A study to evaluate the competency of ICU personnel in mechanical ventilation.

INTRODUCTION: The benefit assessment of mechanical ventilation on clinical outcomes presumes competent caregivers who posses the knowledge and skills to optimize care while simultaneously minimizing potential complications. The purpose of this study was to assess the knowledge of mechanical ventilation among ICU personnel in a university hospital. METHODS: A 20 question survey was administered assessing three areas of knowledge: basic pulmonary physiology related to mechanical ventilation, ventilator management and ventilator safety considerations. The first group consisted of registered respiratory therapists (RRT), and the second a cross section of ICU personnel involved in ventilator management. RESULTS: We evaluated a total of 61 subjects. The mean score for the RRT group was (n=9) 83+10. The mean score for the second group (n=52) was 42+16.1.

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CONCLUSION: There are differences in knowledge related to basic conventional mechanical ventilation, which are most pronounced in non-RRT health care providers in the ICU setting. This can have a significant impact on the quality and safety of patient care thus strategies that improve knowledge and optimize team structure regarding the provision of mechanical ventilation services should be stressed.

INTRODUCTION

Mechanical ventilation remains the single most important therapeutic modality in the intensive care unit. (1) The horrific impact of the polio epidemic of the early 1950's were the major impetus for the development of practical, effective means of providing artificial ventilation. The sophistication of today's microprocessor controlled machines and ventilatory adjuncts have added considerable complexity to the art and science of critical care. Additionally, recent clinical trials have provided clinicians with evidence based approaches to the application mechanical ventilation in various settings. What must not be overlooked is that these life sustaining devices, if not properly managed, can cause or are associated with life threatening complications including volutrauma, barotrauma, biotrauma, tracheal injury, ventilator associated pneumonia and multi-system organ failure. Therefore the knowledge and competency regarding mechanical ventilation of ICU personnel involved in the provision of ventilatory care is an issue of great magnitude.

The purpose of this study was to determine the baseline knowledge and competency of ICU personnel involved in routine ventilator management in our 750 bed university medical center. The evaluation encompassed a cross-section of personnel including pulmonary fellows, first, second and third year residents, medical students, nurse practitioners, certified respiratory therapists and registered respiratory therapists.

We hypothesized that pulmonary fellows, registered and certified respiratory therapists, because of unique training and education, would demonstrate significantly higher levels of knowledge than the other groups. In addition, we expected that Registered Respiratory Therapist would outperform certified respiratory therapists as the RRT group had, by virtue of attaining their credential, demonstrated advanced practice knowledge and competency.

METHODS

A survey was developed by three faculty attending pysicians in the pulmonary/critical care service in conjunction with the director of respiratory therapy and the medical director for the center of pulmonary and critical care. The survey consisted of 20 items and assessed three areas of knowledge: basic pulmonary physiology related to mechanical ventilation, ventilator management and ventilator safety considerations. Each item was a multiple choice question with one correct response (Table one). The research instrument was distributed for appraisal to a range of ICU practitioners who were unconnected to the study, and other experts in the field. The tool was amended accordingly.

The survey was administered to 61 subjects. They included 9 registered respiratory therapists, 2 certified respiratory therapists, 3 nurse practitioners, 12 medical students, 15 PGY1, 10 PGY2, 5 PGY3 and 5 pulmonary Fellows. The pulmonary fellows are actively involved in the management and care of mechanically ventilated patients in both our 18 bed medical intensive care unit and 16-bed respiratory care unit. The nurse practitioners were chosen due to their active participation in the management of mechanically ventilated patients in our institution as well as their extensive involvement in research related to pulmonary critical care. Additionally, nurse practitioners that participated in the survey had an average of 14 years of critical care nursing experience. The registered and certified therapists had an average 7.4 and 19 years of clinical experience respectively.

Frequency and percentages were calculated for nominal data. Ranges, means and medians were calculated for the scores for ventilator knowledge. The hypothesis was tested using a two tailed independent sample tests. A significance level of P < 0.05 was accepted as statistically significant.

RESULTS

Sixty one people completed the survey. Table 2 shows the scores for each participating discipline.

The male to female ratio of the participants was 31:23. There was no statistically significant difference in the mean scores between genders after adjusting for training. We were surprised to see such a pronounced difference between the mean scores of CRTs compared to RRTs and Pulmonary Fellows compared to RRTs. The progression from PGY1 to PGY3 correlated positively and in the anticipated direction with the increased knowledge in the three critical areas evaluated by the survey.

