1A.The current nursing practice Description
The spontaneous breathing trial or the weaning trial is a current nursing practice in the intensive care Unit used in the respiratory care among patients whose respiratory is affected by chronic illness. They refer to a period during which the critically ill patient is breathing without or with minimal assistance. The main goal of respiratory care is to wean patients from the ventilator as soon as possible for facilitate independent breathing by individuals. The weaning process is very crucial aspect in management and recovery of critically ill patients. Approximately 40% of the period of mechanical ventilation is assigned to the weaning process (Zein, Baratloo, Negida & Safari, 2016). Delayed weaning has adverse effects including complications such as ventilator related to pneumonia, ventilator induced ling injury, and ventilator induced diaphragmatic dysfunction. Moreover, premature weaning could result in complications such as respiratory and aspiration muscle fatigue, defective gas exchange, and loss of airway. The weaning predictors are factors used to assist clinicians in determining whether the weaning efforts will be successful or not. The weaning predicators include sleep quality, variability in heart rate, oxidative stress markers, diaphragmatic dysfunction, and hand grip strength. The goal of spontaneous breathing trials is determined as a final guide towards ventilator independence. Spontaneous breathing is defined as the natural breathing whereby gas moves in and out of the lungs in reaction to the respiratory muscles of an individual. Interferences of an individual’s breathing pattern could result in insufficient breathing or ceases breathing completely. In such extreme cases, mechanical ventilation is used to support an individual’s breathing. These spontaneous trials have proved to be effective in correctly projecting the success of spontaneous breathing. Spontaneous breathing trial is the final pathway to the ventilator independence. It examines the ability of the patient to breathe with no ventilator support or while receiving minimum ventilator support. It helps in identification of patients who may not succeed the liberation from mechanical ventilation thus minimize cases of prolonged vent days in hospitals (Zein, Baratloo, Negida & Safari, 2016).
2A. Reasons why the current nursing practice needs to be changed
The current practice of weaning trial or spontaneous breathing trial needs change because of various nursing issue in the unit is the prolonged vent days in the ICU. This problem is facilitated by factors such as inappropriate sedation of weaning between day and night, failure of timely identification of the patient to be extubated, and lack of frequent rounds by physicians, nurses, and charge nurse during and night shift. Comfort and safety among critically ill patients are important care, which is enhanced through sedation. Sedation helps to minimize stress, anxiety, prevent pain, promote invasive procedures, and promote synchrony with mechanical ventilation. However, inappropriate sedation have potential negative impact on the patients. For instance, undersedation or oversedation is related with adverse clinical outcomes that lead to complications such as increased dysfunction of the brain and increased time on mechanical ventilation thereby resulting in prolonged stay in ICU. The sedation problem is contributed to by discrepancies such as institutional bias, variability in individual patient and clinician, history of the patient, and regional preferences. The discrepancies should be addressed to provide appropriate sedation of weaning to achieve the correct balance of sedative drug administration among critically ill patient who require respiratory care.
Identification of the patient to be extubated is a major challenge in the ICU that affects its timing. Extubation is a critical issue and life-threatening decision in the ICU. Weaning trial or spontaneous breathing trial is recommended before extubation. Untimely identification of patients to be extubated leads to prolonged stay in the ICU. Instituting alternative practices to identify the risk of poor outcome would facilitate timely identification of patients to be extubated thus reducing the duration of stay in the ICU. Therefore timely identification of patients who are at increased risk of failure to recover would help to improve outcome and minimize prolonged vent days.
Optimal management of critically ill patients is important in offering care that is consistent and highly reliable. However, there are existing gaps in the frequency of rounds conducted in the ICU by physicians, nurses, and charge nurse during and night shift. Serious adverse events is a common problem in the ICU patients that require close monitoring to prevent any complications that may arise. This problem has been contributed to by shortage of nursing staffing especially those required to take rounds during the night shift making it difficult for clinicians to adequately perform rounds among critically ill patients. Therefore, appropriate and adequate day and night shift staffing would allow nurses to effectively manage patients in ICU in collaboration and minimize associated adverse events.
B. Key stakeholders
Key stakeholders play a crucial role in healthcare and performance who are involved the clinical evidence and decision that supports the interest of the hospital. The key stakeholders within the healthcare system who are part of the current nursing practice include the Chief Executive Officer (CEO), Chief Nurse Officer (CNO), physician, and director. Engagement of these key stakeholders in the prevention of prolonged vent stays and control of factors contributing to this problem is essential in promoting quality and optimal patient care in the ICU. The key stakeholders will work collaboratively to implement the healthcare initiative of improving weaning trials and spontaneous breathing trials thereby preventing prolonged hospital stays. Therefore, they will make significant contributions that would enhance the success of the proposed change in the ICU unit.
