Promoting better weaning practice in PICU : the development, implementation and evaluation of guidelines for weaning children from mechanical ventilation
Keogh, Samantha Jane (2005) Promoting better weaning practice in PICU : the development, implementation and evaluation of guidelines for weaning children from mechanical ventilation. PhD by Publication, Queensland University of Technology.
Introduction: Weaning from mechanical ventilation is defined as the gradual reduction of mechanical support, and replacing this support with spontaneous ventilation. It is a complex process involving assessing the patient's readiness to wean, optimising factors that can impede the process, selecting the most appropriate weaning mode and continually assessing the patient's progress. In paediatric intensive care the clinician must also account for the unique physiological and psychosocial needs of the child.
Aim: The aim of the study was to explore the need for, and impact, of guidelines for weaning children from mechanical ventilation on patient outcomes and staff practice.
Method: The study was multi-dimensional using the Model for Improvement as the conceptual framework and decided into four phases.
Phase one: A survey of Australian PICUs in 2000 revealed that over 2500 children were ventilated over a 12 month-period, with a potential population of 625 children experiencing difficulties with weaning from mechanical ventilation. No guidelines for weaning children from mechanical ventilation were identified at the time. Standardising the approach to weaning had proven successful with the adult population.
Phase two: Collaborative guidelines for weaning, based on available evidence and expert opinion, were drawn up, validated by a panel of experts and safely piloted.
Phase three: The guidelines were then tested using a time series design over two years on a PICU at a tertiary referral children's facility. Results demonstrated that total ventilation time, weaning duration and length of stay were not significantly improved in the experimental group. However, quality indicators were slightly improved and a survival analysis also showed a slightly reduced probability of long term ventilated patients remaining ventilated. Results also demonstrated a reduction in the fluctuation of outcome variables over time indicating improved consistency in weaning due to the guidelines
Phase four: A qualitative analysis of focus group interviews with staff about the impact of guidelines on their practice generated themes, centred on practice development, framework, relationships and challenges. Few previous studies have investigated the perceptions of staff regarding use of practice guidelines. This study identified that staff viewed the use of weaning guidelines favourably and perceived that their implementation improved patient outcomes.
Weaning is a relatively neglected area of intensive care because much of the initial focus of management is resuscitation and stabilisation. This study has demonstrated the positive impact that standardised and collaborative practice can have on patient outcome and clinical practice.