DISCUSSION

The safe and effective administration of mechanical ventilation requires a unique and comprehensive skill set, which is grounded in the principles of applied pulmonary physiology, physics and bioengineering. A foundation in these principles allows the incorporation of knowledge based on technology which is advancing exponentially with new modes of ventilation and techniques of providing artificial ventilation being introduced at an almost alarming rate. For this reason it is not surprising that the skills of mechanical ventilation are generally not taught until late in most respiratory care educational curricula when the use of more complex devices is better assimilated and spans 2 to 3 semesters of didactic, laboratory and practical education.

The benefit assessment of mechanical ventilation or any therapeutic adjunct on clinical outcome presumes that the care provider possesses the skills and knowledge to optimally utilize the equipment and simultaneously minimize potential complications. Other studies have shown that knowledge of even the most basic respiratory are procedures among non-respiratory therapist health care professionals is quite variable and tends to be less then adequate. (7) This is disturbing as the practice of mechanical ventilation and other aspects of respiratory care are often life supporting and error in planning or application can lead to increased morbidity and or mortality. Various organizations have recommended testing competency or requiring certification prior to approval of clinical privileges for specialized diagnostic and therapeutic interventions (e.g. echocardiography, endoscopy). (8,9) We currently do not require a similar level of expertise before clinicians begin the practice of mechanical ventilation. The utilization of respiratory therapists to provide mechanical ventilation services as well as basic modalities of respiratory care is fully supported in the literature and correlated with increased patient safety, improved patient outcomes and decreased cost.

Our study supports the work of others who have demonstrated that registered respiratory therapists are the most logical providers of safe and effective mechanical ventilation. The major limitation of this study is the sample size. Our results reflect the knowledge and competency of a cross section of individuals participating in mechanical ventilation at our institution. A multi-center study should be done as the scope of practice and involvement of various members of the ICU teams related to mechanical ventilation differs widely from one institution to another and may correlate with competency.

One of the main limitations of this study relates to its small sample size. The statistical significance of these findings cannot be precisely interpreted with these small numbers. This study was intended as a pilot study for a future investigation on a larger scale. In spite of its limitations, the magnitude of the difference and consistency of finding provides confidence that these may be truly representative of practice in this area.

CONCLUSION

This study demonstrates a significant difference in the fund of knowledge in conventional mechanical ventilation between registered respiratory therapists and other ICU personnel. There are differences in the knowledge surrounding mechanical ventilation, which are most pronounced in the non-RRT health care providers, which could have significant impact on the quality and safety of patient care. Health care organizations must adopt an approach to ensure that mechanical ventilation services are provided by health care professionals who have appropriate knowledge and experience to optimize care while simultaneously minimizing potential complications.

Readers may contact the author for a list of references at [e-mail]

Alphonso A. Quinones MA, RRT Archana Mishra MD Erfan Hussain MD Arunabh MD David Ost MD Alan Fein MD

Table 1. Sample questions from the written survey

1. Which of the following best reflects alveolar pressure?
a. Positive End Expiratory Pressure
b. Peak Airway Pressure
c. Plateau Pressure
d. Mean Airway Pressure

2. The current recommendation for initial tidal volume ranges for
patients suffering from ARDS are:
a.  6-8ml/kg/ibw
b.  8-10ml/kg/ibw
c. 10-12ml/kg/ibw
d. 12-15ml/kg/ibw

3. During mechanical ventilation with SIMV plus PEEP, the PEEP level is
+10 cmH20 and the peak pressure is 44cmH2O. The PEEP is increased to
15cmH20 and the peak pressure increases to approximately 50cmH20. The
rise in Peak pressure indicates:
a. An expected outcome when PEEP is increased
b. Compliance has increased
c. The presence of pneumothorax
d. Airway resistance has increased
e. Compliance has decreased.

Table 2.

GROUP         N   MEAN

RRT            9  83.30 + 10.0
CRT            2  57.50 + 3.54
NP             3  51.67 + 2.89
MED. STUDENT  12  33.75 + 10.69
PGY1          15  32.07 + 12.93
PGY2          10  50.90 + 15.53
PGY3           5  60.60 + 9.37
FELLOW         5  67.00 + 16.56