1B. Stakeholder Roles
Each of these stakeholders mentioned above will play distinct roles to support the proposed practice change. They have varying viewpoint regarding ways of minimizing the problem of prolonged vent days in the ICU that is important and needed to support the proposed change.
The CEO will create a strategic direction for the team members who will be part of the proposed change and offer both vision and support. The director will lead to the development of transformative culture and establish an enhanced working framework to deliver on performance outcomes.
The CNO will be responsible for making sure the resources, as well as the administrative and clinical leadership, offer support that will enhance successful implementation of the proposed change in the current nursing practice.
The director will be responsible for supporting physicians and ensuring effective workflow to facilitate effective implementation of the proposed change as informed by the CEO. Also, the director will ensure the formation of effective relationships among team members to promote the success of the proposed change.
The physicians will play a role in representing patients. They will articulate and advocate for patients needs and provide suggestions for addressing the issue surrounding mechanical ventilation and the longer stays in hospitals. Also, they will inform other physicians regarding the needed change in the ICU unit that will promote patient safety and quality of care.
C. Evidence critique table
1C. Five Sources
1. Burns, K. E., Meade, M. O., Lessard, M. R., Hand, L., Zhou, Q., Keenan, S. P., & Lellouche, F. (2013). Wean earlier and automatically with new technology (the WEAN study). A multicenter, pilot randomized controlled trial. American journal of respiratory and critical care medicine, 187(11), 1203-1211.
2. Lee, Y. C., Wang, H. C., Hsu, C. L., Wu, H. D., Hsu, H. S., & Kuo, C. D. (2016). The importance of tracheostomy to the weaning success in patients with conscious disturbance in the respiratory care center. Journal of the Chinese Medical Association, 79(2), 72-76.
3. McConville, J. F., & Kress, J. P. (2012). Weaning patients from the ventilator. New England Journal of Medicine, 367(23), 2233-2239.
4. Navalesi, P., Frigerio, P., Patzlaff, A., Häußermann, S., Henseke, P., & Kubitschek, M. (2014). Prolonged weaning: from the intensive care unit to home. Revista Portuguesa de Pneumologia (English Edition), 20(5), 264-272.
5. Newman, R. E., Bingler, M. A., Bauer, P. N., Lee, B. R., & Mann, K. J. (2016). Rates of ICU Transfers after a Scheduled Night-Shift Interprofessional Huddle. Hospital pediatrics, 6(4), 234-242.
C2. Evidence Strength and Evidence Hierarchy in Critique Table
Author/Year Evidence Hierarchy Evidence Strength
Burns, K. E., Meade, M. O., Lessard, M. R., Hand, L., Zhou, Q., Keenan, S. P., & Lellouche, F. (2013).
Lee, Y. C., Wang, H. C., Hsu, C. L., Wu, H. D., Hsu, H. S., & Kuo, C. D. (2016).
McConville, J. F., & Kress, J. P. (2012).
Navalesi, P., Frigerio, P., Patzlaff, A., Häußermann, S., Henseke, P., & Kubitschek, M. (2014).
Newman, R. E., Bingler, M. A., Bauer, P. N., Lee, B. R., & Mann, K. J. (2016). Randomized Control Trial
D. Evidence Summary
The purpose of the study by Burns et al. (2013) is to compare the automated weaning in adult patients with critical illness and to examine the compliance and reception of the protocols of sedation and weaning, recruitment, and its effects on outcomes. The study design include the pilot randomized trial. The study concluded that automated weaning has shown positive impact on patient outcomes that require further investigation. Its benefits include enhance compliance, feasibility, and foster recruitment. The result can be included in the practice by training practitioners on how to use automated weaning to reduce median times to first spontaneous breathing trial, successful extubation, and reduced episodes of protracted ventilation.
The purpose of the study by Lee et al. (2016) to determine the significance of tracheostomy in the weaning to enhance success in patients in the respiratory care center. The study design include a retrospective controlled study. The study concluded that the use of tracheostomy enhances the level of success of weaning patients who have low Glasgow Coma Scale (GCS). The use of GCS has been identified as a criterion used in determining when to extubate the endotracheal tube especially among patients with the depressed mental condition. This helps to minimize the higher rate of mortality among patients with low GCS. The result can be included in the change practice by encouraging nurses to be vigilant in promoting timely identification of patients to be extubated through use of strategies such as noninvasive positive-pressure ventilation and tracheostomy.
The purpose of study by McConville and Kress (2012) is to determine how critically ill patients can be discontinued from mechanical ventilation as soon as possible. The study design was systematic reviews. The study result indicated that the use of preventive non-invasive positive-pressure ventilation in patients as well as extubation have shown success in spontaneous breathing trial however it may pose significant risk in failed discontinuation of mechanical ventilation. The result can be included in the change practice through application of universally aggressive approach towards discontinuation of mechanical ventilation. This approach involves early spontaneous breathing and aims to reduce the period of mechanical ventilation thus leading to reduced associated ICU complications.
