|Year : 2019 | Volume
| Issue : 3 | Page : 162-166
Evaluation of critical care providers' knowledge in basic mechanical ventilation management: An opportunity for improvement
Hajed Marzouk Al-Otaibi
Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
|Date of Web Publication||9-Dec-2019|
Dr. Hajed Marzouk Al-Otaibi
Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, P.O. Box 80200, Zip Code 21589, Jeddah
Source of Support: None, Conflict of Interest: None
Objectives: This investigation aims to evaluate the knowledge of critical care providers in mechanical ventilation (MV) management and to assess the impact of a 2-day educational package on their knowledge. Materials and Methods: Eighty-nine physicians and nurses attended a 2-day educational course about basic MV management. The basic MV course was conducted in February to June 2017 at Majmaah, Hail, and Arar, Saudi Arabia. Participants were part of a pre-MV course assessment and answered 12 items on a multiple choice questionnaire. After the course, participants repeated the same test (post-MV course assessment). Participants were asked to rate their knowledge of MV management on a scale of 1-10 (before and after the basic MV course). Results: Forty critical care providers (14 physicians and 26 nurses) completed the basic MV course. The participants' clinical experience, on average (±standard deviation), was 5.96 ± 4.6 years. Clinical experience favored physicians. The pre-MV course score for all participants was 4.7 ± 2.29 out of 12, while the post-MV course score was 5.65 ± 2.47. There was a significant statistical difference between pre- and post-MV assessment scores (P = 0.03). Differences between physicians and nurses were significant, on both pre-MV course assessment (P = 0.01) and post-MV course assessment (P = 0.006). There was significant correlation between clinical experience and preassessment scores (r = 0.37; P = 0.03). Conclusion: The present investigation shows that MV management knowledge of critical care providers in hospitals located in small cities is limited. Therefore, it is advisable that critical care providers engaged in continuous professional educational activities related to MV management.
Keywords: Assessment, critical care providers, educational package, mechanical ventilation
|How to cite this article:|
Al-Otaibi HM. Evaluation of critical care providers' knowledge in basic mechanical ventilation management: An opportunity for improvement. Saudi J Health Sci 2019;8:162-6
|How to cite this URL:|
Al-Otaibi HM. Evaluation of critical care providers' knowledge in basic mechanical ventilation management: An opportunity for improvement. Saudi J Health Sci [serial online] 2019 [cited 2020 Jan 22];8:162-6. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/3/162/272439
| Introduction|| |
Mechanical ventilation (MV) management is a common practice in critical care units. MV is one of the major indications for admission to intensive care units (ICUs).,,, Generally, MV is indicated when there is an imbalance between the patient's capability and demands. Therefore, it is commonly indicated in acute respiratory failures, cardiac failure, neuromuscular diseases, drug overdose, sepsis, and other well-documented indications. Unfortunately, MV is not without complications. These complications might arise from endotracheal tube insertion and placement, lung injury, ventilator-associated pneumonia (VAP), respiratory muscle atrophy, and some related physiological and psychological problems.,
Management of MV cannot be simplified. It requires a very good knowledge in a complex and dynamic interaction between several ventilatory variables. This knowledge and skill need to be incorporated into accurate and efficient decisions about best practice while also avoiding ventilator-related complications., Earlier studies have reported that the knowledge of ICU residents, for example, does not support the safe and efficient practice of MV. Hence, it was concluded that continuing education and educational sessions are critical to improve knowledge, build up clinical judgments, and promote best practice. Indeed, early reports have shown that improving health care providers on some aspects of MV would have a positive impact on patient's outcomes. It has been shown that an educational intervention that aims to improve health-care providers' knowledge in MV would significantly decrease hospital length of stay, reduce the rate of VAP, decrease the number of unsuccessful weaning trails, and improve MV management.
Hospitals in small cities are striving for optimum patient care. However, limited resources, shortage of staff, and scarceness of educational activities impose restrictions. Therefore, it is advisable that critical care providers engaged in continuous professional educational activities related to MV management. The primary aim of this study was to evaluate critical care providers' knowledge on basic MV management in small city hospitals, as well as the impact of educational packages.
| Materials and Methods|| |
Convenience sampling method was used for recruitment. All participants were invited to attend a 2-day course about basic MV management, which was conducted at three small cities: Majmaah, Hail, and Arar (Saudi Arabia) on three different dates. The basic MV course was conducted from February to June 2017. All health-care providers who work in critical care units were invited from almost all hospitals in each city. Invitations were simultaneously sent to relevant departments in each hospital, given that there was no intention to select or exclude any hospital. Participants were not aware of the pre- and post-MV course assessments. Before starting the basic MV course, a 12-item multiple choice questionnaire was administered to all participants, as a pre-MV course assessment. Participants had 20 min to complete the assessment. The first page of the assessment tool is a survey, with data about participants' gender, specialty, and clinical experience; they were asked to rate their perceived knowledge of MV on a scale from 1 to 10, with 1 indicating a lack of knowledge and 10 indicating ample knowledge. Evaluation of participants' perceived knowledge about MV was conducted twice, before and after the basic MV course.
