A pediatric mechanical ventilation educational initiative in two intensive care units

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A pediatric mechanical ventilation educational initiative in two intensive care units

https://doi.org/10.21203/rs.3.rs-2187050/v1

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Introduction: Inappropriate ventilator settings, non-adherence to a lung-protective ventilation strategy, and inadequate patient monitoring during mechanical ventilation can potentially expose critically ill children to additional risks. We set out to improve team theoretical knowledge and practical skills regarding pediatric mechanical ventilation and to increase compliance with treatment goals.

Methods: An educational initiative was conducted from August 2019 to July 2021 in a neonatal and pediatric intensive care unit of the University Children's Hospital, Hamburg-Eppendorf, Germany. We tested baseline theoretical knowledge using a multiple choice theory test (TT) and practical skills using a practical skill test (PST), consisting of four sequential Objective Structured Clinical Examinations of physicians and nurses. We then implemented an educational bundle that included video self-training, checklists, pocket cards, and reevaluated team performance. Ventilators and monitor settings were randomly checked in all ventilated patients. We used a process control chart and a mixed-effects model to analyze the primary outcome.

Results: Staff members took part in 183 theory tests (TT) and 169 practical skill tests (PST). The initiative was associated with a substantial increase in staff TT and PST performance (CI) (TT: 80 [77.2–82.9]% vs. 86 [83.1–88.0]%, PST: 73 [69.7–75.5]% vs. 95 [93.8–97.1]%), self-confidence, and compliance with mechanical ventilation treatment goals (87.8% vs. 94.5%).

Discussion: Implementing a pediatric mechanical ventilation education bundle improved theoretical knowledge and practical skills among multi-professional pediatric intensive care staff and increased treatment goal compliance in ventilated children.

Managing mechanical ventilation (MV) for infants, children, and adolescents is a complex skill. MV of neonates and children is a life-saving procedure but can also lead to severe complications such as ventilator-associated lung injury.(Bresesti et al., 2021; M. C. Kneyber et al., 2014; Koopman et al., 2019; A. van Kaam, 2011) Severely diseased lungs are especially susceptible to shear forces due to high tidal volume (TV).(Brower et al., 2004) Lung-protective MV aims to create physiological conditions to prevent lung damage. International guidelines for neonatal and pediatric MV recommend avoidance of high TV and delta pressure (peak inspiratory pressure [PIP] - positive end-expiratory pressure [PEEP]) in acute respiratory distress syndrome.(M. C. J. Kneyber et al., 2017; Pediatric Acute Lung Injury Consensus Conference, 2015; Tume et al., 2017; Fan et al., 2018) Although few robust data are available, excessive TV and pressures may also injure healthy lung tissue in mechanically ventilated children.(Heath and Hauser, 2022; Lee et al., 2020; Sutherasan et al., 2014)

In our institution, the nursing staff prepared and set up the ventilators, whereas the physicians adjusted settings according to clinical indications. The combination of this task sharing with inconsistent approaches regarding ventilator settings and the lack of specifically defined goals during MV led to inappropriate ventilator setup and settings, non-adherence to a lung-protective ventilation strategy, and inadequate patient monitoring. Multi-professional educational programs can improve theoretical knowledge and skills(Baker et al., 2005; Caeymaex et al., 2022; Guilhermino et al., 2018; Nicholls et al., 2016), but their effect on mechanical ventilation settings and compliance to treatment goals in actual pediatric patients remains unclear.

This multi-professional educational initiative aimed to improve team knowledge and practical skills regarding pediatric MV and to optimize compliance with treatment goals that included a lung-protective ventilation strategy. The first aim was to achieve consensus on a specification and standardization of ventilator setup, parameter settings, and a lung-protective MV strategy for all ventilated children. Therefore, we tested both nurses’ and physicians’ baseline theoretical knowledge and practical skills regarding MV in children to develop and implement a highly standardized specific educational program. The second aim was to increase theoretical knowledge and practical staff performance regarding MV. The third aim was to increase compliance with patient-specific treatment goals including a lung-protective ventilation strategy to > 90% during the twelve months after the intervention.