The purpose of the study by Navalesi et al. (2014) is to determine how the transfer of patients from ICU to home unit would help to address the issues that lead to prolonged mechanical ventilation. The study design include qualitative study. The results indicated that issues such as high workloads for staff, paucity of beds, fast patient turnover, and the need for continuous treatment and monitoring contribute to complexity and time consuming in the respiratory care center. The result can be included in the change practice through taking into consideration the key issues including staffing, criteria for admission and discharge, and location. Addressing these issues would result in improved patient outcomes.
The purpose of the study by Newman et al. (2016) is to study the impact of a scheduled night-shift interprofessional huddle on the rate of ICU transfers. The study concluded that early implementation of the interprofessional huddle in the night shift reduces high-risk transfers to the ICU leads to improved job satisfaction among healthcare professionals in the respiratory care. This result can be included in the change practice by implementation of the interprofessional huddle in the night shift that would result in the creation of an effective unit and lead to improved outcomes.
E. Recommend Best Practice
The best practice for addressing the problem of prolonged vent days and the underlying factors such as inappropriate sedation, untimely identification of patients to be extubated, and infrequent ward rounds includes the use of skillful combination of a reliable technology, effective teamwork, and customized protocols. Burns et al. (2013) assert that customized protocols provide guidelines for weaning, spontaneous breathing trials, and extubation. Enhanced ventilator technology has contributed to the identification of therapy options that minimize or prevent complications related to mechanical ventilation. Also, it has facilitated improvements of the ICU environment by enhancing effectiveness the workflow and safety thereby maximizing patient outcomes and reducing costs and complexity associated with prolonged vent days. The new technology consists of various tools that support weaning such as the PS program that examines the readiness of a patient to be weaned and allows for proper changes to be made based on the feedback obtained regarding respiratory rate control. Moreover, it helps to prevent human errors such as inappropriate sedations, provides healthcare professionals with tools that assist in better decision making, improve overall communication, and it also captures and maintains patient clinical data that is essential in the weaning and extubation process.
Furthermore, the use of a decision-support tool such as the CareFusion’s Knowledge Portal assists providers in resolving issues in weaning process and sedation by offering them with weaning and sedation analytics that promote improved patient care. For instance, if the sedation reaches a specified marker, the clinician is alerted by the Knowledge Portal indicating the patient is ready to start the SBT process. Also, the Knowledge Portal can assist hospitals to track trends that may enable the clinician to recognize any changes in the patient condition. Additionally, it may keep data that may help the clinician to determine the average length of ventilator stay. Therefore, it helps to save money and human resources whereby nurses may not be required to conduct frequent wards rounds because all information is provided by the Knowledge Portal. Team approach leads to successful weaning. It is important for the respiratory therapist to work in collaboration with physical therapists, nurses, physicians, and nutritionists. Teamwork promotes good clinical assessment and the effective use of evidence-based practices that may contribute towards addressing gaps in sedation and protective strategies in respiratory care in the ICU (Burns et al., 2013)
F. Practice Change Model
Kotter’s 8-Step Change Model is appropriate to apply to the proposed practice change in the respiratory care center. Kotter provides eight steps to leading change including creating urgency around change that assist in triggering initial motivation of the organizational members to embrace change. The second step involves forming a powerful coalition through identifying effective change leaders in the organization to lead change and continue to create urgency around the need for change. The third step includes establishing a clear vision for change that will help every member of the organization to understand easily and remember. The fourth step includes frequent and powerfully communicating the vision in decision making, in solving problems, and in everything done in the organization. The fifth step includes removing obstacles identified in the change process. This empowers the team members to execute the organizational vision and help to move forward the change process. The sixth step involves the creation of short-term wins that are achievable will motivate the members of the organization to embrace and implement the change process. Success is a motivator, and a taste of early victory contributes towards the participation of individuals in the change process. The seventh step includes building on the long-term change that will help in identification of what to what to improve and available opportunities for change. The eight-steps involves making changes become part of the organization that helps to determine what needs to be done and make continuous efforts that will assist in providing change with a solid place in the culture of the organization (Mørk, Krupp, Hankwitz & Malec, 2017).
