ rolefor the management of invasive ventilation in the Aus-tralian intensive care setting (ICU).1,2 Australian critical carenurses participate actively in ventilation decision-makingand have high levels of responsibility for, and autonomy in,the management of mechanical ventilation and weaning.Internationally nurses also are recognized for their role inthe use of non-physician led protocols directed at achievingtimely weaning from mechanical ventilation in ICU.3—5

Mechanical ventilation supports patients whose respira-tory function is compromised by drugs, disease, or otherconditions that result in the failure of ventilatory and/or gasexchange mechanisms.6,7 Patients presenting to the emer-gency department (ED) who require mechanical ventilationare acutely ill and require a period of stabilisation prior totransfer to a specialised unit such as an ICU for ongoingand definitive management. As such, these patients needconstant monitoring and ongoing intervention to detect andtreat changes in their ventilatory status. Patients receiv-ing invasive mechanical ventilation require, at minimum, a1:1 nurse-to-patient ratio,8 and care must be delivered bysuitably experienced and educated members of the inter-disciplinary team.

The duration of ventilation in the ED is influenced notonly by patient factors relating to their presenting condi-tion, but also by organisational issues including hospital/ICUbed availability and local demand for ED services. Risingdemand for ED services and the relative shortage of hos-pital beds have been identified as factors contributing toincreases in ED length of stay (LOS).9 Delays in dispositionof patients requiring mechanical ventilation rapidly exhaustthe availability of clinical resources in the ED and have aprofound effect on clinician workload. Extended deliveryof mechanical ventilation in EDs may threaten the qualityof care delivered to this vulnerable patient population andadversely affect patient outcome.

The purpose of the current study was to develop a pro-file of role responsibility and nursing scope of practice aswell as educational support for the management of venti-lated patients in Australian EDs. Organisational, staffing andskill-mix patterns of these EDs were identified to provide adescription of department characteristics that potentiallymay influence ventilation practice.

Methods

Study design and setting

A survey was sent to nurse managers of 24 Australian EDsparticipating in a contemporaneous 2-month prospectiveobservational study of ventilation management in early

2007.

Expressions of interest to participate in both the surveyand accompanying observational study were extended to allVictorian Emergency Minimal Dataset (n = 30)10 facilitatedcontributors to the by the College of Emergency Nursing Aus-

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39

ralasia (CENA) nurse manager group. Expressions of interestere also extended to nurse managers and ED directors inther States and Territories (n = 18) to provide representa-ion across Australia and ED classifications. The institutionaleview boards of RMIT University and all participating sitespproved the technical and ethical components of the pro-ocol, waiving the need for informed consent.

The survey was revised from a previous study examiningentilation practices in Australian ICUs2 by one of the studynvestigators (LR) and sent to medical and nursing ED clini-ians to assess clinical sensibility. The survey was designed toollect the following information: ED demographics includ-ng location, number of ED trolleys, nursing and medicaltaffing numbers, as well as nurse-to-patient ratios foratients receiving invasive and non-invasive mechanicalentilation. Also collected retrospectively from the ED infor-ation systems were the total number of ED presentations,

ospital and ICU admissions, and the distribution of triageategories during the 2-month study period associated withhe contemporaneous observational study of mechanicalentilation. Data on the number of ventilated (invasive andon-invasive) patients were recorded during their ED pre-entation by ED clinical staff.

The survey requested information on the use ofuidelines, policies, or protocols for mechanically ven-ilated patients with various presenting conditions, theequirement for competency assessment for mechanicalentilation, education provided on the application ofechanical ventilation and nurses’ contribution to mechan-

cal ventilation decision-making. Participants were asked toate ED nurse autonomy for decision-making related to inva-ive mechanical ventilation, defined as the ability to makeentilation decisions and implement them without directupervision of a medical colleague, and nursing contributionowards invasive mechanical ventilation decision-making onwo 10 cm visual analogue scales.

Organisational and workforce data from the surveys wereummarised as mean ± standard deviation, while interval oron-normally distributed data were expressed as mediannd interquartile range. Counts and proportions were usedor categorical data.

