title: Decisional responsibility for mechanical ventilation and weaning: an international survey.
abstract: BACKGROUND
  Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.
  
  
  METHODS
  A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.
  
  
  RESULTS
  Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.
  
  
  CONCLUSIONS
  Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.
authors.affiliation: Lawrence S, Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, M5T 1P8, Canada. louise.rose@utoronto.ca
authors.forename: Louise
authors.initials: L
authors.lastname: Rose
authors.forename: Bronagh
authors.initials: B
authors.lastname: Blackwood
authors.forename: Ingrid
authors.initials: I
authors.lastname: Egerod
authors.forename: Hege Selnes
authors.initials: HS
authors.lastname: Haugdahl
authors.forename: José
authors.initials: J
authors.lastname: Hofhuis
authors.forename: Michael
authors.initials: M
authors.lastname: Isfort
authors.forename: Kalliopi
authors.initials: K
authors.lastname: Kydonaki
authors.forename: Maria
authors.initials: M
authors.lastname: Schubert
authors.forename: Riccardo
authors.initials: R
authors.lastname: Sperlinga
authors.forename: Peter
authors.initials: P
authors.lastname: Spronk
authors.forename: Sissel
authors.initials: S
authors.lastname: Storli
authors.forename: Daniel F
authors.initials: DF
authors.lastname: McAuley
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
mesh_terms: D003422:Critical Care / Q000379:methods / Q000458:organization & administration; D003430:Cross-Sectional Studies; D019538:Health Care Surveys; D006801:Humans; D010348:Patient Care Team / Q000458:organization & administration / Q000706:statistics & numerical data; D010820:Physicians; D012121:Respiration, Artificial / Q000379:methods* / Q000451:nursing / Q000706:statistics & numerical data; D015300:Ventilator Weaning / Q000379:methods* / Q000451:nursing / Q000706:statistics & numerical data