Best Practice in Prolonged Mechanical Ventilation: A Qualitative Study of Healthcare Provider Perspectives

Abstract

Background & Purpose: Patients who require Prolonged Mechanical Ventilation (PMV) are a relatively small but complex and vulnerable subset of patients treated in the intensive care unit (ICU). Significant heterogeneity in practice patterns exists and best practice is largely unknown. The goal of this study is to engage healthcare providers (HCPs) to identify and describe best care practices for patients requiring PMV.

Methods: A qualitative descriptive method was used. Using purposeful sampling, we recruited medical doctors (MD), nurse practitioners (NP), registered nurses (RN) and respiratory therapists (RT) from hospitals across Alberta to participate in virtual, semi-structured interviews. Interviews were recorded, transcribed verbatim and analyzed concurrently using the principles of thematic analysis.

Results: We identified 5 best practice themes: 1) patient and family engagement 2) team dynamics: collaboration and autonomy 3) developing a structured plan and process 4) ICU physical environment 5) discharge and disposition. Overall, these themes represent a collaborative approach to PMV that includes structured planning and comprehensive care.

Conclusion: Patients requiring PMV are a complex clinical population with unique needs. The themes identified can be adopted in existing ICU environments and can guide the expansion of high-quality PMV programs.

Key Words: Prolonged Mechanical Ventilation; Healthcare Providers; Qualitative Description Critical Care Medicine; Patient-Centered Care; Intensive Care Unit.

Implications for Nursing

• Best practice for patients on prolonged mechanical ventilation is poorly defined.
• This qualitative study identified 5 best practice themes from interviews with healthcare providers that can be implemented and improve care for this population.
• The themes of improved patient and family engagement, collaboration and autonomy within the health care team and developing a structured plan and process are not costly and can have a significant impact on patient care.
• Optimizing the ICU physical environment and post critical illness care will require future resource allocation and will not occur without supporting evidence.
• Research studies like ours are needed so resources can be appropriately allocated by policymakers and providers, along with a greater standardization of high-quality care practices for patients and their families.

Introduction

Invasive Mechanical Ventilation (IMV) in patients with respiratory failure is a common practice in the intensive care unit (ICU). The majority of these patients are extubated early upon recovery from acute critical illness; however, approximately 5-10 percent of these patients require prolonged mechanical ventilation (PMV) (Lamas, 2014). This term has been variably defined as ≥96 hours to ≥21 days of IMV (Rose et al., 2017).  These patients have long ICU stays and often have multiple complex respiratory and non-respiratory care needs. The standard ICU model may be insufficient for this population and negatively impact patient care. This is due to the nature of ICU, which is fast paced with intensivists changing weekly and prioritization is given to high acuity patients (Nelson et al., 2010, Minton et al., 2018).

Liberation from the ventilator, referred to as “weaning,” is often the primary goal for this population in an ICU setting. There are few guidelines and consensus statements available to assist health experts (MacIntyre, 2004; MacIntyre et al., 2005), with significant variability in clinical practice (Ambrosino et al., 2018., Rose et al., 2015.,Burns et al., 2021; Kahn et al., 2018; Rose, Blackwood, Burns et al., 2011., Vitacca., 2011). While liberation from mechanical ventilation is important, there is increasing recognition and attention directed to other aspects of the patient’s care including nutrition, mobility, psychosocial factors, and discharge planning (Minton et al., 2018).

A recent ethnographic study by Rak et al. (2020) examined PMV-related care practices and organizational structures that were associated with outcomes of mortality, liberation from mechanical ventilation and functional status. Protocols and pathways were a key theme identified, however additional aspects of interdisciplinary care approaches and organization practices such as interprofessional communication, lower staff to patient ratios and leadership are also needed. There is a paucity of literature in this field therefore, we aimed to describe themes perceived by experienced HCPs to be important to the care of patients who require PMV.

Given the complexity and multidisciplinary nature of ICU it is important that current practice models are continuously evaluated, and best practices are identified and implemented into ICU care.