Relative risk ratios were calculated to determine theentilator settings most likely adjusted based on an indepen-ent nursing decision (compared to the binary alternativef a decision made by other ED team members). Theotal scores for each visual analogue scale were calculatednd the mean, range and standard deviation determined.omparisons between principal referral EDs and those oth-rwise classified11 were performed using Student’s t tests orann—Whitney tests for continuous data and Chi-square orisher exact tests for categorical data. A P value of <0.05as considered statistically significant.

esults

mergency department characteristics

total of 21 of the 24 ED nurse managers returned ques-ionnaires. Of these 12 out of 21 (57.1%) questionnairesere from Victorian ED nurse managers, 6 out of 21 (28.6%)ere from New South Wales, and there were 1 out of

40

Table 1 Emergency department characteristics.

Characteristics (N = 21) n/Na (%)

ED classificationPrincipal referral (A1) 10/63 (16)Large major cities (B1) 3/23 (13)Large regional and remote (B2) 1/20 (5)Medium major cities (C1) 2/25 (8)Other 5/16 (31)

Cubicles, median (IQR) 18 (13—24)Resuscitation trolleys, median (IQR) 2 (2—3)

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a Data based on 21 of the 147 emergency departments thusclassified according to the Australian Hospital Manual Peer Groupdefinitions.11

1 (4.8%) each from South Australia, Queensland, Tasma-ia, and West Australia. The majority were classified asrincipal referral centres, EDs situated in hospitals thatrovide the full range of specialty services,11 Emergencyepartment non-resuscitation trolley numbers ranged fromto 42. Resuscitation capacity ranged from 1 to 8 trolleys

Table 1).During the 2-month study period, the median number of

D presentations was 6044 (IQR 3618 to 6974). Following EDresentation, the median number of hospital admissions was430 (IQR 906 to 2540) which included 46 (IQR 33 to 100)CU admissions. When examined according to Australasianriage Scale (ATS) categories, patients triaged as ATS cat-gory 4 presented to participating EDs most frequentlymedian 2285, IQR 1272 to 3096). The median number ofatients triaged as ATS category 1 was 25 (IQR 10 to 52),nd ATS category 2 patients was 412 (183 to 651). For the 2-onth study period 552 episodes of mechanical ventilation

ere recorded, of which 307/552 (55.6%) were episodes of

nvasive mechanical ventilation (gas flow delivered via anndotrachel tube) and 245 (44.4%) were episodes of non-nvasive ventilation (NIV) (gas flow delivered via face mask).atients receiving invasive and non-invasive mechanical ven-

(dmnt

Table 2 Nursing and medical staffing of participating EDs.

Full-time staff equivalents To

NursesSenior nursesa 12Registered nurses 31Division 2 nursesb 3Graduate qualificationc, % 42

Physiciansd

Consultants 5Registrars 8Residents 9Emergency medicine traininge, % 29

Figures reported are mean (standard deviation, range).a Senior nurses include nurse managers, associate nurse managers, c

nurse specialists.b Division 2 nurses, undertake a 1-year program and work under the sc Tertiary qualification related to the emergency specialty.d Consultants are the most senior practising medical staff, residentse Graduate level medical education specializing in emergency medici

L. Rose, M.F. Gerdtz

ilation were triaged more frequently into ATS triage codesand 2 compared to other triage codes (P < 0.0001).

mergency department staffing

he majority of EDs employed a full-time nurse manager.nly one ED had no nurse manager. One or more full-ime nurse educators were employed in 14/21 (66.6%) EDs;/21 (19.0%) EDs had no nurse educator and a further 3/2114.3%) EDs employed nurse educators as fractional appoint-ents. Fourteen of the 21 (66.6%) EDs employed Division 2

urses. Table 2 shows the number of nurses and physiciansmployed by department and per ED trolley. The medianercentage of nurses holding a postgraduate specialty qual-fication was 35.0% (IQR 31 to 58). More nurses in principaleferral centres held postgraduate specialty qualificationsompared to other ED classifications (median 48.5% versus5.0%, P = 0.05).

anagement of mechanical ventilation

ll participating EDs identified a 1:1 nurse-to-patient ratioor patients receiving invasive mechanical ventilation. Foratients requiring NIV, reported nurse-to-patient ratiosanged from 1:1 to 1:3. Ten out of the 21 (47.6%) EDseported having institutional guidelines for the managementf invasively ventilated patients; guidelines for manage-ent of NIV were more frequently available (13/21, 61.9%).

