1

NursesNurses’’ Role in Mechanical Role in Mechanical

Ventilation: an International Ventilation: an International

PerspectivePerspectiveLouise RoseLouise Rose

Lawrence S. Bloomberg Professor in Critical Care Nursing

University of Toronto

Adjunct Scientist Li Ka Shing Institute, St Michael's Hospital

Research Scientist, Mount Sinai Hospital

louise.rose@utoronto.ca

Why is it important to make Why is it important to make

international comparisons?international comparisons?

�� Comparisons between countries are Comparisons between countries are

no only useful but essential tono only useful but essential to……....�� identify available resources in different identify available resources in different

countriescountries

�� interpret study resultsinterpret study results

�� study the efficacy/effectiveness of critical study the efficacy/effectiveness of critical

care itself and the influence of various care itself and the influence of various

organizational factorsorganizational factors

•• WunschWunsch et al, 2007 et al, 2007 CurrCurr OpinOpin Crit CareCrit Care

Why is Mechanical Ventilation Why is Mechanical Ventilation

Important for Nurses?Important for Nurses?

�� 24 hour bedside presence 24 hour bedside presence

�� Nurses able to:Nurses able to:•• identify changing physiological responses and initiate identify changing physiological responses and initiate

interventions without delayinterventions without delay

•• recognize weaning readinessrecognize weaning readiness

�� Availability of RTs differs Availability of RTs differs institutionally/internationallyinstitutionally/internationally

•• RN lack of understanding for ventilatory/weaning RN lack of understanding for ventilatory/weaning processes may increase duration of mechanical processes may increase duration of mechanical

ventilation ventilation and and

result in negative patient outcomesresult in negative patient outcomes

�� Patients who undergo prolonged mechanical Patients who undergo prolonged mechanical ventilation require multidisciplinary, multiventilation require multidisciplinary, multi--system system approachapproach

WhatWhat’’s Happening in s Happening in

CanadaCanada……

With thanks to Ms Orla SmithWith thanks to Ms Orla Smith

St MichaelSt Michael’’s Hospitals Hospital

ICU ProfileICU Profile

�� Canadian ICUs admit approx 100,000 Canadian ICUs admit approx 100,000 patients each yearpatients each year

�� Conservatively consume 8% of hospital Conservatively consume 8% of hospital budgetbudget

�� Survey of 98 Canadian ICUs in 2003:Survey of 98 Canadian ICUs in 2003:•• median number of ICU beds ~ 14median number of ICU beds ~ 14

•• median number of staffmedian number of staff--physicians ~ 5physicians ~ 5

•• median number admissions/ICU/yr ~ 751median number admissions/ICU/yr ~ 751

•• overnight physician coverage ~ 51% (adult overnight physician coverage ~ 51% (adult ICUs )ICUs )

Parshuram et al (2006). Crit Care Med. 34: 1674-1678

ICU StaffingICU Staffing

MOHLTC, 2005

2

Mechanical Ventilation in OntarioMechanical Ventilation in Ontario

Key epidemiological trends 1992Key epidemiological trends 1992--2000:2000:�� >150,000 non>150,000 non--cardiac surgery patients received cardiac surgery patients received

mechanical ventilationmechanical ventilation

�� Incidence of mechanical ventilation increased by 9% Incidence of mechanical ventilation increased by 9%

�� 10% of all mechanically ventilated patients had >1 10% of all mechanically ventilated patients had >1

episode of mechanical ventilationepisode of mechanical ventilation

�� 30% increase in mechanical ventilation days30% increase in mechanical ventilation days

•• Mechanical ventilation days consume one of every 16 Mechanical ventilation days consume one of every 16

hospital inpatient bed dayshospital inpatient bed days

�� Mortality increased by 22%Mortality increased by 22%

Needham et al. (2004). Crit Care Med. 32:1504-1509

Needham et al. (2004). Crit Care Med. 32 1504-1509

Needham et al. (2004). Crit Care Med. 32 1504-1509

Change in patient characteristics Change in patient characteristics

from 1992 to 2000from 1992 to 2000

�� ↑↑ >80 years old>80 years old

�� ↑↑ respiratory diseaserespiratory disease

�� ↓↓ cardiovascular disease and cardiovascular disease and

neoplasmsneoplasms

�� ↑↑ inpatient and 30inpatient and 30--day mortalityday mortality

Ventilation in Ontario in 2026Ventilation in Ontario in 2026�� Number of Number of

mechanically mechanically ventilated patients ventilated patients projected to increase projected to increase by 80%by 80%•• crude increase of >30%crude increase of >30%