We performed this educational initiative in the 12-bed Pediatric Intensive Care Unit (PICU) and the 15-bed Neonatal Intensive Care Unit (NICU) of the Level-IV University Children’s Hospital, University Medical Center Hamburg-Eppendorf, Germany, between August 2019 and July 2021 after approval of the local ethical review committee (Ethikkommission der Ärztekammer Hamburg, Germany).

A multi-professional team of physicians and nurses supervised the project. During the planning phase, we collected ideas and suggestions on potential improvements and current problems related to pediatric MV from the medical and nursing teams of both ICUs. In addition, we regularly exchanged ideas via a “Kanban Board” through surveys and regular team feedback rounds (Fig. 1). Checklists for set-up and settings according to treatment goals were fixed permanently and visibly to each ventilator. Additionally, pocket cards were distributed to all staff summarizing essential educational topics and mnemonic aids. A team consisting of intensive care nurses, physicians, medical education specialists, and communication experts developed the instructive content for a 30-minute educational film. The film covered the above-mentioned treatment goals, ventilation, oxygenation, inhaled nitric oxide (iNO), and complications of MV. We trained staff members by showing the film, answering questions, and discussing critical topics during training sessions in both ICUs. In addition, each staff member had access to the film from home and any hospital computer for self-study (Fig. 1).

In joint discussions and regular feedback rounds, a highly standardized approach was developed and adapted to set up ventilators and to establish specific start settings according to patient weight categories. After several team feedback rounds during staff meetings, we expanded the contents of the checklists, pocket cards, and educational film (Fig. 1).

We developed a theory test (TT) following the specific topics of a validated testing tool for pediatric mechanical ventilation(O'Boyle et al., 2014) to evaluate physicians’ and nurses’ theoretical knowledge at baseline. A questionnaire recorded the participant’s profession and experience. We randomly assigned the participants to one of two TTs of equal difficulty using a randomization list. The two TTs consisted of 15 multiple-choice questions on the following topics: ventilation, oxygenation, iNO, high-frequency oscillatory ventilation (HFOV), and complications of MV.

A practical skill test (PST), consisting of four sequential Objective Structured Clinical Examinations (OSCE)(Brannick et al., 2011; Burgess et al., 2020; Nicholls et al., 2016; Nyangeni et al., 2022) was taken directly at a modified ICU workplace. We randomly assigned the participants to one of the two equally difficult PSTs using a randomization list. Assessors observed the participants during the PST and assigned a maximum of 30 points based on performance-structured checklists. The PST simulated four clinical challenges that may occur during mechanical ventilation: A) set up and connect a ventilator including a humidification system (while time was measured), B) start a ventilator and set ventilation parameters and alarm limits for a postoperative patient (newborn, 3 kg body weight with healthy lungs), C) modify MV according to a blood gas analysis showing respiratory acidosis or alkalosis, D) adjust the ventilator settings following a sudden improvement or deterioration of lung compliance indicated by corresponding device alarms. After the intervention, the staff was re-tested using the other previously unassigned TT and PST.

We agreed on MV treatment goals consisting of a lung-protective ventilation strategy for all patients using synchronized mandatory intermittent ventilation (SIMV) and HFOV as a rescue MV mode. We specified recommendations regarding the initiation of MV, ventilator setup, and settings for different weight categories from 0.5 to 80 kg. The specifications referred to PIP, PEEP, inspiration time, respiratory rate, pressure support, trigger sensitivity, and TV and minute volume for SIMV; and mean airway pressure, amplitude, frequency for HFOV. In addition, we defined oxygenation targets to avoid hyperoxia, MV monitoring frequency, alarm limit ranges for all respirator settings, and the use of humidified gas for patients ventilated longer than 24 h.(M. C. J. Kneyber et al., 2017; Pediatric Acute Lung Injury Consensus Conference, 2015; A. H. van Kaam et al., 2021) We emphasized a standardized display setting showing pressure, flow, volume curves, and alarm limits.