ight out of the 10 EDs that had institutional guidelinesor mechanical ventilation also had guidelines for NIVse. Few EDs had institutional guidelines for the manage-ent of patients with specific indications for mechanical

entilation such as chronic obstructive pulmonary disease3/21, 14.3%), asthma (4/21, 19.0%), traumatic brain injury

4/21, 19.0%), and paediatric patients (1/21, 4.8%). Theevelopment of national evidence-based guidelines for theanagement of mechanically ventilated (both invasive and

on-invasive) patients in the ED was viewed favourably byhe majority of respondents (20/21, 95.2%).

tal in department Per ED trolley

.2 (7.2, 27) 0.6 (0.2, 0.8)

.2 (21.2, 27) 1.4 (0.6, 3.0)

.5 (5.8. 22) 0.2 (0.4, 2)

.9 (18.8, 69) 2.1 (2.1, 9.4)

.1 (4.2, 14) 0.2 (0.1, 0.4)

.7 (5.5, 17) 0.3 (0.2, 0.8)

.0 (4.5, 17) 0.4 (0.2, 0.9)

.4 (32.5, 100) 0.7 (0.9, 2.4)

linical nurse educators, clinical nurse coordinators, and clinical

upervision of a registered nurse.

are the most junior.ne.

ED Nurse manager ventilation survey 41

Table 3 Ventilation decisions made by ED nursing staff independentlya.

Setting change (N = 20) n % (95% CI) Relative riskb (95% CI)

Ventilator rate 12 57 (36—78) 1Increase in FiO2 12 57 (36—78) 1Decrease in FiO2 12 57 (36—78) 1Tidal volume 10 47 (26—69) 0.83 (0.43—1.61)Decrease of pressure support 9 43 (22—64) 0.75 (0.37—1.50)Increase of pressure support 9 43 (22—64) 0.75 (0.37—1.50)Decrease of PEEP 9 43 (22—64) 0.75 (0.37—1.50)Increase of PEEP 8 38 (17—59) 0.67 (0.37—1.39)Mode 8 38 (17—59) 0.67 (0.37—1.39)

a Participants were asked to identify decisions that led to setting adjustments made independently by nursing staff more than 50% of

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Nine (42.9%) nurse managers reported nurses indepen-dently adjusted a range of ventilator setting changesincluding titration of tidal volume, set respiratory rate,pressure support and FIO2. The most frequent change in ven-tilator settings made independently by ED nursing staff werealterations to the set ventilator rate and FIO2 (both 12/21,57.1%) (Table 3). Nurses did not make any adjustments toventilator settings in 7/21 (33.3%) EDs. Nurses held a similarlevel of responsibility for changes in tertiary referral centresas in other ED classifications (P = 0.67).

Overall, nursing autonomy, as rated on a 10 cm visualanalogue scale, was perceived as moderate (median 5.0,IQR 3.0 to 8.0) whereas nursing contribution to mechani-cal ventilation decision-making was frequently considered(median 7.0, IQR 5.0 to 8.5). The perceived level of auton-omy did not differ in tertiary-referral EDs compared toother ED classifications (mean 4.7 versus 6.0, P = 0.4). Sim-ilarly, nursing contribution to ventilation decision-makingwas similar across ED classifications (mean 6.7 versus 6.8,P = 0.9). Autonomy was lower (mean 3.2 versus 7.0, P = 0.01)and nurses made less contribution to ventilator decision-making (mean 5.4 versus 7.9, P < 0.001) in EDs wherenurses infrequently selected and titrated ventilator set-tings.

Participants commented that nursing autonomy and con-tribution to mechanical ventilation decision-making varieddue to the experience level of both nurses and physi-cians. Additionally the opportunity to become experiencedin ventilation was not readily available. Site number 15 com-mented that:

‘Due to the infrequency of ventilation it is difficult tobecome an expert in this field.’

