Research paper
Protective lung strategies: A cross sectional survey of nurses knowledge and use in the emergency department

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Abstract

Background

Mechanical ventilation (MV) is commonly used in emergency departments (EDs). Protective lung strategies (PLS), comprising of low tidal volume (6 mL/kg), control of oxygen and plateau pressures, and administration of positive end expiratory pressure (PEEP) has been shown to reduces the risks associated with MV but there is little evidence exists about nurses’ knowledge or application of PLS. Our aim was to explore nurses knowledge and application of PLS in Australian EDs.

Methods

Descriptive, exploratory design utilising an online questionnaire. A convenience sample was recruited via the College of Emergency Nursing Australasia mailing list and secondary snowball sampling was used to optimise response rate.

Results

There were 157 participants. PLS are being used in most EDs (n = 104, 75%) and clinical practice guidelines (CPG) are often available (n = 86, 62%). Most ED ventilators are capable of implementing PLS, but measurement of plateau pressures was infrequent (n = 46%). Participants demonstrate appropriate knowledge, but reported varying levels of confidence and perceived autonomy when implementing PLS in the ED.

Conclusion

PLS are being used in Australian EDs, aligning with best available evidence. Nursing staff have good levels of PLS knowledge. Development of an evidence-based CPG may improve confidence when implementing PLS and may pave the way for ED nurses to expand their scope of practice.

Introduction

Mechanical ventilation (MV) is a frequently applied therapeutic intervention in the Emergency Department (ED). Application of MV is not without risk, and there is a range of associated complications including lung trauma and the development of acute respiratory distress syndrome (ARDS). The concept of a protective lung strategy (PLS) (delivery of a low tidal volume (6 mL/kg), aggressive control of positive end expiratory pressure (PEEP), fraction of inspired oxygen and plateau pressures) has developed over the last 15 years as an approach to reduce risks associated with MV. Emerging evidence with a focus on MV in the ED context suggests that measures to prevent the development of ARDS should begin in the ED [1], [5]. Despite increasing recognition of the relationship between MV and the development of ARDS, studies show that ED patients are continuing to receive injurious tidal volumes, and implementation of PLS still not routine [1], [2].

Implementing PLS poses unique challenges in the ED context, as there are technical aspects that may inhibit ED clinician’s ability to implement PLS. Inspiratory plateau pressures are infrequently monitored and are not considered a standard ventilator observation in the ED [2]. ED ventilators are most commonly transport ventilators, and are often unable to measure plateau pressures, which is an integral element of a PLS [3]. Anecdotal evidence suggests major metropolitan centres still regularly use ventilators that do not have the capacity for plateau pressure measurement and have limited capacity for titration and delivery of oxygen. There is also increasing recognition that decisions made early in the resuscitation phase whilst in the ED, such as initial and ongoing ventilator settings may impact on clinical outcomes [1], [2]. Underlying pathophysiological processes associated with ventilator associated lung injury from injurious tidal volumes in patients with ARDS can occur within hours, which is particularly relevant to the ED context. The development of ARDS is associated with increased mortality, duration of mechanical ventilation, non-pulmonary organ failure and increased lengths of stay [4].

In the Australian context, ED nurses play a pivotal role in managing patients who are mechanically ventilated. Clinical decision making (particularly ventilator settings), care and management is shared by medical and nursing staff [3]. This differs somewhat internationally; in North America (United States and Canada) most ventilator management decision making is in the realm of the Respiratory Technician or Therapist, with nurses having a secondary role [6]. This role of the Respiratory Therapist is unique to North America, there is no Australian or European equivalent.

Safe practice for patients receiving this highly complex intervention requires ED nurses to have an in-depth understanding of the technology, and the clinical application including effects on lung physiology [7]. With increasing ED lengths of stay, it is vital that strategies for optimal management of ventilation are implemented [8]. The only published research around Australian ED ventilation practices was in 2007; a contemporary investigation of current ventilation practices was timely. The aim of the study was to identify clinical practice patterns and explore the current knowledge of Australian emergency nurses related to the implementation of PLS in adult mechanically ventilated patients.

Section snippets

Study design

The study utilised a descriptive, exploratory design utilising a self-reporting cross-sectional survey administered via an online survey platform. A three-part survey was developed that collected demographic information, sought information on clinical practice patterns and explored nursing knowledge using validated clinical scenarios. The survey was reviewed for clinical acceptability, face validity and was pilot tested. The sample was obtained from two sources; the College of Emergency Nursing

Sample characteristics

There were a total of 157 participants. The highest proportion of age reported was in the 25–34 year category (n = 64, 41%) and the majority of participants (n = 123, 78%) were female. Most participants worked in a metropolitan ED (n = 115, 73%), with 32 (20%) working in a regional ED, and 10 (7%) in a rural ED. Participants worked a mean of 31 h per week (SD = 8.2) and had a varying range of ED nursing experience in terms of years worked (Med = 8, Q1 5, Q3 12.5). There were 87 participants (55%) from the

Discussion

The results from this study show that PLS are being used in Australian EDs to inform decisions around MV. The only available evidence describing Australian ED ventilation to compare practice patterns was the seminal work by Rose and Gerdtz [3] that explored mechanical ventilation practices in Australian EDs in 2007. No other recent studies looking at Australian practices were identified, and few international studies specifically exploring ED ventilation are available.

ED nurses are required to

Limitations

The sample of nurses obtained represents a cross-section of ED nurses, with a range of experience, qualifications and states represented. The majority of participants completed the questionnaire in its entirety, which suggests an appropriately designed and timed questionnaire. However, there is poor generalisability of results due to the high level of sample bias inherent in the nature of convenience sampling. Whilst the sample target was reached, it still could be considered a low response

Conclusion

PLS are currently being used by Australian ED nurses to inform the clinical care of adult mechanically ventilated patients, which aligns with the best available evidence. Australian ED nursing staff have good levels of knowledge regarding this approach to MV. Australian EDs are appropriately equipped to implement PLS in terms of functionality of ventilators, but understanding and measurement of plateau pressures is an area of focus for future education and clinical practice improvements. Future

Authorship

S.C. and R.W. conceived and designed the study. SC, RW and SK developed the study protocol. S.C., S.K., A.M.K. and R.W. designed and tested the study instruments. S.C. and R.W. supervised data collection. S.C. and R.W. analysed the data. S.C., R.W., S.K. and A.M.K. prepared and approved the manuscript.

Disclosures

S.C. used this study towards completion of a Masters of Nursing (minor thesis).

S.C. received scholarship support from the Australian College of Nursing and from Western Health towards the completion of a minor thesis.

Funding

S.C. received scholarship support from the Australian College of Nursing and from Western Health towards the completion of a minor thesis.

Acknowledgments

Thanks to Dr. Louise Rose and Dr. Marie Gerdtz for the use of their validated clinical scenarios.

Thanks to the ED nursing staff at both Footscray and Sunshine EDs and the Centre for Education, Western Health for their support

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