Before and after the intervention, we performed random and unannounced checks of the ventilator and monitor settings in all invasively and non-invasively ventilated patients in both ICUs. The checks were performed approximately twice per week, but not on consecutive or fixed days, and at varying day times to ensure unpredictability (Fig. 1). In addition, ventilator displays and alarm limits were checked. Treatment goal violations were categorized as follows: a) ventilator setup: humidification not turned on, or no water in the humidification system; b) ventilator display: absent or incomplete displays of pressure, volume, flow curves or alarm limits; c) volume target monitoring: missing or non-optimal (inappropriately high or low) limits for minute volume or TV; d) pressure target monitoring: delta pressure > 15 mmHg, PIP > 30 mmHg; missing, or inappropriately high or low limits for PEEP or CPAP pressure; e) saturation limits (SpO2) monitoring: inappropriately high or low limits.

Statistical Analysis

A required minimum sample size of N = 44 participants was calculated to detect a 10% improvement in participants’ overall performance, assuming an overall performance mean of 75% and a standard deviation of 15% with a specified power of 90% and a significance level of 0.05. Continuous variables were expressed as mean (95% confidence interval [CI]). A random allocation sequence was generated using the sample function in R with a 50% probability. Discrete data were compared between groups with the Chi-square test, and effects were reported as Cramer’s V effect sizes. A paired two-tailed t-test was used to compare continuous variables before and after the intervention, and effects were reported as Cohen’s D effect sizes. For the performance comparison, only those participants who had taken part at both test times were included. Linear regression models were calculated for predictor variables (study phase, profession, professional experience) to analyze their impact on the participants’ theoretical knowledge and practical skills performance. Treatment goal adherence over the study period was visualized using a statistical process control chart and adherence rate analyzed using a mixed-effects model to account for multiple checks per patient. P values less than 0.05 were considered significant. Statistical analyses were performed using R 4.1.2 (2021-11-01) (R Core Team, Vienna, Austria).

We performed 183 TTs (93 pre-, 90 post-intervention). Sixty-seven participants completed the TT pre- and post-intervention (47 nurses, 20 physicians). Twenty-six participants were tested only once before (17 nurses, nine physicians), 23 only once after implementation (17 nurses, six physicians). In addition, we performed 169 PSTs (93 pre-, 63 post-intervention). Fifty-four participants completed the PST pre- and post-intervention (34 nurses, 20 physicians). Thirty-nine participants were tested only before (30 nurses, nine physicians) and nine after the intervention (seven nurses, two physicians). The reasons for taking a test only once were: dismissal, maternity leave, or unavailability. Supplementary Fig. 1 shows the recruitment of participants for the TT and PST and the analyses performed. To compare participants' performance, we included only those who had completed the tests at both time points (Table 1).

Table 1

Characteristics of participants who were tested before and after the intervention
	Nurses	Physicians
Theory Test
Number of participants	n = 47	n = 20
Professional experience, years
0–5	17 (25.4)	15 (22.4)
6–10	3 (4.5)	1 (1.5)
11–15	8 (11.9)	2 (3)
16–20	4 (6)	1 (1.5)
> 20	15 (22.4)	1 (1.5)
Practical Skill Test
Number of participants	n = 34	n = 20
Professional experience, years
0–5	12 (22.2)	15 (27.8)
6–10	3 (5.6)	1 (1.9)
11–15	7 (13)	2 (3.7)
16–20	2 (3.7)	1 (1.9)
> 20	10 (18.5)	1 (1.9)
* Categorial variables are shown as counts (percentage).

Staff TT and PST performance in percent (CI) improved significantly after the intervention compared to before (TT: 86 [83.1–88.0]% vs. 80 [77.2–82.9]%, P < 0.001, d = 0.61; PST: 95 [93.8–97.1]% vs. 73 [69.7–75.5]% vs., P < 0.001, d = 2.2). A subgroup analysis by professional groups also showed a substantial improvement in TT performance among nurses (before: 77.4 [73.9–80.9]%, after: 82.6 [79.9–85.3]%, p < 0.001, d = 0.562) and physicians (86.2 [82.3–90.1] vs. 92.6 [88.8–96.4]%, P = 0.005, d = 0.699). Also, both professions performed better in the PST after the intervention (nurses before: 75.9 [72.9–78.9]% vs. after: 97.5 [96.6–98.5]%, p < 0.001, d = 2.35; physicians before: 67 [61.6–72.4]% vs. 92 [88.2–95.8 ]%, P < 0.001, d = 2.11). Physicians (before: 578 [495–661] s vs. after: 390 [313–468] s, P < 0.001, d = -0.90), and nurses (before: 273 [249–297] s vs. after: 208 [189–227] s, P < 0.001, d = -0.92) needed significantly less time (mean [CI]) for ventilator setup after the intervention than before (Fig. 2).