•• annual increase of 2.3%annual increase of 2.3%

�� Mechanical ventilation Mechanical ventilation days will consume 1 of days will consume 1 of every 9 hospital every 9 hospital inpatient bed daysinpatient bed days•• indicative of increased inindicative of increased in--

patient acuitypatient acuity

�� Worsening shortage of Worsening shortage of intensivists and critical intensivists and critical care nursescare nurses Needham et al. (2005). Crit Care Med, 33 574-579

Relevant Studies: Clinician Roles in Relevant Studies: Clinician Roles in

Weaning in CanadaWeaning in Canada

Burns et al. (Unpublished data)

Standards for Critical Care Nursing Standards for Critical Care Nursing

PracticePractice

� The critical care nurse:

� collects data using technological supports

• anticipates and/or recognizes actual or potential immediate life

threatening health crises including:� Ineffective airway clearance, breathing patterns, and impaired gas exchange

� intervenes to provide effective airway clearance by:

• positioning

• managing airway, adjunctive airways, and secretions

• administering pharmacologic agents

• managing secretions

� intervenes to correct an ineffective breathing pattern by:• administering pharmacologic agents as ordered

• troubleshooting inadequate mechanical supports

• manually ventilating

• assisting with interventions

3

�� The critical care nurse: The critical care nurse:

�� interpretsinterprets diagnostic data including:diagnostic data including:

•• arterial and venous blood gases and other laboratory arterial and venous blood gases and other laboratory

resultsresults

•• ventilation informationventilation information

•• weaning parametersweaning parameters

�� intervenesintervenes to correct impaired gas exchange by managing to correct impaired gas exchange by managing

changeschanges inin::

•• oxygenationoxygenation

•• minute ventilationminute ventilation

•• modes of ventilationmodes of ventilation

�� intervenesintervenes to promote successful weaning from ventilatory to promote successful weaning from ventilatory

support by ensuring adequate nutrition, pain management, support by ensuring adequate nutrition, pain management,

rest, and alleviation from anxietyrest, and alleviation from anxiety

Standards for Critical Care Nursing Standards for Critical Care Nursing

PracticePracticeNursesNurses’’ Role in CanadaRole in Canada

�� Little empirical dataLittle empirical data

�� Not focused on manipulation of the Not focused on manipulation of the

ventilator or decisionventilator or decision--makingmaking

�� Focus directed towards care of the Focus directed towards care of the

ventilated patientventilated patient

•• ongoing assessment and surveillanceongoing assessment and surveillance

•• symptom managementsymptom management

•• optimizing patient for weaningoptimizing patient for weaning

WhatWhat’’s happening in the s happening in the

United StatesUnited States……

With thanks to Dr Susan Frazier With thanks to Dr Susan Frazier and Sarah Kelly and Sarah Kelly

ICU ProfileICU Profile

� Approx 5980 ICUs

• approx 55,000 pts per day

• 4245 (71%) in non-teaching community hospitals

• 3183 (53%) have no intensivist coverage

• 20% had in-house physician coverage on weekends,

12% on week nights and 10% of week end nights

• respiratory insufficiency primary reason for admission

• nurse-to-patient ratio 1:2

• RT ratios vary across institutions

� Angus et al. (2006) Crit Care Med. 34: 1016-1024� Brilli et al. (2001) Crit Care Med. 29: 2007-2019

Mechanical Ventilation in the USMechanical Ventilation in the US

�� Population adjusted incidence of Population adjusted incidence of mechanical ventilation mechanical ventilation ↑↑ 11% 11% (1996(1996--2002)*2002)*

• No corresponding increase in ICU beds

•• >64 years of age >64 years of age -- ↑↑ 4%4%

•• 1818--64 years of age 64 years of age –– ↑↑ 19%19%

•• higher burden of cohigher burden of co--morbidities (morbidities (CharlsonCharlsonindex) index)

•• proportion of patients ventilated >96 hours proportion of patients ventilated >96 hours increased from 33% to 35%increased from 33% to 35%

•• adjusted mean hospital charges rose 12%adjusted mean hospital charges rose 12%

*Data from North Carolina

Carson, et al. (2006) J Intensive Care Med. 21: 173-182

Relevant Studies in the USRelevant Studies in the US

�� Mail surveyMail survey

�� ParticipantsParticipants

•• Random sample Random sample -- American Association of Critical American Association of Critical