The 12-item multiple choice questionnaire was prepared by senior respiratory therapists (RTs). The questionnaire covers basic aspects of MV management. It was then revised and approved by two university professors who are specialized in respiratory therapy. There was no major modification on the questionnaire.
Once the MV course started, no precourse assessment was permitted. By the end of the course, participants were asked to repeat the same assessment. None of the participants knew they would have an assessment after the course, and none knew it would be the same at the previously completed assessment. Participants were given 20 min to complete the post-MV course assessment. For analysis purposes, on average, any precourse assessment score or postcourse assessment score <40% is considered poor.
The 2-day program focuses on interactive workshops with hands-on skills training, simulation, and case studies to supplement lectures on fundamental MV principles and technology. Several key issues on MV were discussed, including respiratory failure, modes and settings of invasive ventilation, patient-ventilator monitoring and assessment, complications of MV, and discontinuing MV.
The learning objectives of the basic MV course included understanding respiratory failure and indications of MV, understanding the basic principles of MV (including the various modes and parameters of MV), and utilizing various patient-ventilator system monitors (i.e., ventilator graphics for assessment, monitoring, and troubleshooting). Moreover, MV strategies for specific diseases and complications associated with MV were discussed. Furthermore, the learning objectives include identifying and discussing essential adjunctive therapies for the patients on MV, familiarizing participants with the complications and hazards associated with MV, and understanding the methods of discontinuing ventilatory support (weaning).
The basic MV course is composed of 12 oral presentations and four workshop sessions. Each presentation lasted 30 min, while each workshop lasted 45 min. On the 1st day, there were six presentations. These presentations cover the physiology of breathing, introduction to MV, and components of mechanical ventilators. The morning session also covers basic ventilator setup, introduction to MV modes, and pressure ventilation versus volume ventilation. On the afternoon, there were three workshops: basic ventilator setup, introduction to MV modes, and volume ventilation versus pressure ventilation.
On the 2nd day, there are six presentations and one workshop. The 2nd day covers basic ventilator management, clinical cases in MV management, and monitoring mechanically ventilated patient, as well as discontinuing MV, complications of MV, and basic MV graphics. The workshop was conducted in the afternoon. The participants were distributed into three groups. Each session lasted for 2 h. This workshop addressed MV setup and case management.
The study was approved by the Armed Forces Hospitals Eastern Region Institutional Review Board Committee. Data were anonymized by removing any personal information for the purpose of confidentiality.
Participants' demographics were calculated with descriptive statistics. Paired t-tests were used to evaluate the difference between pre-MV course assessment scores and post-MV course assessment scores. An independent t-test was used to evaluate differences in performance between physicians and nurses in both pre-MV course assessment and post-MV course assessment. A correlation coefficient evaluated the clinical experience and perceived knowledge against pre- and post-MV assessment scores. P < 0.05 was considered as statistically significant. All statistical analyses were conducted with SPSS version 22 (IBM, Armonk, NY, USA).
| Results|| |
There were 89 participants who attended the course, while only 40 (45%) participants completed the pre- and post-MV course assessments. Participants who did not provide demographic data or failed to complete either the pre- or post-MV course assessment were excluded. Twenty-two female participants attended the course. Fourteen of the course attendees were physicians, while the rest of the participants were nurses. [Figure 1] illustrates the perceived knowledge of health-care providers before and after the MV course.
|Figure 1: The perceived knowledge of participants before and after the mechanical ventilation course|
Click here to view
The clinical experience of all participants ranged from 0.5 to17 years, with an average (±standard deviation) of 5.96 ± 4.6 years. Clinical experience favored physicians in comparison to the nurses. The pre-MV course score for all participants, on average, was 4.7 ± 2.29 out of 12, while the post-MV course score, on average, was 5.65 ± 2.47. [Table 1] presents the pre-MV course and post-MV course scores for physicians and nurses, while also showing the perceived knowledge of both groups before and after the MV course.