To identify the predictors of staff performance, we analyzed the intervention itself, the participants’ professional experience, the professional group, and the testing regime on the participants’ TT and PST performance by computing linear regression models. The study phase (timepoint) had the most substantial impact on staff performance in percent (CI) (TT: -5.6 [-8.7–2.4]%, P < 0.001; PST: -22.9 [-26.1–-19.7]%, P < 0.001). Physicians performed better than nurses in the TT (12.3 [9.17–15.4]%), but worse in the PST (-6.2 [-9.2– -3.2]%). Inexperienced staff (professional experience < 5 years) performed worse in the TT than more experienced staff (-7.38 [-10.2– -4.5]%, P = 0.001), whereas this effect was not true for the PST (-2.6 [-5.47–0.17]%, P = 0.07). The testing regime (number of tests absolved) had no impact on performance, indicating that whether a candidate was tested before and after or only once after the intervention was irrelevant (1.8 [-1.6–5.3]%, P = 0.30) (Fig. 3).

Self-confidence among both professions increased significantly after bundle implementation(Nurses: p = 0.048; Physicians: p = 0.02) as Supplementary Fig. 2 illustrates.

A total of 3103 parameters were examined during 322 random checks in 105 MV patients pre-intervention (October 2019–June 2020) and a total of 3476 parameters were evaluated during 340 random checks in 108 MV patients post-intervention (January 2021–July 2021) (Fig. 1). The post-intervention compliance with treatment goals was significantly and persistently above the target of 90% (Fig. 4).

A mixed-effects model with a random term (Patient ID) that accounted for the multiple checks per patient confirmed that the mean compliance increased significantly by 6.7% from 87.8% before the intervention to 94.5% (P < 0.001) (sTable 1), with slightly lower compliance in the PICU than in the NICU.

Implementing a pediatric MV educational program improved theoretical knowledge and practical skills in both nurses and physicians, and increased compliance with treatment goals in two pediatric intensive care units.

We report significant post-intervention improvements in theoretical knowledge and practical skill performance among both professional groups. However, staff had already performed strongly during baseline evaluation (Fig. 2). Nurses scored lower on the TT compared to physicians. In contrast, nurses performed better than physicians in the PST and ventilator setup. We expected this result due to the local task assignments. The implementation significantly improved physicians’ practical skills and significantly reduced the time that physicians and nurses needed to set up a ventilator. The staff of both professions with limited experience (0–5 years) scored lower in the TT than more experienced staff (> 5 years). Inexperience was not a relevant factor in PST performance (Fig. 3), indicating that nurses, in particular, acquire theoretical knowledge with increasing professional experience. We used an educational film available to the team as a self-learning offering which was well adopted (Fig. 1) and proved to be a resource-effective and efficient measure for standardized and contemporary training.(Singer and Bonvillian, 2013) We tested the theoretical knowledge of the participants but moreover their practical skills in using the equipment and their abilities to respond to clinical challenges using OSCE. Although OSCE can only partially reflect clinical reality(Baker et al., 2005; Brannick et al., 2011; Nicholls et al., 2016), in our study setting, OSCE was well suited to test the psychomotor skills of the participants. In addition, self-confidence regarding pediatric ventilation improved in both professional groups after the intervention (Supplementary Fig. 2). With patient safety, the high staff turn-over(Hayes et al., 2012), and the high proportion of inexperienced staff in intensive care units in mind, a practical, consistent, and resource-effective education is of great importance in health care(Caeymaex et al., 2022; Guilhermino et al., 2018).