Several participants from various ED classifications iden-

tified selection of ventilator settings was frequently theresult of collaborative discussion. One respondent com-mented that:

‘Often [selection of ventilator settings] is initiated bynursing staff and discussed with medical staff for con-firmation’ (participating site number 1).

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ff greater than 50% of the time. Alteration of ventilator rate andtting adjusted independently.

ducation for mechanical ventilation

espondents reported various prerequisites were requiredor ED nurses to be responsible for mechanically ventilatedatients ranging from a formal university postgraduate spe-ialty qualification to completion of an orientation programnd learning packages. The majority of ED nurse managers13/21, 61.9%) reported that some form of competencyssessment took place for ED nursing staff prior to un-receptored care of mechanically ventilated patients. Nurseanagers from 7/13 (53.8%) EDs that mandated competency

ssessment reported that this occurred annually. Reassess-ent of competency was ad hoc or was not performed in

ther EDs.In the majority of EDs (20/21, 95.3%) education on

he principles and practical application of mechanical ven-ilation was delivered by senior ED nursing staff. Oneespondent reported that no education for mechanical ven-ilation was provided in their ED. ED medical staff or ICUtaff (both nursing and medical) were additional providers ofducation to a small number of EDs (3/21 [14.3%] and 2/219.5%] respectively. A further 2 (9.5%) ED nurse managerseported that ventilator companies also provided educationn mechanical ventilation.

iscussion

n this study all EDs reported a 1:1 nurse-to-patient ratio fornvasively ventilated patients, ratios for patients receivingIV differed institutionally. Equivalent ratios are maintainedor ventilated patients in ICU and are recommended byhe Joint Faculty of Intensive Care Medicine.8 Recently aimilar recommendation has been made in a draft positiontatement by the College of Emergency Nurses of Australa-ia (CENA) on the management of mechanically ventilatedatients in the ED. This recommendation must be consideredn light of its impact on the availability of resources for otheratients present in the ED. ED managers need to ensure safe

taffing levels and optimal patient care is maintained for allD patients, not just those requiring mechanical ventilation.

The mission of EDs is to provide immediate life-savingare including assessment, diagnosis, and treatment ofedical and surgical emergencies. Consequently, EDs are

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either designed nor resourced for constant monitoringnd intervention beyond initial assessment and stabilisa-ion posing a threat to the safety of critically-ill ventilatedatients experiencing a protracted ED LOS.12 There is someorth American data to suggest adverse outcomes may bettributable to patients experiencing a delay in ICU admis-ion. In a large retrospective study of patients admitted fromhe ED to an ICU, patients who spent greater than 6 h board-ng in ED after ICU admission had a longer hospital LOS andncreased ICU and hospital mortality compared to patientsransferred to ICU within 6 h of admission.13 However thistudy was unable to elucidate on specific variables that maynfluence patient outcome due to its study design. Furtherork is required to understand the implications of delayed

CU admission for critically-ill ventilated patients.Variability in the nurse-to-patient ratio for patients

eceiving NIV may reflect uncertainty about workload andonitoring requirements. American Thoracic Society guide-

ines for the management of NIV in ED state a 1:1urse-to-patient ratio should be provided by skilled clini-ians in the first few hours of treatment.14 Similar guidelineseleased by the British Thoracic Society do not makeecommendations on staffing ratios. Currently, there iscant evidence to guide staffing decisions, however someuthors recognise patients receiving NIV in the acute phasef respiratory failure may consume equivalent time andtaff resources as patients requiring invasive mechanicalentilation.15 Further work is needed to identify safe staffingevels for patients receiving non-invasive ventilation in theD.

Participating EDs identified that institutional guidelinesor ventilation management were not always available. Pre-entation of patients requiring mechanical ventilation maye infrequent in some EDs. Lack of consistent exposureo patients receiving mechanical ventilation means thatome clinicians, particularly those with less experience, mayack confidence in managing these patients. Safe deliveryf mechanical ventilation requires experienced and skilledlinicians, and inappropriate mechanical ventilation or fail-re to recognise monitoring priorities may place patientst risk.16 Local guidelines or protocols are recommendeds tools to guide clinicians, particularly those with infre-uent exposure to ventilation.17 These guidelines shouldrovide information on the indications for ventilation (bothnvasive and non-invasive) as well as contraindications, andive simple instructions on ventilator set up and monitor-ng priorities. Guidelines and protocols are advocated asays to direct safe practice and avoid unnecessary varia-