|Table 1: Comparison of critical care providers' performances before and after the mechanical ventilation course |
Click here to view
A paired t-test comparing the total pre-MV course scores against post-MV course scores, for all critical care providers, indicates a statistically significant difference (P = 0.03). [Figure 2] illustrates the performance of all critical care providers in the pre-MV course assessment and post-MV course assessment. On the other hand, the independent t-test shows a significant difference in performance between physicians and nurses in the pre-MV course assessment scores (P = 0.01). Furthermore, the independent t-test shows a significant difference in performance between physicians and nurses in the post-MV course assessment scores (P = 0.006).
|Figure 2: The performance of all critical care providers in pre- and post-mechanical ventilation course assessments on the 12-item, multiple choice questions|
Click here to view
The correlation between participants' clinical experience and pre-MV course scores was significant (r = 0.37; P = 0.03). However, there is no correlation between the critical care providers' perceived knowledge scores before the MV course and their pre-MV course scores (r = −0.02; P = 0.92). Similarly, there was no significant correlation between post-MV course scores and post-MV course perceived knowledge scores (r = 0.20; P = 0.22).
| Discussion|| |
This investigation has shown that the MV knowledge of critical care providers working in hospitals located in small cities is limited. However, cumulative clinical experience has a positive impact on their knowledge of basic MV management. Moreover, the perception of critical care providers' competence in basic MV was not compatible with their actual performance. Following a 2-day course, a statistically significant improvement in performance was detected.
Almost 20 years ago, it was well recognized that there is a deficiency in the MV knowledge among the internal medicine residents in the United States. These authors recommended developing specific learning objectives for MV. These learning objectives were advised to be impeded into the training curricula. Conversely, residents in the emergency rooms had shown good basic knowledge in MV. It was reported that their scores correlated with their level of training. The authors have called for incorporating more educational materials into emergency medicine training programs. Similarly, nurses' knowledge of MV was reported to be unsatisfactory. In one large European study that included 318 ICUs, among 11 categories of intensive care-related individuals, the performance of nurses was lowest in the ventilation domain. The nurses scored an average of 66% across all 11 categories, but performance in respiration and ventilation was considered poor. Furthermore, the nurses' performance varied considerably across European countries. The authors of the study attributed this variation in performance to variation in the autonomy of nurses to adjust and manage MV among countries. The present investigation did not compare the nurses' knowledge of MV against other domains. Nevertheless, the nurses' performance is comparable to their performance on previous reports. More importantly, our data show improving performance with cumulative clinical experience. These findings are in line with others. However, a positive relationship between health-care performance and cumulative clinical experience does not always exist.
In North America, Saudi Arabia, and probably other countries, RTs play a major role in MV management.,, Therefore, RTs would work closely with critical care physicians to deliver good patient care. RTs share responsibility for MV initiation, adjustment, monitoring, and weaning. Thus, the role of critical care nurses in the management of MV is limited. However, in Saudi Arabia, hospitals in small cities lack the benefits of having RTs. The reasons for this are multifactorial and beyond the scope of this report. Therefore, physicians and nurses are collaboratively fully responsible for MV management. This is sometimes not limited to Saudi Arabia., Anecdotally, some critical care physicians and nurses gain knowledge in MV management through clinical practice. Thus, those critical care physicians and nurses should be engaged in continuous professional education to sharpen their skills and enhance their knowledge about MV management. The present data show that the knowledge of these critical care providers is below average. The data also show that the performance of the physicians surpasses that of the nurses. However, the superiority of critical care physicians is unlikely to compensate for any deficiency in the nurses' performance. The role of critical care nurses in caring for the mechanically ventilated patients cannot be undervalued. An improvement in nurses' knowledge and skills is likely to enhance and optimize MV management. Here, it was shown that a 2-day intensive course was able to enrich nurses' knowledge and (probably) sharpen their skills. Such courses have been shown to improve knowledge and skills. We assume that the improvement of critical care providers' knowledge and skills would translate into better patient outcomes.
MV management usually takes place in a dynamic and fast-paced clinical environment. Periodically, MV-related scientific evidence emerges from randomized controlled trials. Critical care providers need to adopt the newly emerging MV-related evidence and incorporate them into daily practice., Therefore, enhancing knowledge and sharpening MV-related skills will likely reduce MV-related adverse events and improve outcomes. The majority of MV-related adverse event are believed to arise from human errors. Therefore, engaging critical care providers in periodic educational activities and clinical training is advisable. These educational activities should combine active and passive learning styles. Active learning is a form of bedside teaching and direct involvement in patient care. Passive learning combines traditional didactic methods, such as lectures, conferences, and workshops. Therefore, according to the present data, it would be recommended that critical care providers be regularly engaged in clinical educational sessions. This is strongly recommended for critical care providers working in hospitals located in small city or rural settings. Moreover, it would be advisable that critical care providers undergo a periodic annual competency-based assessment. This would provide minimum standardization for the practice and enhance patients' safety.