Methods

Design

This study was performed in Alberta, Canada, a province with approximately 4.4 million people and 17 ICUs with approximately 9.7 adult ICU beds per 100,000 people [(Canadian Institute of Health Information (CIHI), 2016; Munan et al, 2023)].  There is variability in models of care across the province however most adopt 1:1 or 2:1 nurse-to-patient ratios and provide multi-disciplinary team-based care which includes respiratory therapists, physiotherapists, and dietitians. Urban centers operate predominantly in a closed model (patients are assigned to an Intensivist) whereas the open model (the attending provider is a non-Intensivist physician) exists in some urban and many rural sites.

This study utilized a qualitative descriptive method (Sandelowski, 2000). Qualitative description (Sandelowski, 2000, Sandelowski, 2010) was chosen as the method as it aligns with the study’s goal to describe best practice themes that are pragmatic and relevant to clinicians. We did not choose a theoretical model and instead identified data driven themes. 

Study recruitment and data collection occurred between October 2020 and July 2021. Ethics approval was obtained through the University of Alberta Health Research Ethics Board. Purposeful sampling was used to recruit HCPs who have experience with PMV (Coyne, 1997). The research team contacted clinical colleagues and unit managers working in hospitals across Alberta by email to participate and/or distribute the study information.  Participants were eligible if they were a Medical Doctor (MD), Nurse Practitioner (NP), Registered Nurse (RN), or Respiratory Therapist (RT) with self-reported experience providing direct care to patients on PMV. An informed consent document was sent to each participant to read and sign prior to the interview.

The research team used established methods (Kallio et al., 2016) to develop the semi-structured interview guide collaboratively. The interview guide was pilot tested and edited with consultation from RNs, RTs and MDs. The interview guide was modified by HC, MM and EM on 3 distinct occasions throughout the data collection period to elaborate and expand on themes identified in the completed interviews. See appendix-A for the final interview guide.

Members of the research team (MM, HC) performed one-on-one semi-structured interviews utilizing zoom video conferencing software (n=26) and an in-person approach (n=4). The interviews were approximately 10-45 minutes in duration and were audio-recorded and transcribed by a professional medical transcriptionist. All identifying information was removed during the transcription process. De-identified transcripts were uploaded into NVivo (QSR International Pty Ltd. Version 12, 2018) and analyzed concurrently with data collection. Lead author MM performed inductive, iterative coding on the transcripts using the principles of reflexive thematic analysis to develop the initial coding frame. The phases of reflexive thematic analysis included familiarization of the text through reading and re-reading the transcripts, coding the transcripts and generating initial themes (Braun & Clarke, 2006; Braun & Clarke, 2021).   Once the initial coding frame and themes were identified, author HC, a second-year medical student, utilized this coding frame and independently coded all transcripts to ensure the reliability of findings (Morse, 2015). The last three steps of reviewing and developing themes, refining and naming themes and writing the report were done collaboratively among members of the research team. 

Memos were taken immediately after the interview to record the interviewer’s reflections and key points. The research team met after performing and coding every 5 interviews to collaboratively discuss discrepancies and differences in codes until a consensus was reached. Authors EM, KS, and KS are experts in the field and provided input based on years of clinical experience treating patients requiring PMV. Data were collected until all authors were confident that concepts and variations were sufficiently explored (Saunders et al., 2018).A modified version of the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist was developed to ensure rigor and transparency (Tong et al., 2007) and can be found in the Supplementary Information.

Results

Participant characteristics

We interviewed 30 HCPs, (MD; n = 10 (33%), RT; n = 10, (33%) RN; n = 5 (17%) and NP; n = 5 (17%)). Our sample included 20 females and 10 males. The majority of participants (28) worked in the major cities of Edmonton and Calgary in Alberta and two worked outside of Edmonton and Calgary. See Table 1 for participant characteristics.

Table 1

 Participant Characteristics.

Key Themes

We identified 5 key themes and 13 subthemes from qualitative analysis (Table 2).

Table 2

Themes and subthemes

Patient and Family Engagement

Patients and families were described by healthcare providers as important members of the team and encouraged their involvement in decision making and the development of treatment plans.  Healthcare providers indicated that patients with supportive and encouraging families were more motivated to participate in their treatment plan.

“It is a team effort, and the team obviously includes the patients themselves as well as families. The families are the cheerleader team for the patients that are trying to wean” (NP6).