ion in ventilation practice, particularly for less experiencedlinicians.18

The results of this survey suggest nurses in some Aus-ralian EDs have an active and collaborative role in decision-aking for patients receiving invasive and non-invasive

entilation. The inclusion of ventilator decision-makingithin the ED nurse scope of practice, however, was notonsistent across surveyed EDs. Comments made by surveyespondents suggested individual ED and staff characteris-

ics appeared more influential on nurses’ scope of practicehan the ED classification in which they practiced.

A recent study of ventilator management by Aus-ralian critical care nurses also reported that nurses werectively involved in decision-making and had high lev-

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L. Rose, M.F. Gerdtz

ls of responsibility and autonomy.2 This finding contrastseports in the international literature that indicate respon-ibility for mechanical ventilation resides primarily withhysicians.19—21 No other identified studies have describedhe scope of practice of ED nurses for ventilation decision-aking, either internationally or in Australia from which toraw comparisons.

Educational and competency requirements required toanage care of the ventilated patient also varied across

urveyed EDs. In some EDs no formal assessment of com-etency was routinely undertaken. Mechanical ventilationan be considered a high risk, low frequency interventionn many EDs. A minimum preparation standard is warrantedue to the risks associated with inappropriate applicationf mechanical ventilation, as well its infrequent occur-ence in some ED settings. The recent draft CENA positiontatement recommends minimum preparation through anvidence-based competency program completed prior toaking responsibility for the management of mechanicallyentilated patients. Further work needs to be undertakeno identify the educational needs of ED nurses related toechanical ventilation and priorities of competency assess-ent across the diversity of ED classifications.

imitations

his study summarised aspects considered important for theelivery of mechanical ventilation representing only a smallumber of EDs within Australia recruited as a convenienceample. Victorian practice was over represented comparedo reports from other States and Territories. As such, ouresults may not be representative of all Australian EDs.evertheless the variety in size, category and geographic

ocation of the participating EDs may represent an adequateross-section of practice.

Another limitation was the potential for reporting biasossibly resulting in an over representation of the ED nurses’ole. Similar evaluation of the perceptions of ED physicianss needed to fully quantify the ventilatory decision-makingxperience in Australian EDs. Also due to the administra-ive requirements of the nurse manager role, the perceptionf nurse autonomy and influence on ventilation decision-aking may be different to other ED nurses more directly

nvolved in clinical care.

onclusion

linician knowledge and experience as well as the provisionf adequate resources are vital for the safe implementa-ion of mechanical ventilation in the ED. Nurse-to-patientatios for the management of invasively ventilated patientsppear consistent across EDs and conform to those used forentilated patients in the ICU. More research is requiredo establish the most appropriate nurse-to-patient ratio

al administrators must recognise the substantial role thatustralian ED nurses have in the management of mechanicalentilation. Consistency in the use of guidelines, and in edu-ation and competency assessment is required to promoteatient safety.

ED Nurse manager ventilation survey

Conflict of interest

The authors have no potentially conflicting interests todeclare.

Funding Interests

This study was supported by a Major Research Grant fromthe Nurses Board of Victoria. The views expressed in thismanuscript do not necessarily represent those of the NursesBoard of Victoria.

Acknowledgements

This study was based upon survey results from the emer-gency departments in the following Australian hospitals:State of Victoria: The Alfred Hospital, The Angliss Hos-pital, Bairnsdale Hospital, Ballarat Base Hospital, BendigoHealth, Central Gippsland Health Service, East WimmeraHealth Service, Goulburn Valley Health, Mildura Base Hos-pital, The Northern Hospital, The Royal Melbourne Hospital,St Vincent’s Hospital; State of New South Wales: CanterburyHospital, Mona Vale Hospital, The Prince of Wales Hospital,St Vincent’s Hospital, Wollongong Hospital; State of WesternAustralia: Kalgoorlie Hospital; State of Queensland: Nam-bour Hospital; State of South Australia: The Royal AdelaideHospital; State of Tasmania: The Royal Hobart Hospital.

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