Care Nurses (AACN) (n = 3500)Care Nurses (AACN) (n = 3500)

•• Inclusion criteriaInclusion criteria

�� providing direct patient care for providing direct patient care for ≥≥ 8 hours/week to adult 8 hours/week to adult

mechanically ventilated patients mechanically ventilated patients

•• Response rate 793/3500 (23%)Response rate 793/3500 (23%)

Frazier & Kelly (2007). Am J Crit Care 16: 305

Funding University of Kentucky Faculty Research Support Award

4

Use of Weaning Guidelines

41

83

54 5357

89

53

6365

93

40

66

0

10

20

30

40

50

60

70

80

90

100

Protocol Assessment SBT Team

Proportion

Small

Medium

Large

*

*

*

*

* Significant difference in response between respondents based on hospital size, p < 0.04

Frazier & Kelly (2007). Unpublished data

Role of Nurse in Ventilator Weaning

58

27

95

68

0

10

20

30

40

50

60

70

80

90

100

Readiness

assessment

Initiation Monitoring Discontinue

Proportion

Nurses in small hospitals less likely to assess weaning

readiness (p = 0.02)Frazier & Kelly (2007). Am J Crit Care 16: 305

RT/RNRT/RN--led Weaning Protocolsled Weaning ProtocolsNonNon--physicianphysician--led Weaning led Weaning

ProtocolsProtocols

P = 0.0003

WhatWhat’’s Happening in the s Happening in the

United KingdomUnited Kingdom……

With thanks to Dr Bronagh BlackwoodWith thanks to Dr Bronagh Blackwood

QueenQueen’’s University, Northern Irelands University, Northern Ireland

ICU Profile in UKICU Profile in UK

�� 11--2% of total bed numbers2% of total bed numbers

�� 80% are 80% are ‘‘closedclosed’’ unitsunits

�� Majority are mixed/general ICUs Majority are mixed/general ICUs

�� Average ICU ~4Average ICU ~4--6 beds 6 beds

•• (20+ beds in some tertiary centres)(20+ beds in some tertiary centres)

•• 45% of hospitals also had a high dependency unit45% of hospitals also had a high dependency unit

�� Throughput 400Throughput 400--1800 pts/yr1800 pts/yr

�� Mean APACHE II score 16.5Mean APACHE II score 16.5

�� Cardiovascular, Cardiovascular, GI,andGI,and respiratory admissions respiratory admissions

most prevalentmost prevalent

Audit Commission (1999) Critical to Success. Audit Commission: London

5

Staffing ProfileStaffing Profile

�� 22––7 medical consultants responsible for clinical 7 medical consultants responsible for clinical

care/ICUcare/ICU

•• few fullfew full--time intensivists time intensivists –– most have anaesthetic or most have anaesthetic or

medical sessions in addition to ICU commitmentmedical sessions in addition to ICU commitment

•• junior doctor staffing levels lower in UK than Europe junior doctor staffing levels lower in UK than Europe

�� General policy in UK is 1:1 nurse patient ratioGeneral policy in UK is 1:1 nurse patient ratio

�� 45% of nurses in UK hold ENB 100: 645% of nurses in UK hold ENB 100: 6--12 month 12 month

qualification in critical care specialtyqualification in critical care specialty

�� No RTsNo RTs

Audit Commission (1999) Critical to Success. Audit Commission: London

The NurseThe Nurse’’s Roles Role

>50%

>95%

>20%

Weaning from Mechanical VentilationWeaning from Mechanical Ventilation

� Since 1997, focus on decreasing unacceptable variations in practice• White Paper: the New NHS (DoH 1997)

• A First Class Service: Quality in the new NHS (DoH 1998)

� 2000 – establishment of critical care nurse consultants, practice development teams

� NHS Survey of Weaning and Long-term ventilation (2002)

• 22% of hospitals responding to survey used weaning protocol

• 1% used weaning team

• Rest clinician-led –though professional group of ‘clinician’ not specified

�� ..