F1. Model Justification
I chose Kotter’s 8-Step change model because it is a powerful and successful tool for implementing change and innovation in the respiratory care to maintain clinical and scientific progress. It is widely accepted change model across various organizations that have been identified as an effective model for facilitating implementation of organizational change. The 8-Step offers a roadmap for achieving change within the organization by promoting understanding of change, designing effective change processes, and implementing the respiratory care protocols. Following Kotter’s 8-Step change helps to prevent failures and improves the ability of the organization to implement change thus increasing the chances of success. Organizations do not need to adjust to the changes but rather follow these steps and promote achievement in the implementation of proposed change in the respiratory care to minimize cases of prolonged vent days (Mørk, Krupp, Hankwitz & Malec, 2017)
F2. Model to Guide Implementation
Kotter’s 8-step change model will guide the implementation of the proposed practice change by creating a sense of urgency by highlighting the effects of changing, offering effective feedback to individual providers on their performance, and increasing the standards of performance of promoting success of the implementation of the proposed change. A sense of urgency can also guide the implementation of the change by fostering identification of potential threats, evaluating opportunities to be exploited, and get support from stakeholders. Also, the change model will guide implementation of change by creating a clear and simple vision that is communicable. Moreover, the advocated change should be facilitated by institutional leaders. It can be applied in the identification of key stakeholders and true leaders, and their emotional commitment to implement proposed change, and team building through ensuring the team consists of a good mix of people and checking areas of weakness. Furthermore, the change model will help guide the determination of values that are crucial to the change process, and establishing a strategy to execute the vision. Moreover, the change models guide the team in developing a structure for change that will help in eliminating obstacles such as resistance towards change and promote achievement of desired goals. The change model also guides in the analysis of the advantages and disadvantages of the goals of the change initiative. It provides an opportunity for analysis of the areas that need improvement and developing new ideas that promote new change and setting of goals that foster achievement of the proposed change. Consequently, the change model will guide in the change ideals and values and help to ensure successful implementation of the proposed change process (Mørk, Krupp, Hankwitz & Malec, 2017).
G. Barriers to Implementation
Change is often met with resistance and incorporation from some members of the organization that may hinder effectiveness in the implementation of the change model. The possible barriers to the change efforts may include the 8 common errors in the organization including tolerating increased complacency, failure to establish an adequate powerful coalition, misjudging the power of vision, under-communication of the vision, allowing obstacles to hinder new vision, failure to establish short-term wins, declaring victory very soon, and overlooking to present changes steadfastly in the corporate culture. However, these barriers can be addressed by implementing Kotter 8-Step change models to provide a specific solution to these problems.
H. Ethical Implications
Implementation of research involves a wide range of specific ethical considerations that guide the health research ethics. The ethical principles guide effective application the proposed interventions in the clinical research. Implementation of research depends heavily on individual consent, which is an important aspect of ethics of research. Consent is a demonstration of an individual’s willingness to participate in the research study without coercion. Justification of ethics of research is validated by various factors including informed consent, right to privacy, and confidentiality of data among others. However, failure to take these aspects into consideration may result in significant ethical implications. For instance, the possible ethical implications that may arise while planning or implementing the proposed practice change of preventing prolonged stays in the respiratory care center include problems in achieving the right to privacy and informed consent, confidentiality of data, declaration that no patient data was presented in the article and that no experiments were conducted on humans, and protection of study subjects. These factors could cause major roadblocks to the successful implementation of change. Therefore, failure to adequately address the ethics of research could lead to improved quality and objectivity of research.
- Burns, K. E., Meade, M. O., Lessard, M. R., Hand, L., Zhou, Q., Keenan, S. P., and Lellouche, F. (2013). Wean earlier and automatically with new technology (the WEAN study). A multicenter, pilot randomized controlled trial. American journal of respiratory and critical care medicine, 187(11), 1203-1211.
- Lee, Y. C., Wang, H. C., Hsu, C. L., Wu, H. D., Hsu, H. S., and Kuo, C. D. (2016). The importance of tracheostomy to the weaning success in patients with conscious disturbance in the respiratory care center. Journal of the Chinese Medical Association, 79(2), 72-76.
- McConville, J. F., and Kress, J. P. (2012). Weaning patients from the ventilator. New England Journal of Medicine, 367(23), 2233-2239.
- Mørk, A., Krupp, A., Hankwitz, J., and Malec, A. (2017). Using Kotter’s Change Framework to Implement and Sustain Multiple Complementary Icu Initiatives. Journal of nursing care quality, 33(1), 38-45.
- Navalesi, P., Frigerio, P., Patzlaff, A., Häußermann, S., Henseke, P., and Kubitschek, M. (2014). Prolonged weaning: from the intensive care unit to home. Revista Portuguesa de Pneumologia (English Edition), 20(5), 264-272.
- Newman, R. E., Bingler, M. A., Bauer, P. N., Lee, B. R., and Mann, K. J. (2016). Rates of ICU Transfers after a Scheduled Night-Shift Interprofessional Huddle. Hospital pediatrics, 6(4), 234-242.
- Zein, H., Baratloo, A., Negida, A., and Safari, S. (2016). Ventilator Weaning and Spontaneous Breathing Trials; an Educational Review. Emergency, 4(2), 65.