The present investigation has several limitations. First, the sample size is small. A larger sample size would definitely give more strength to the conclusion. Second, the assessment tool is capable of evaluating the theoretical knowledge but not psychomotor skills. Although the psychomotor skills were not directly evaluated, it was partially measured through the 12-item multiple choice assessment tool. The third potential limitation is the lack of a control group. Nevertheless, the current data have shown that critical care providers in hospitals located in small cities would benefit from educational activities and clinical training in MV management.
| Conclusion|| |
The knowledge of MV management among critical care providers in hospitals located in the small cities is limited, which is likely to negatively impact the care of mechanically ventilated patients. Therefore, it is advisable that critical care providers undergo periodical, intensive MV management-related courses. Critical care providers should also complete an annual competency-based assessment for MV management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Esteban A, Anzueto A, Alía I, Gordo F, Apezteguía C, Pálizas F, et al.
How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000;161:1450-8.
Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, et al.
Characteristics and outcomes in adult patients receiving mechanical ventilation: A 28-day international study. JAMA 2002;287:345-55.
Needham DM, Bronskill SE, Calinawan JR, Sibbald WJ, Pronovost PJ, Laupacis A. Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers. Crit Care Med 2005;33:574-9.
Tobin MJ, editor. Principles and Practice of Mechanical Ventilation. New York: McGraw†Hill; 2006.
Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, Rabuel C, et al.
Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med 2011;183:364-71.
Blackwood B, Junk C, Lyons JD, McAuley DF, Rose L. Role responsibilities in mechanical ventilation and weaning in pediatric intensive care units: A national survey. Am J Crit Care 2013;22:189-97.
Al-Faouri IG, Abu Al Rub RF, Jumah DM. The impact of educational interventions for nurses on mechanically ventilated patient's outcomes in a Jordanian University hospital. J Clin Nur 2013;23:2205-14.
Cox CE, Carson SS, Ely EW, Govert JA, Garrett JM, Brower RG, et al.
Effectiveness of medical resident education in mechanical ventilation. Am J Respir Crit Care Med 2003;167:32-8.
Lynch-Smith D, Thompson CL, Pickering RG, Wan JY. Education on patient-ventilator synchrony, clinicians' knowledge level, and duration of mechanical ventilation. Am J Crit Care 2016;25:545-51.
Hendryx MS, Fieselmann JF, Bock MJ, Wakefield DS, Helms CM, Bentler SE, et al.
Outreach education to improve quality of rural ICU care. Results of a randomized trial. Am J Respir Crit Care Med 1998;158:418-23.
Wilcox SR, Seigel TA, Strout TD, Schneider JI, Mitchell PM, Marcolini EG, et al.
Emergency medicine residents' knowledge of mechanical ventilation. J Emerg Med 2015;48:481-91.
Fulbrook P, Albarran JW, Baktoft B, Sidebottom B. A survey of European intensive care nurses' knowledge levels. Int J Nurs Stud 2012;49:191-200.
Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Intern Med 2005;142:260-73.
Rose L, Blackwood B, Burns SM, Frazier SK, Egerod I. International perspectives on the influence of structure and process of weaning from mechanical ventilation. Am J Crit Care 2011;20:e10-8.
Al-Otaibi HM, Al Ahmari MD. The respiratory care profession in Saudi Arabia: Past and present. Ann Thorac Med 2016;11:237-42.
] [Full text]
Alotaibi G. Status of respiratory care profession in Saudi Arabia: A national survey. Ann Thorac Med 2015;10:55-60.
] [Full text]
Rose L, Nelson S, Johnston L, Presneill JJ. Decisions made by critical care nurses during mechanical ventilation and weaning in an Australian intensive care unit. Am J Crit Care 2007;16:434-43.
Rebuck D, Dzyngel B, Khan K, Kesten RN, Chapman KR. The effect of structured versus conventional inhaler education in medical housestaff. J Asthma 1996;33:385-93.
Clark NM, Gong M, Schork MA, Evans D, Roloff D, Hurwitz M, et al.
Impact of education for physicians on patient outcomes. Pediatrics 1998;101:831-6.
Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, et al.
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8.
Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, et al.
Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med 2008;177:170-7.
Bion JF, Abrusci T, Hibbert P. Human factors in the management of the critically ill patient. Br J Anaesth 2010;105:26-33.
Joyce MF, Berg S, Bittner EA. Practical strategies for increasing efficiency and effectiveness in critical care education. World J Crit Care Med 2017;6:1-2.
[Figure 1], [Figure 2]