Rationales for NurseRationales for Nurse--led Protocolsled Protocols

�� Evidence from US = Evidence from US = ↓↓ ventilator daysventilator days

�� Initiatives expanding nurse role/ Initiatives expanding nurse role/ improving patient outcomesimproving patient outcomes•• Scope of Professional Practice, 1992Scope of Professional Practice, 1992

•• Comprehensive Critical Care, 2000Comprehensive Critical Care, 2000

•• Critical to Success, 2002Critical to Success, 2002

�� Weaning inefficient due to need for Weaning inefficient due to need for medical approval to progress weaningmedical approval to progress weaning

�� NonNon--uniform nursing clinical expertise to uniform nursing clinical expertise to lead weaning processlead weaning process•• Protocols standardizing practice, guiding junior Protocols standardizing practice, guiding junior

staff and optimizing patient outcomestaff and optimizing patient outcome

6

Study ConclusionsStudy Conclusions

� ICU cultures & interprofessional working practices may also influence findings• Kollef protocols had least effect in unit where

weaning delegated to nurses (7.9-hours longer)

• Marelich reported no effect in unit that had a standardised multi-disciplinary approach

� Thus, while protocols may streamline practice & reduce variability where this exists, they do not affect outcomes in units where good communication & standardised practice already exists.

WhatWhat’’s Happening s Happening

DownunderDownunder……

ICU ProfileICU Profile

�� 195 ICUs in Aus and NZ195 ICUs in Aus and NZ�� Majority are combined units, very few Majority are combined units, very few

specializedspecialized�� All All closed closed intensivistintensivist--led led unitsunits

�� Aus: 1233 available beds/20325,926 Aus: 1233 available beds/20325,926 populationpopulation

�� Mean beds 13/ICUMean beds 13/ICU�� ICU admission 2.24% of overall hospital ICU admission 2.24% of overall hospital

admissionsadmissions

�� Median LOS: 43 hoursMedian LOS: 43 hours�� Median APACHE II 15.57Median APACHE II 15.57

Intensive Care Resources & Activity: Australia and New Zealand 2003-2005

ICU WorkforceICU Workforce

�� 3.9 beds/intensivist3.9 beds/intensivist

�� ICUs also staffed by senior ICUs also staffed by senior

registrars/registrars and residentsregistrars/registrars and residents

�� 1:1 nurse1:1 nurse--toto--patient ratiopatient ratio

�� 56% of RNs hold postgraduate 56% of RNs hold postgraduate

specialty qualificationspecialty qualification

�� No RTsNo RTs

�� Interdisciplinary team focusInterdisciplinary team focus

Intensive Care Resources & Activity: Australia and New Zealand 2003-2005

Bellomo et al. (2007) Curr Opin Anaesth, 20:100-105

Nursing Input Medical Input Only

n % (95% CI) n % (95% CI)

Readiness to wean 46 85 (73-93) 8 15 (7-27)

Weaning method 39 72 (58-84) 15 28 (16-42)

Readiness to extubate 36 67 (53-79) 18 33 (21-47)

Weaning failure 51 94 (85-99) 3 6 (1-15)

Nursing input defined as either independent or collaborative

Ventilation Decisions made by Ventilation Decisions made by

Nursing Staff IndependentlyNursing Staff IndependentlySetting Change (N = 54) n % (95% CI) Relative risk (95% CI)

Increase in FiO2 49 91 (80-97) 1

Decrease in FiO2 46 85 (73-93) 0.9 (0.8-1.1)

Ventilator rate 35 65 (51-77) 0.7 (0.6-0.9)

Decrease of pressure support 31 57 (43-71) 0.6 (0.5-0.8)

Increase of pressure support 31 57 (43-71) 0.6 (0.5-0.8)

Tidal Volume 26 48 (34-62) 0.5 (0.4-0.7)

Mode 20 37 (24-51) 0.4 (0.3-0.6)

Decrease of PEEP 16 30 (18-44) 0.3 (0.2-0.5)

Increase of PEEP 15 28 (16-42) 0.3 (0.2-0.5)

7

2 4 6 8 100

2

4

6

8

10

12

14

16

Nursing Influence

Number of Responses

Nursing Autonomy and InfluenceNursing Autonomy and Influence

2 4 6 8 100

2

4

6

8

10

12

14

16

Nursing Autonomy

Number of Responses median of 7.0

Low High

median of 7.7

Low High

� Three-monthprospective study

� Bedside nurses serially documented each ‘decision episode’

�any event that resulted in adjustment to ventilator settings

Ventilator DecisionsVentilator Decisions

All (n =3986) FiO2 excluded (n = 2320)0

1000

2000

3000

4000 Nurse

Collaborative

Medical

64%

46%

Median 6 decisions per patient per day of ventilation

DecisionsDecisions

�� Nurses initiated weaning in 249/306 Nurses initiated weaning in 249/306

(81%) patients who underwent (81%) patients who underwent

weaningweaning

�� Exclusively nursing decisionsExclusively nursing decisions�� 896 (75%) all decisions prior to weaning896 (75%) all decisions prior to weaning