This initiative defined numerous aspects regarding ventilator setup, the visible display of all relevant parameters, and specifications for alarm limits and patient monitoring during MV. Compliance with these treatment goals was only accessible through random checks of patients and respirators. The mean compliance to treatment goals rose rapidly by about 7% after the intervention, well above the aim of 90%, and remained at this high level (Fig. 4). This effect was also significant after correcting for multiple checks in some patients calculating a mixed-effects model (sTable 1). Incorrect respirator setup, settings, and missing alarm limits occurred significantly less frequently after the intervention, reflecting higher team compliance with treatment goals. To our knowledge, this study is the first to report improvements in the team's theoretical knowledge, practical skills, and immediate improvements in compliance with MV treatment goals in actual pediatric patients after an educational intervention. However, whether improved team knowledge and optimized ventilator settings lead to improved patient outcomes or patient safety for ventilated children should be investigated in future studies.

Limitations

We conducted the study at only one institution. The distribution of roles in the setup of ventilators and their adjustment may vary locally, and additional specialized professionals may be involved in respiratory management, thus restricting the generalizability of the results. In addition, pediatric ventilator management is a complex skill, and neither international recommendations nor universal agreements exist among experts regarding MV goals for children. We, therefore, defined local treatment goals and MV settings and adapted the educational program to local requirements. We did not validate the TT and PST but only tested their stringency and practicability on ten volunteers, respectively, with these results not being included in the analysis. However, we initially developed the TT based on a set of key objectives of a validated published testing tool for pediatric mechanical ventilation(O'Boyle et al., 2014). Although we did not determine the difficulty level of the two TTs and PSTs, due to the study design, each participant acted as their control by being randomly assigned to take one of the tests for baseline evaluation and completing the other test after the intervention. Blinding of the TT and PST assessors and random checks were impossible because of the study design. Knowing that they participated in the initiative, the treating team may have changed their behavior (Hawthorne effect).

Implementation of a pediatric mechanical ventilation education bundle significantly improved theoretical knowledge, practical skills, and self-confidence among multi-professional intensive care staff and increased treatment goal compliance in actual pediatric patients of two intensive care units.

HFOV High-frequency oscillatory ventilation

ICU Intensive Care Unit

NICU Neonatal Intensive Care Unit

PEEP Positive end-expiratory pressure

PICU Pediatric Intensive Care Unit

PIP Peak inspiratory pressure

PST Practical Skill Test

MAP Mean arterial pressure

MV Mechanical Ventilation

SIMV Synchronized mandatory intermittent ventilation

TV Tidal volume

TT Theory Test

Conflict of Interest Disclosures: The authors have no conflicts of interest relevant to this article to disclose.

Funding/Support: This educational initiative was supported by “HANSE Förderpreis”, donated by Wissenschaftlicher Verein zur Förderung der klinisch angewendeten Forschung in der Intensivmedizin e.V. (WIVIM), Bremen, Germany.

Role of Funder: The WIVIM had no role in the design and conduct of the study.

Contributors’ Statement

Dr Deindl conceptualized and designed the study, coordinated and supervised data collection, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript.

Mr Mehrzai collected data, conducted the initial analyses, and reviewed and revised the manuscript.

Dr Höfeler, Dr Ebenebe, Ms Lange, Ms Bergers, Ms Dreger, and Ms Maruhn developed educational materials and checklists, collected data, and critically reviewed and revised the manuscript for important intellectual content.

Dr Moll-Koshrawi advised on the study design, teaching methods, and training content. In addition, she helped interpret the data and critically revised the draft for important intellectual content.

Dr Demirakça and Prof Singer were involved in the intervention planning, helped develop the study design, and revised the draft critically for important intellectual content.

Dr Vettorazzi advised on the study design, critically discussed the results, revised the draft for important intellectual content, and supervised the statistical analysis.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgments

All authors thank Petra Julie-Gilb for her excellent advice on the media content, Axel Kirchhoff for the video recording, Eva Hecht for the video editing, and all PICU and NICU team participants supporting this project. We also thank Medical Education Specialists Constantin Trepte and Parisa Moll-Koshrawi for their excellent educational program and team training advice.

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No competing interests reported.

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A pediatric mechanical ventilation educational initiative in two intensive care units

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Abstract

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Introduction

Methods

Statistical Analysis

Results

Discussion

Limitations

Conclusions

Abbreviations

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Supplementary Files

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