Active patient and family involvement was believed to lead to clinical improvement including successful weaning, mobility, survival, and ICU discharge. Healthcare providers expressed that there is variability in the level of engagement with some families present and involved while others were not involved in care. Communicating with patients and families about their daily goals was identified as a strategy to increase patient and family involvement.

“I don’t think we sit down and ask them, what is your goal today…which we could do…Is your goal today to get off the vent for x amount of time or…is your goal today to sit up in the chair vented for x amount of time” (NP3).

Motivating and empowering patients to understand and participate in their treatment plan was perceived to be a vital aspect of successful liberation from the ventilator. In comparison to other HCPs, MDs were more likely to highlight the importance of patient engagement in the treatment plan.

“They are the one that has to run the marathon, we are just there to cheer them on and give them the tools. It has to be them” (MD7).

Regular updates for families about the patient’s prognosis and options regarding disposition should be done with honesty and empathy while being mindful of any language or cultural barriers that may hinder the families’ understanding of the situation. This can include utilizing translational services, diversity and inclusivity education and training and identifying barriers between HCPs and patients and families.  

 “You’re stating the facts but you’re stating it in a very gentle manner where the families can understand and if there is any language barrier or cultural barrier, always be mindful of that as well” (RT6).

Team Dynamics: Collaboration and Autonomy

When participants were asked about the ideal team dynamics for providing care to patients on PMV, HCPs highlighted the importance of collaboratively creating a treatment plan and agreeing on goals to avoid any confusion and ensuring that information conveyed to the families is consistent.

“If we are not all on the same page, on the same plan, communicated regularly, people start to tell patients and families different things and they start to get confused on expectations” (RT5).

Collaborative goal setting could be accomplished through complex patient meetings, which ensure that everyone on the team has an opportunity to share their perspectives and center the discussion on individual patient goals. NPs and RNs were more likely to highlight the significance of open communication within the healthcare team.

 “Something that has improved since we started the complex patient meetings weekly, is that communication piece between physicians about what the patient’s goal is” (RN2).

Autonomy for non-physician members of the team was highlighted. While physicians are involved in making any major decisions, nurses and allied health professionals should be empowered to act within their scope of practice to achieve the shared goals. Compared to other HCPs, RTs were more likely to emphasize the importance of autonomy in the weaning process.

 “Having autonomy means that you are…. encouraged as part of that team to really practice to your full scope of practice” (MD9).

Developing a Structured Plan and Process

When participants were further questioned on the use of specific guidelines and protocols, they reported that the weaning plan should be individualized and adapted depending on the patient’s progress. HCPs shared mixed perspectives about the importance of protocols in liberating patients from the ventilator. Some HCPs preferred using a protocol while others preferred clinical judgement and perceived protocols to be barriers to success. Protocols and guidelines were thought to assist HCPs that are new to the team or if a particular disease process has not been handled by the team before.

 “It’s always good to have kind of a guide, especially to individuals maybe who are just starting” (RT6).

 Others reported that, although protocols act as a guide in the weaning process, they are not definitive and need to be modified and tailored to the patient’s needs.

“A protocol is a guideline. It is not carved in stone and I think trying to apply them is appropriate, but I think your clinical judgement in the variability that each patient has is going to be your guide” (NP4).

The need to establish a system to evaluate progress consistently on a weekly and a monthly basis was a suggested area for improvement. Charts in the patient’s room were identified as helpful tools to track progress and mobilization plans in a way that facilitated communication transfer among HCPs. These charts were considered “good visuals” that motivated patients and families to stay engaged.

“We keep a graph or a chart in the patient’s room so that they can see their progress. Usually, it’s just a simple bar graph of time, how long they are coming off each day” (RT5).

When HCPs were asked about their approach to evaluating progress and transfer of care, there was emphasis on consistency across disciplines and recognition that care can easily become disjointed when staff physicians change weekly. Progress and tracking can be hindered when the plan and approach are altered frequently.

“Measuring progress, I think sometimes it definitely falls off because care is sometimes disjointed. You will have a staff physician that will come on for a week and off for a week” (NP3).

Intensive Care Physical Environment

There was no clear consensus on the ideal physical space for patients requiring PMV. Some HCPs considered the ICU to be the ideal weaning environment due to the presence of a multidisciplinary team and the expertise of critical care providers.