�� 1642 (60%) during weaning1642 (60%) during weaning

�� 4638 changes to ventilator from 4638 changes to ventilator from

3986 decisions3986 decisions

•• nursing staff made 3905 (98%)nursing staff made 3905 (98%)

Adjustments by Other GroupsAdjustments by Other Groups

�� Adjustments initiated solely by Adjustments initiated solely by medical staffmedical staff

��39% PEEP 39% PEEP

��31% inspiratory pressure 31% inspiratory pressure

��29% extubations29% extubations

�� Adjustments initiated by nurses Adjustments initiated by nurses and medical staff in collaborationand medical staff in collaboration

��68% extubations68% extubations

��31% mode 31% mode

��26% other26% other

Setting Changes According to Setting Changes According to

Professional GroupProfessional Group

n (%)

Total Nursing Medical Collaborative

Mode 1238 613 (49) 244 (20) 381 (31)

Frequency 296 223 (75) 45 (15) 28 (10)

VT 80 62 (77) 10 (13) 8 (10)

Pinsp 60 30 (50) 19 (32) 11 (18)

PS 536 367 (68) 112 (21) 57 (11)

PEEP 341 159 (47) 135 (40) 47 (14)

FiO2 1725 1480 (86) 147 (8.5) 98 (5.5)

Extubation 307 4 (1) 92 (30) 211 (69)

Other 55 22 (40) 22 (40) 11 (20)

Total 4638 2960 826 852

8

Exclusively Nursing DecisionsExclusively Nursing Decisions

�� ExclusivelyExclusively nursingnursing decisions, prior to and during decisions, prior to and during weaning, associated withweaning, associated with::

•• post operative respiratory failurepost operative respiratory failure oror coma coma

•• duration of ventilation duration of ventilation ≤≤ seven daysseven days

�� NursingNursing decisions were less common decisions were less common

•• respiratory disease (pneumonia, ARDS, COPD)respiratory disease (pneumonia, ARDS, COPD)

•• multiple organ dysfunction (higher SOFAmax score) multiple organ dysfunction (higher SOFAmax score)

�� NursingNursing decisions more common all patient decisions more common all patient

categoriescategories

•• exception exception waswas COPCOPD (D (collaborativecollaborative))

�� MMore medical decisionore medical decision--making was observed in making was observed in

patients with higher SOFAmax scorespatients with higher SOFAmax scores

ConclusionsConclusions

�� Nurses Nurses �� majority of changesmajority of changes

•• ranged in complexity from ranged in complexity from commencement of commencement of

weaningweaning to to FiOFiO22 titrationtitration

•• pre/post weaningpre/post weaning

•• across spectrum of severity of illnessacross spectrum of severity of illness

�� CollaborativeCollaborative decisionsdecisions more frequent in more frequent in

patients patients with with higher severity of illness and higher severity of illness and

predominantly respiratory diseasepredominantly respiratory disease

•• extubation decisions collaborative extubation decisions collaborative in naturein nature

�� Exclusively medical decisions infrequentExclusively medical decisions infrequent

�� Automatic PS adjustment Automatic PS adjustment

�� RealReal--time monitoring of respiratory time monitoring of respiratory statusstatus

�� Recommends Recommends ‘‘separationseparation’’ on on successful spontaneous breathing trialsuccessful spontaneous breathing trial

�� Reduced duration of weaning in Reduced duration of weaning in European context European context

•• 3 vs 5 median days3 vs 5 median days

Lellouche, et al. Am.J Respir.Crit Care Med. 174 (8):894-900, 2006.

Time to Time to ““Separation PotentialSeparation Potential””

Time in hours from randomisation to the time of declaration of “separation potential”

0 3 0 6 0 9 0 1 2 0 1 5 00 .0 0

0 .2 5

0 .5 0

0 .7 5

1 .0 0

N u m b e r a t r is k

S m a rtC a re /P S 5 1

C o n tr o l 5 1

1 9

1 5

9

1 0

7

4

4

3

4

2

S m a r t C a r e /P S

C o n t r o l

L o g r a n k te s t P = 0 .3

T im e t o " S e p a r a t io n " (h )

Pobability of Remaining Ventilated

Univariate Hazard Ratios for Univariate Hazard Ratios for

reaching reaching ““Separation PotentialSeparation Potential”” Reference Univariate

