Sunday, June 10, 2012

Why Aren't Your Patients Weaning? Don't Blame Nursing

The successful weaning and extubation of ventilated patients decreases hospital length of stay and reduces morbidity and mortality. One tool utilized to facilitate this process is “wean predictors” incorporated into RCP driven protocols to determine whether a patient may advance to a spontaneous breathing trial (SBT).

In a previous post [1] I mentioned that the level of sedation was the foremost reason why patients did not progress to a spontaneous breathing trial with a prevalence of 48%. 

This is concerning since it is a standard of care to provide ventilator patients with a daily "sedation vacation" or a interruption or decrease in sedation to assess neurological status and wean readiness.

This poses many questions:
  1. Why is so much sedation being used?
  2. Is this a educational factor or behavioral factor?
  3. Is a better screening tool needed to assess the level of sedation?

 The bedside RN is the one who routinely administers & titrates the level of sedation, so are they to blame? 

This would be the most likely scapegoat, however there are other system factors to consider.

First, are the Respiratory Therapist coordinating assessing wean readiness with nursing performing the sedation vacation? 

Second, what modes of ventilation does your facility currently use? Is it a mode that requires micromanagement and associated with patient ventilator asynchrony?

So nursing may be in charge of sedation administration, conversely your choice in ventilator mode determines the quantity they may have to deliver.