“Staying in ICU is the best place to wean the patients…they are seen on a regular basis….people are much more tuned into where the patients are at and how much we can push them” (RN1).

Others felt the ICU was not ideal for this population due to excessive noise and a focus on acute patients. A dedicated weaning unit staffed by a multidisciplinary team with expertise in PMV and focused solely on this patient population was thought to be the ideal setting. This would enable cohorting patients based on their unique needs and future direction. In comparison to other HCPs, MDs were more likely to highlight the significance of cohorting patients. (Table 2)

“The time it takes with some of these patients is a different time course and some of the expertise and rehab goals are different than what is done in the day-to-day ICU care. It is beneficial to have a distinct unit or place of care for patients” (MD9).

Discharge and Disposition

Participants noted that preparation for discharge required a significant amount of time and that collaboration with the patients and families was critical to ensure patients have necessary supports in place post-discharge.

“When the patient gets here, we start thinking about the discharge plan. It can be very complex, and it can take a very long time. We get to know the patients and get to know the family supports…by talking to them we get a sense for what are the possibilities” (NP5).

Post-discharge from the ICU was identified as a clear area for improvement. Participants reported that non-acute illness issues such as speech and nutrition must be addressed. For best care, participants thought most patients should be followed in the clinic as well as in the community depending on the patient’s needs and that a connection to the acute care team should remain for a period of time. The ideal model of post-hospital care was somewhat unclear.

“When patients and families leave hospital, we always give them the option of calling back to the ICU if they run into any troubles” (NP5).

 Lack of appropriate follow-up by HCPs in the community was attributed to a lack of funding and community resource access. RTs were more likely to highlight the need for better community resources for patients requiring PMV post-discharge.

“The follow up after they get out of the hospital is something that there needs to be a lot of focus on because the community has always sort of suffered from the funding side of healthcare” (RT7).

Family and caregiver education and role clarity were stressed as necessary for the care of these patients once they have transitioned to a setting outside of the ICU.

“The nursing staff…help transition to the community as well. Ensuring that families are well suited and well prepared, knowledgeable and educated in all these different components that they will be responsible for looking after on their own with much less support” (NP5).

Discussion

We utilized qualitative description to describe 5 themes and 13 subthemes that reflect the participant’s perspectives of best practices for care of patients requiring PMV. These findings have clinical implications, including recognizing and promoting current models of care that are viewed as favorable and adopting these clinical approaches at underperforming sites and units. 

Patient and family engagement in the care plan has been identified in previous studies as vital to successful outcomes in the PMV population (Cederwall et al., 2018).Pettersson et al. (2012) found that patient motivation was important for weaning and psychological support and that motivation from HCP’s can facilitate this engagement. Rose et al. (2022) interviewed patients and found that processes such as communication with the patient on progress and planning and using communication aids promoted psychosocial well-being. 

Patient and family communication with physicians is often inadequate and familial expectations around prognosis can vary significantly from those of physicians (Cox et al., 2009). This reinforces the importance of continual and consistent communication between physicians and family. 

The theme team dynamics: collaboration and autonomy mirrors findings by Rak et al. (2020) who found that interdisciplinary communication in the form of team meetings and multidisciplinary rounds promoted successful liberation from mechanical ventilation and improved survival. Collaborative decision-making has been shown to be an important factor for weaning and lack of collaboration led to a prolongation of the weaning process due to delayed recognition of changing clinical course and extubation readiness (Rose, 2011). Daily multidisciplinary rounds are a core tenet of ICU care and are associated with a decrease in mortality (Kim et al., 2010). Our findings suggest that in addition to daily multidisciplinary rounds, weekly complex patient meetings should occur to discuss and implement goal setting, progress, and discharge planning. These meetings should include the core clinical team as well as the patient and family members. Having family members present in the ICU has been shown to promote health and survival for patients (Haugdahl, 2018).

