Discussion
Invasive ventilation in the emergency department: Part 2: Implications for patient safety

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Summary

The use of mechanical ventilation in the Emergency Department requires adequate resources in order to maintain patient safety and avoid potential risks. Moreover, developments in technology require increased knowledge of mechanical ventilation techniques to address the complexity of decision-making involved. Organisational issues and system factors have the potential to negatively impact on the ability of the emergency service to provide optimum care to patients receiving mechanical ventilation. These issues include staffing and skill-mix, demand on emergency services, role-delineation, scope of practice, and current mechanisms for monitoring of quality and safety. Furthermore, in response to advances in ventilator technology, current education programs for both nursing and medical staff require review to ensure that they provide comprehensive information about the types of ventilation techniques now available and the relative risks and benefits associated with their application.

This article is the second in a two-part series and explores the educational and organisational factors that impact upon safety and quality of care delivered to patients receiving mechanical ventilation in the emergency department. Recommendations for future policy development, curriculum review and reporting mechanisms to support further research in the application of mechanical ventilation in the emergency department are made.

Introduction

Mechanical ventilation is life-saving technology used to support patients with compromised respiratory function. The use of mechanical ventilation is associated with a range of risks that may be precipitated via the inappropriate application of the technology. Importantly, the cost of care increases exponentially for patients receiving mechanical ventilation when ventilator-associated complications arise. Therefore, it is essential to use the safest and most effective form of ventilation for the shortest possible duration.

Previous studies of ventilation practices describe international trends in Intensive Care Units (ICUs), and in particular, the delivery and discontinuation of mechanical ventilation.1, 2 In contrast to the vast amount of scientific literature informing the use of mechanical ventilation in ICUs, there is a lack of data to describe current ventilation practices in Emergency Departments (EDs) and the role ED nurses have in the management of ventilation.

This article is the second in a two-part series focussing on mechanical ventilation in the ED. Specifically, it will present a critical review of the organisational, educational and socio-political influences that impact upon the management of mechanical ventilation in EDs. In Australia, there are no standards to guide nurses’ decision-making when caring for patients receiving mechanical ventilation. Consequently, recommendations for practice, education review and future research to address aspects of current practice that negatively impact upon patient safety will be made.

Section snippets

Implications for patient safety

The morbidity and mortality associated with receiving mechanical ventilation are dependent on both the underlying severity of illness and the development of ventilator-associated complications that include among other risks: ventilator-associated lung injury (VALI), airway trauma, and nosocomial infection.3, 4 Additional complications can occur when ventilation is applied inappropriately. Examples of this include the presence of extra-alveolar gas resulting in pneumothoraces or subcutaneous

Complexity of decision-making

The contextual differences between ED and ICU environments are likely to influence both nurses understanding of the application, risks and benefits of mechanical ventilation, and their level of skill in managing a patient receiving this intervention. Anecdotally, many ED nurses lack confidence in making decisions about mechanical ventilation. Emergency department nurses do not have the same consistent level of daily exposure to ventilators as their ICU colleagues and consequently receive less

Education of ED nurses and scope of practice

Australian specialist nurses are trained through formal postgraduate education programs via the university system. Currently, minimum standards require that 50% of nursing staff employed within ICUs must hold a postgraduate critical care qualification.9 However, there are no similar recommended minimum standards for ED nurses. Arguably, nurses holding a postgraduate qualification in either ICU or ED have a different level of responsibility for mechanical ventilation practices compared with most

Organisational issues and system factors

The duration of ventilation within the ED is not only dependent upon patient related factors but also on a range of external organisational factors. In situations where ICU beds and Operating Room facilities are assured, the duration of mechanical ventilation within the ED is short as patients will be rapidly transferred to the appropriate unit. Increasingly, patients may be ventilated in the ED for extended periods due to resource limitations in other in-patient units.

Rising demand for ED

Monitoring for safety and quality

Despite use of mechanical ventilation in the resuscitation and ongoing ventilatory management of ED patients, there are no comprehensive data available that specifically documents the practices of mechanical ventilation in EDs nationally. Isolated information on subsets of patients is available. For example, the Victorian State Trauma Registry reported, of the 1684 patients requiring hospitalisation due to trauma in 2003/2004, 35% (587 patients) had an ICU stay requiring mechanical ventilation

Recommendations

From this discussion of factors that impact upon the delivery of invasive ventilation in the ED, several recommendations for practice, education, and future research can be made. First, there is a need for a position statement from the College of Emergency Nursing Australasia (CENA) and the Australasian College for Emergency Medicine (ACEM) on minimum staffing levels for patients receiving mechanical ventilation in the ED similar to those for ventilated patients in ICU. A further position

Conclusion

To summarise, the use of mechanical ventilation in EDs requires intensive nursing resources, including clinicians who are trained in the application and monitoring of ventilation and the detection of ventilator-associated complications. At local and international levels, ventilation practices in EDs are not documented. Several aspects of the current emergency system have the potential to negatively impact on the safety of patients receiving mechanical ventilation. Inappropriate application of

Competing interests

None declared.

Funding

None declared.

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