1 Nuffield Department of Anaesthetics and Intensive Care Unit, Oxford, UK. 2 Department of Anaesthesia and Intensive Care, Stoke Mandeville Hospital, Aylesbury, UK
Corresponding author: Department of Anaesthetics, D floor, Jubilee Building, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK. E-mail: rocherj@onetel.net.uk
Accepted for publication: May 5, 2003
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Abstract |
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Methods. Using variables that are routinely documented by intensive care nurses, we assessed the relationship between ventilator settings and arterial blood gas values on 30 consecutive ventilated patients admitted to intensive care units at both a teaching and a district hospital. Data were recorded twice daily and the proportions of data points where there was unnecessary hyperventilation were recorded at each centre.
Results. The initial audit results showed clear differences in practice between the teaching hospital and the district hospital. After an intensive education programme, during which an active role for nursing staff in ventilator management was encouraged, supported by simple protocols, practice in the district hospital was re-audited and found to closely mirror that in the teaching centre.
Conclusions. To assist progress towards the use of a protective ventilation strategy in intensive care units in the UK, we devised a simple, robust audit method. We have shown how this method can give a more uniform practice of ventilation in critical care units, with the introduction of nurse-run protocols.
Br J Anaesth 2003; 91: 41920
Keywords: intensive care, audit; ventilation
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Introduction |
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Most intensive care in the UK is provided in small general hospitals. Until recently, 48% of UK intensive care units had fewer than six beds.3 In an attempt to remedy this, intensive care services in the UK have been organized into critical care networks. The primary purpose of these networks is to organize the provision of intensive care beds and to rationalize the transport of sick patients between hospitals and avoid transfers outside the local area.3 However, academic units, at the hub of each critical care network also have the important function of coordinating therapeutic strategies and undertaking comparative audit in order to ensure consistent best practice throughout the network.3
We set out to devise an audit technique that could be used simply and reproducibly in intensive care units to identify and measure deviation from best ventilation practice. Simple measures were chosen to estimate the proportion of time that patients were ventilated at inappropriately high pressures or tidal volumes, exposing patients to an unnecessary risk of barotrauma (Fig. 1).
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Methods and results |
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The initial results revealed a high proportion of non-ideal ventilatory settings in the district hospital (Fig. 1). In the light of these findings, an education programme was undertaken at the district hospital. In addition, a simple protocol was written to support increased involvement of nursing staff in the set-up and adjustment of mechanical ventilators. In outline, this protocol suggested lower (8 ml kg1) initial or default tidal volume settings than were previously being used, and limitation of peak inflation pressure to 32 cm H2O if the arterial pH was greater than 7.32. In addition, a strategy for increased use of positive end-expiratory pressure to improve oxygenation was outlined, and it was suggested that the initial treatment of respiratory acidosis with a ventilator rate below 20 min1 should be to increase the ventilator rate rather than the inflation pressure. Six months after this process was completed, ventilation at the district hospital was re-evaluated (Fig. 1), and this showed a significant improvement in ventilation practice at the district hospital.
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Comment |
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The process of audit in intensive care is evolving as best practice is determined in specific treatment areas.4 For effective audit, simple robust tests are required which do not involve significant extra clerical work and can therefore be undertaken with minimal extra resources. The audit test described here only gives an approximation to ventilation practice on intensive care units and then only to certain aspects of this practice. Because of its simplicity, however, it can be used easily and quickly to address this specific issue. The specific cut-off values we used represent a pragmatic application of currently available data from patients with ARDS2 and may need adjustment to suit local needs and targets. The tests could then lead to uniform best practice in critical care networks; it is likely that in many instances district units will be found to be performing better than teaching/hub hospitals.
It is particularly notable that an education programme aimed at nursing staff as well as medical staff, with protocols that were subsequently used by the whole team, improved ventilation practice in a small intensive care unit in a district hospital. This success shows the value of involving a multidisciplinary team in intensive care to facilitate progress towards modern practice.
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References |
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2 Anonymous. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342: 13018
3 Department of Health. Comprehensive critical care: a review of adult critical care services. London: Department of Health, 2000
4 Frutiger A. Process quality in the intensive care unit. Acta Anaesthesiol Scand Suppl 1997; 111: 146[Medline]