3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item The opinions of a multidisciplinary team in paediatric intensive care units regarding weaning protocols for mechanical ventilation(2015) Njolomole, Abbie NBackground: Despite the empirical evidence of the significance of weaning protocols in Intensive Care Units, variations still exist in the adoption of weaning protocols. Multidisciplinary teams hold the responsibility for the introduction and development of weaning protocols in PICU. Purpose: To explore and describe the opinions of multidisciplinary teams practicing in the paediatric and cardiothoracic ICU at an academic hospital in Johannesburg concerning weaning protocols from mechanical ventilation. Design: Qualitative descriptive. Method: Data was collected from multidisciplinary team comprising of registered nurses (n=8) and doctors (n=2) practicing in PICU and CTICU who were purposively selected using semi-structured interviews to obtain qualitative information on their opinions regarding weaning protocols. Data collected was analysed using a Braun and Clarke method of qualitative thematic analysis. Seven categories were identified in which three themes, which provided the fundamental structure of the findings for the discussion, emerged and included the following: Unstructured weaning – the current practice. Recognition of the need for weaning protocols. Being not in favour of weaning. Results: The majority of the multidisciplinary team members recognise the need to develop weaning protocols in PICU for standardisation of practice. Currently there are no weaning protocols and a multidisciplinary approach was identified as an important strategy to develop the protocols. However, nurses practicing in PICU are not trained in Critical Care nursing which poses a challenge to the practice. Conclusion This study indicates that there is need for the development of weaning protocols in PICU. Although nurses are weaning patients in PICU, there are no standardised weaning protocols to guide the practice. The study therefore suggests the need to develop weaning protocols through multidisciplinary approach and training of nurses in critical care nursing to improve knowledge base and skills. Keywords: Mechanical ventilation, weaning, protocols, paediatric patients, opinions/perception and multidisciplinary team.Item The nature of involvement of physiotherapists in South Africa in the weaning of mechanically ventilated patients(2014-09-11) Morar, DipnaMechanical ventilation (MV) is the defining event of intensive care unit (ICU) management. Although it is a lifesaving intervention in patients with acute respiratory failure and other diseases, a major goal of critical care clinicians should be to liberate patients from MV as early as possible to avoid the multitude of complications and risks associated with prolonged MV. Such complications include an increase in mortality, morbidity and ICU length of stay (LOS), as well as reduced functional status and quality of life (Moodie et al 2011; Gosselink et al 2008). Rapid weaning however has its own potential problems such as fatigue or cardiovascular instability, either of which may ultimately delay the weaning process. Premature extubation, leading to reintubation, is associated with increased risk of pneumonia and mortality (Brown et al 2011; Meade et al 2001 (a)). In view of this, there has been increasing interest in delivering more consistent practice in ICUs by developing weaning protocols that provide structured guidelines to achieve prompt and successful weaning. Many studies have shown the benefit of allied health care worker (nurses and physiotherapists) driven weaning protocols in decreasing MV days and costs (MacIntyre 2005; Dries et al 2004; Ely et al 2001). Objectives: The objectives of this study were to determine a) if the number of patients in the ICU has an influence on physiotherapists’ involvement in the weaning of patients from MV, b) if the type of ICU has an influence on physiotherapists’ involvement in the weaning of patients from MV, c) if physiotherapists are involved in the development and implementation of weaning protocols for mechanically ventilated patients in their ICUs, d) if physiotherapists are involved in titration of ventilator settings for patients during the weaning process, e) what modalities physiotherapists in South Africa use to facilitate respiratory muscle strengthening to assist weaning of patients on MV, f) if physiotherapists in South Africa are involved in the extubation of ventilated patients, g) if there is a difference in involvement in weaning of mechanically ventilated patients between newly qualified physiotherapists and experienced physiotherapists. The last objective of this study was to determine if current physiotherapy involvement in the weaning of patients from MV in South Africa is in line with international physiotherapy practice according to the literature. Method: A questionnaire was