Mechanical ventilation, weaning practices, and decision-making in European pediatric intensive care units

Abstract

Objectives:
This survey had three key objectives. (1) To describe responsibility for key ventilation and weaning decisions in European pediatric intensive care units (PICUs) and explore variations across Europe. (2) To describe the use of protocols, spontaneous breathing trials (SBTs), non-invasive ventilation (NIV), high flow nasal cannula (HFNC) use, and automated weaning systems. (3) To describe nurse-to-patient staffing ratios and perceived nursing autonomy and influence over ventilation decision-making.
Design: Cross-sectional electronic survey.
Setting: European PICUs.
Participants: Senior ICU nurse and physician from participating PICUs.
Interventions: None
Measurements and main results: Response rate was 64% (65/102) representing 19 European countries. Determination of weaning failure was most commonly based on collaborative decision-making (81% PICUs, 95% confidence interval (CI) 70%–89%). Compared to this decision, selection of initial ventilator settings and weaning method were least likely to be collaborative (relative risk (RR) 0.30, 95% CI 0.20–0.47) and (RR 0.45, 95% CI 0.32–0.45). Most (>75%) PICUs enabled physicians in registrar (fellow) positions to have responsibility for key ventilation decisions. Availability of written guidelines/protocols for ventilation (31%), weaning (22%), and NIV (33%) was uncommon, whereas sedation protocols (66%) and sedation assessment tools (76%) were common. Availability of protocols was similar across European regions (all P values >0.05). HFNC (53%), NIV (52%) to avoid intubation, and SBTs (44%) were used in approximately half the PICUs >50% of the time. A nurse-to-patient ratio of 1:2 was most frequent for invasively (50%) and non-invasively (70%) ventilated patients. Perceived nursing autonomy (median (IQR) 4 (2, 6) and influence (median (IQR) 7 (5, 8)) for ventilation and weaning decisions varied across Europe (P values 0.007 and 0.01 respectively) and were highest in Northern European countries.
Conclusions: We found variability across European PICUs in interprofessional team involvement for ventilation decision-making, nurse staffing, and perceived nursing autonomy and influence over decisions. Patterns of adoption of tools/adjuncts for weaning and sedation were similar.