The theme of developing a structured plan and process was an interesting and controversial theme. Weaning and liberation from mechanical ventilation is a component of this structured plan. Though using weaning protocols has been shown to be effective and decrease the amount of time in ICU and days on MV (Blackwood et al., 2010; Saura et al., 1996), the selection, uptake and implementation of these protocols is difficult (McLean et al., 2006). Physicians may be reluctant to utilize a protocol due to the perceptions that it restricts clinical judgment and that standard protocols may not be appropriate for difficult to wean patients (Hansen & Severinsson, 2009). Since the PMV population is so heterogeneous in disease etiology, and variably defined, standardizing the management of all PMV patients is likely a disservice to many individuals. Nonetheless, care pathways such as the ABCDEF bundle (Pun et al., 2019) are effective, have had good uptake, and have been adapted for the long-term acute care setting (Balas et al., 2016). The development of care pathways and bundles adapted to the PMV population should also be considered.

In the province of Alberta, Canada, most patients on PMV are cared for in an ICU. The structure of intensive care in Alberta has many benefits for patients including 1:1 nursing care and a comprehensive multidisciplinary team. However, conventional ICUs may also exhibit deficiencies in PMV care. For instance, clinicians may be obligated to focus their time and attention on short-stay patients who are medically unstable, rather than engaging with PMV users to develop a comprehensive care plan. Patients on PMV also require a different approach to care and specialized expertise that may not be familiar to ICU clinicians who care for these patients infrequently. A study by Minton et al., found that long term ICU patients had different care needs than the traditional short-stay ICU patients and this was underrecognized. For example, patients on PMV are often awake more than short-stay ICU patients and may require more communication and psychological supports (Minton et al. 2018).

Specialized weaning centers have been established in other countries such as Germany, Italy and Ontario, Canada (Carpenè et al., 2010; Rose & Fraser, 2012; Windisch et al., 2020).These centers have been shown to be cost-effective and have similar outcomes to patients treated in ICU’s (Lone & Walsh, 2011; Sison et al., 2021). Lone et al found that the establishment of a regional weaning unit could reduce acute ICU bed usage by 8-10% (Lone & Walsh, 2011). Given the increasing prevalence of ICU strain (Bagshaw et al., 2017), it may be prudent to establish specialized physical environments where patients requiring PMV can be cohorted to receive dedicated care with a greater focus on rehabilitation, liberation from mechanical ventilation and discharge planning, and staffed by a multidisciplinary team of clinicians with expertise and an interest in this unique population.

In the past decade, disposition and discharge following an ICU stay has gained significant attention in literature (Desai et al., 2011; Herridge et al., 2011; Pandharipande et al., 2013). Survivors of PMV have multiple complex transitions in care and significant functional disability that often requires institutional, or homecare supports (Rose et al., 2014; Unroe et al., 2010). A landmark study by Herridge et al., (2011) found that survivors of acute respiratory distress syndrome (ARDS) had significant functional limitations up to five years after hospitalization. Participants in our study identified continuity of care beyond the ICU, including discharge planning, caregiver education, and home mechanical ventilation (HMV) clinic follow-up to be important aspects of the care pathway for patients on PMV.

The transition from PMV to long-term or permanent mechanical ventilation can be especially complex and often requires significant planning and family/institutional support. A recent review performed by Best et al. (2023) found that families often have unmet support needs post-discharge. A key theme in our study was that practice models in this population must include pro-active discharge preparation and comprehensive transfers of care that include both patient and family members. Collaborative partnerships with community respiratory therapy programs, homecare services and primary care may all be helpful to ensure patients are adequately supported after discharge. We recommend that clinicians caring for patients on PMV establish and maintain these partnerships. Additionally, the Society of Critical Care Medicine suggests the use of standardized screening tools and functional assessments to facilitate continuity of care and post-ICU recovery (Mikkelsen et al., 2020).Our findings suggest that determining best practices for patients who require PMV is and requires more dedicated research.

While the themes identified in this paper provide pragmatic suggestions for healthcare providers and leaders, further study with patients and family members with lived experience of PMV is necessary to develop best care standards, guidelines, and programs for this population. 