developed by the researcher using available literature on the nature of involvement of physiotherapists in the weaning of mechanically ventilated patients. Content validation of the questionnaire was achieved after a panel of senior cardiopulmonary physiotherapists analysed each question and their recommendations and adjustments were implemented. Physiotherapists who practice cardiopulmonary physiotherapy in adult ICUs of hospitals in the public and private sectors in South Africa were sought and targeted for the study. The self-administered questionnaire was then posted or emailed to the physiotherapists identified for inclusion into the study. Results: A total of 425 questionnaires were distributed to physiotherapists who practice cardiopulmonary physiotherapy in adult ICUs of hospitals in South Africa. Of the 425 questionnaires distributed, 200 questionnaires were sent via the postal system and 225 were sent via email with a link to an online survey. The response rate for the postal questionnaires was 54.5% (n=109) and 33.3% (n=75) for the emailed questionnaire, giving a combined response rate of 43.3%. The results showed that 76% of South African physiotherapists are not or are seldom involved in the weaning of mechanically ventilated patients in adult ICUs. They are not involved in the development of weaning protocols (74%, n=51), titration and adjustment of MV settings (>80%, n=154), spontaneous breathing trails (67%, n=119) and non-invasive ventilation (58%, n=101). Physiotherapists working in South Africa are somewhat involved in extubation (16%, n=28). The most common physiotherapy modalities used in ICU to facilitate respiratory muscle strengthening are exercises (81%, n= 138), early mobilisation out of bed and deep breathing exercises. (77%, n=134). Physiotherapists’ involvement in the weaning of mechanically ventilated patients are not influenced by the type of ICU they work in (p>0.05), type of physiotherapy degree they have (p=0.24) or whether they are newly qualified physiotherapists or experienced physiotherapists (p=0.43). Conclusion: This survey shows that most physiotherapists who work in adult ICUs in South Africa are not involved in the weaning of mechanically ventilated patients. The survey does show that there is a need for physiotherapists to reconsider their role in ICU with regards to weaning patients from MV as current practice is not in keeping with the international practice of respiratory therapists in the United States of America (USA) and physiotherapists in the United Kingdom (UK), Australia and Europe.Item Intensive care nurses' knowledge of evidence based guidelines regarding weaning the mechanically ventilated patient(2014-08-26) Fischer, Jacquie LouiseEvidenced based practice (EBP) guidelines have been developed to reduce variation in weaning, provide quality of care and patient satisfaction. Nurse led weaning has been shown to reduce weaning time, and therefore it was important to identify whether nurses have sufficient knowledge to implement EBP regarding weaning (Hansen, Fjaelberg, Nilsen et al, 2008);(Crocker, 2002:272). Weaning protocols are associated with 25.0% reduction in the duration of mechanical ventilation time, a 78.0% reduction in weaning duration, and 10.0% reduction for length of stay in ICU (Blackwood, Alderdice, Burns et al, 2011:9). The purpose of the study was to evaluate and describe intensive care nurses’ knowledge of EBP guidelines with regard to weaning the mechanically ventilated patient. Five adult intensive care units at two tertiary public sector academic hospitals were used to conduct the study in order to determine barriers to EBP. A non-experimental, descriptive, prospective two-staged design was utilized in this two part study. In Stage I of the study, the sample size comprised six (n=6) specialist expert members selected from the ICU’s at the study site using a non-probability purposive sampling method. In Stage II of the study, the sample size comprised eighty (n=80) intensive care nurse respondents selected from the ICU’s using simple random sampling. The data collection instrument developed by the researcher comprised 40 items relevant to nursing practice derived from EBP weaning guidelines. Respondents were asked to rate all the items independently using a 4-point Likert scale. Findings indicated that intensive care nurses lack adequate knowledge on weaning the critically ill patient from the mechanical ventilator. The Dreyfuss model of skill acquisition shows that improved skill performance in nursing is based on experience as well as education, yet this study showed the opposite (Dracup & Bryan-Brown, 2004). Years of experience did not influence nurses’ knowledge level, as there was no statistical difference in these items. Differences in knowledge scores between the primary nurse and shift leaders were minimal, although significant (p<0.05), indicating that shift leaders were more knowledgeable than primary nurses.