Hazard ratio (95% CI) P value

SmartCare/PS Control 0.79 (0.52-1.20) 0.27

Age, ≥ median, (y) < Median 0.95 (0.90-1.00) 0.06

Male gender Female 1.63 (1.04-2.56) 0.03

APACHE II ≥ median < Median 0.90 (0.77-1.06) 0.21

SOFAmax per 5 points 0.57 (0.42-0.77) <0.0005

NMBs No NMBs 0.76 (0.51-1.15) 0.20

Corticosteroids No corticosteroids 0.35 (0.17-0.72) 0.004

Glucose (maximum)

(mmol/L) ≥ overall median

< overall median

0.68 (0.51-0.91)

0.008

Coma No coma 1.40 (0.84-2.33) 0.19

Univariate Cox proportional hazards model with only the indicateUnivariate Cox proportional hazards model with only the indicated covariated covariate

Reference Multivariate

Hazard ratio (95% CI) P value

SmartCare/PS Control 0.69 (0.44-1.09) 0.12

Age, ≥ median, (y) < Median 0.99 (0.92-1.05) 0.67

Male gender Female 1.81 (1.03-3.19) 0.04

APACHE II ≥ median < Median 0.98 (0.80-1.19) 0.82

SOFAmax per 5 points 0.83 (0.54-1.26) 0.38

NMBs No NMBs 0.65 (0.40-1.07) 0.09

Corticosteroids No corticosteroids 0.57 (0.25-1.31) 0.19

Glucose (maximum) (mmol/L) ≥ overall median

< overall median

0.73 (0.53-0.99)

0.04

Coma No coma 1.53 (0.82-2.88) 0.19

Multivariate Hazard Ratios for

reaching “Separation Potential”

Multivariate Hazard Ratios for Multivariate Hazard Ratios for

reaching reaching ““Separation PotentialSeparation Potential””

Multivariate Cox proportional hazards model adjusted for all othMultivariate Cox proportional hazards model adjusted for all other variables.er variables.

Test of proportional hazards assumption: P = 0.97 (Test of proportional hazards assumption: P = 0.97 (SchoenfeldSchoenfeld residuals)residuals)

9

All 1All 1°° and 2and 2°° OutcomesOutcomes**

* Estimated median durations (Kaplan* Estimated median durations (Kaplan--Meier)Meier)

Separation

Wean

Ventilation

ICU Stay

0

2 4

4 8

7 2

9 6

1 2 0

1 4 4

1 6 8

1 9 2 S m a r tC a r e /P S

C o n tr o l

P = 0 .3

P = 0 .6

P = 0 .9

P = 0 .7

Duration (h)

ComplicationsComplications

Characteristic n (%) SmartCare/PS Usual weaning P value*

Reintubation

Within 48 hours 5 (10) 6 (12) 1.0

NIV post extubation 8 (16) 6 (12) 0.8

Self extubation 0 0 1.0

Tracheostomy 6 (12) 8 (16) 0.8

Duration of ventilation >21 days 2 (4) 3 (6) 1.0

Death

On protocol 2 (4) 1 (2) 0.4

In ICU 7 (14) 1 (2) 0.06

* Fisher exact tests* Fisher exact tests

ConclusionsConclusions

�� Weaning with SmartCare/PSWeaning with SmartCare/PS

comparable tocomparable to

weaning by weaning by qualified and ventilationqualified and ventilation--

experienced ICU nursesexperienced ICU nurses working with working with

trained intensiviststrained intensivists

�� Advantages of SmartCare/PS may vary Advantages of SmartCare/PS may vary

according to ICU clinical organisationaccording to ICU clinical organisation

Final WordsFinal Words�� Nursing role in mechanical ventilation and Nursing role in mechanical ventilation and

weaning differs internationallyweaning differs internationally

�� RT role decreases RN direct involvement in RT role decreases RN direct involvement in ventilation decisionventilation decision--makingmaking

�� Care of the ventilated patient is not just about Care of the ventilated patient is not just about the ventilatorthe ventilator

�� Need to consider:Need to consider:•• Ongoing assessment and coordination of care activitiesOngoing assessment and coordination of care activities

•• Symptom management: sedation, agitation, delirium, Symptom management: sedation, agitation, delirium, pain, pain, dyspneadyspnea……

•• Optimizing patient outcome: nutrition, mobility, sleepOptimizing patient outcome: nutrition, mobility, sleep……

•• Safety: prevention of adverse and nosocomial events Safety: prevention of adverse and nosocomial events