Limitations

Participants were all English language speakers and were recruited in the province of Alberta. Though the authors tried to have representation from all jurisdictions in the province, the rural areas are underrepresented in our sample. Recruitment was done through purposeful sampling by our research team and included a variety of HCPs including RTs, RNs, NPs and MDs working in different jurisdictions throughout the province of Alberta, however sampling bias may be present, and it is possible we may have selected a cohort of HCPs with an interest in PMV. Some of the HCPs interviewed had experience in pediatric ICUs. We believe this is likely not a strength or a limitation as there is overlap in the themes that would emerge from both pediatric and adult ICUs but do note that there are certainly important differences (Henderson et al., 2017). The majority of interviews were performed virtually utilizing Zoom video conferencing software and therefore some non-verbal communication and nuances may have been missed. The interviews were conducted only once and represent a single point in time. The study was performed during the COVID-19 pandemic and while there have been changes to practices during the COVID-19 pandemic, most participants had more than 5 years of practice experience and much of what was stated reflects care models pre-COVID-19. We acknowledge that changes in clinical practice during the COVID-19 pandemic could have an impact on the responses provided.

Conclusion

This study utilized a qualitative descriptive approach to identify and describe five key themes that HCPs perceive to support best care for the unique ICU subpopulation who require PMV in Canada. These recommendations are pragmatic, and organizations and HCPs can adopt many without additional cost. Further work is needed to understand the potential benefits of widespread adoption of dedicated PMV units in the Canadian context, and to determine best practices for discharge and follow-up of patients requiring PMV and their families. 

Author Notes:

Matthew Munan MSc; Covenant Health, Misericordia Community Hospital Intensive Care Unit. Edmonton, Alberta

Harleen Cheema BSc; University of Alberta, Faculty of Medicine and Dentistry. Edmonton, Alberta

Kimberly Scherr RN, NP; Covenant Health, Misericordia Community Hospital Intensive Care Unit. Edmonton, Alberta

Kevin Solverson MD, MSc, FRCPC; Department of Critical Care Medicine, Faculty of Medicine. University of Calgary. Calgary, Alberta.

Sarah K. Andersen, MD, MSc, FRCPC; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta.

Erika MacIntyre MD, FRCPC; Covenant Health, Misericordia Community Hospital Intensive Care Unit. Edmonton, Alberta, Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta. Edmonton, Alberta, Division of Respirology, Department of Medicine, University of Alberta. Edmonton, Alberta.

Corresponding Author

Erika MacIntyre, MD, FRCPC

Assistant Clinical Professor, Department of Critical Care Medicine

Division of Respirology, Department of Medicine, University of Alberta

Intensivist and Respirologist, Misericordia Community Hospital,

16940 87 Ave, Edmonton, AB, T5R 4H5

Office: 735-2858; Fax: 735-2953; email: Erika.mcacintyre@covenanthealth.ca

Acknowledgements

The authors would like to sincerely thank the 30 HCPs who gave their valuable time to participate in this study. We would like to acknowledge Kelsey Huber who transcribed the interviews.

Funding and Conflict of Interest

The author team received funding from the Covenant Foundation Research Infrastructure Grant, #360.CFND.1819.081; The funding body had no role in the study design, analysis, and reporting. The views expressed herein represent the views of the authors and do not necessarily represent the views of the project funders. The authors have no conflicts of interest to declare.

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Appendix- A

Interview Guide

Introduction

Thank you for being part of the study. The purpose of this study is to understand your perspectives and experiences of caring for patients on prolonged mechanical ventilation in the ICU. For the purpose of this study we define it as ventilation lasting over 7 days.

We want to obtain your perspectives and experiences on care for patients on PMV. The purpose of this study is to develop guidelines and best care practices for this population. Any identifying information will be removed from your answers.

Semi-Structured Interview Questions

1.     What is your position description, where do you work and how long have you been involved in the care of patients with PMV?

2.     What is the importance of collaboration and autonomy among members of the healthcare team in the care of patient on PMV?

3.     How is progress evaluated for patients on PMV?

4.     Are there specific weaning/guidelines or standard management that you use? Do you think these are important? 

a.      How do you reconcile this with experience and clinical judgement?

b.     What are key components of an effective guideline/protocol?

5.     How is discharge planning/transfer of care approached?

a.      When is discharge planning started?

6.     What role do patients and family play in decision making and treatment plans?

7.     How do you approach differing prognostic expectations between you and the family?

a.      How should this be approached in an ideal model?

b.     Where does this go wrong and what should we NOT do?

8.     In your opinion what is the ideal model for care in the PMV population?

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