Weaning from prolonged mechanical ventilation. The experience at a regional weaning center.

STUDY OBJECTIVE: The aim of this study was to describe the facility, patient population, outcome of treatment, and survival of patients transferred to a regional weaning center (RWC) after prolonged mechanical ventilation in the ICU setting. DESIGN: Retrospective record review. SETTING: Regional weaning center. PATIENTS: Four hundred twenty-one consecutive ventilator dependent patients were transferred from ICU care for attempted weaning over a 36-month period. MEASUREMENT AND RESULTS: Acute catastrophic surgical, traumatic, or septic illness resulted in ventilator dependency with much greater frequency than decompensated COPD. Of the 421 patients, 116 died and 287 survived with outcome known at discharge. Of the 287 who survived, 212 were freed from ventilator support. Patients who weaned were ventilator-dependent for 46.9 +/- 2.9 days before transfer to the RWC. Almost half of those weaned were discharged to their homes. Survival at 6 months and 1 year after discharge was 44 percent and 28 percent respectively, and it was greater for those at home than for those discharged to an extended care facility (ECF). The RWC care was approximately $1,500 per patient day less costly than ICU care, and $208 per patient day less costly than noninvasive respiratory care unit care. CONCLUSIONS: Selected patients who become ventilator dependent for prolonged periods in the ICU may be transferred to an RWC with the expectation of successful weaning in a majority of cases.

Predictors of weaning after 6 weeks of mechanical ventilation.

STUDY OBJECTIVE: To identify variables associated with weaning outcome in long-term ventilator-dependent patients. Using those variables, to construct models to predict weaning success and to test the accuracy of those models. DESIGN: Retrospective medical record review. SETTING: Regional weaning center (RWC). PATIENTS: An initial group of 421 and a subsequent group of 170 consecutive patients referred for attempted weaning after 6 weeks of mechanical ventilation. MEASUREMENTS AND RESULTS: Data obtained on admission to our facility were analyzed for correlation with weaning outcome. In the initial patient group, selected variables which correlated with weaning success were alveolar-arterial oxygen pressure difference (P[A-a]O2), BUN, BUN/creatinine ratio (each with p < or = 0.001), and female gender (p = 0.04). We used these variables in logistic regression models to predict weaning success in this population. We then tested the models in the 170-patient validation group using both standard and receiver operating characteristic (ROC) curve analysis. The ROC analysis indicated 59% accuracy using P(A-a)O2 alone and 68% accuracy using all previously mentioned variables. We used data from all 565 patients with known outcome and omitted BUN/creatinine ratio to fashion a simple scoring system to predict weaning success with 70% accuracy using P(A-a)O2, BUN, and Gender--the A+B+G score. CONCLUSION: In patients suffering prolonged mechanical ventilation, models incorporating simple measurements allowed construction of a score to predict weaning success at our RWC.

The Sessing scale for assessment of pressure ulcer healing.

OBJECTIVE: To describe a new observational scale, the Sessing scale, for measuring the progression of pressure ulcers. CRITERION STANDARDS: Changes in Shea stage and the diameter of healing pressure ulcers. SUBJECTS: A cohort of 84 nursing home residents with pressure ulcers. RESULTS: There were strong relationships between changes in healing as measured by the Sessing Scale and those measured by the Shea Scale (Spearman's r = 0.90; P < .0001), and between changes in the Sessing scale compared with changes in ulcer diameter (Spearman's r = 0.64; P < .001). Test-retest reliability was good (Kappa = 0.84) in a sample of 50 subjects. CONCLUSION: The Sessing scale is a simple, easy to use, observational instrument with validity and reliability for the assessment of progression of pressure ulcers in a clinical or research setting. Findings indicate that the Sessing scale, with its description of granulation tissue, infection, drainage, necrosis, and eschar, measures an important domain of wound healing that is independent and perhaps as important to clinicians and researchers as either Shea stage or ulcer size.

Risking involvement with cancer patients.

The helping relationship has been identified by Brammer (1988) as central to the practice of nursing. This study explored the process of developing special relationships with cancer patients. Interviews were conducted with 32 nursing personnel. The grounded theory method of constant comparative analysis was selected for this investigation. An open-ended interview guide explored the difference between the usual relationships nurses had and the special relationships they formed with selected patients. A basic psychosocial process, "risking involvement" in special relationships with cancer patients, was identified. The willingness to risk involvement took the forms of resisting involvement or practicing involvement.

Collaborative planning of patient care in the prenatal, labor and delivery, and neonatal settings.

Self-care consumer and nursing movements have emphasized the role of the patient as an active participant in the planning and implementation of care. A nursing model that focuses on the interaction that takes place between the nurse and patient as they develop and implement a collaborative plan of care is presented. Three examples of how the model has been used in maternal-child health settings are given.

The development of the Intersystem Model.

A nursing model has been developed which guides curriculum development and nursing practice at Azusa Pacific University School of Nursing; the Intersystem Model. It is a model which focuses on the interaction between nurse and patient/client and requires that the nurse assess the knowledge base, the values and the behaviours that are brought to a specific patient situation by both the nurse and the patient/client. Using the system concepts of supra and subsystems, person can be defined as the individual, the family or the community. An intrasystem assessment of the biological, psychosocial and spiritual subsystems of the person is carried out, as well as an assessment of the developmental environment. The developmental environment consists of all the events, factors and influences which have made the person what he is at the time he enters a specific encounter requesting nursing action for an illness situation he is unable to resolve independently. Positive and negative variables are identified and a score on sense of coherence is assigned. Sense of coherence is a construct which includes three components: comprehensibility, meaningfulness and manageability. In using the model, each component is scored from low to high. Through a collaborative process, a joint plan of care is developed in order to increase the sense of coherence the patient/client experiences about the health problem and the plan is evaluated by rescoring on sense of coherence. An example of how the Intersystem Model has been used with a diabetic patient in the community is presented, as well as diagrams illustrating the way the nursing process is carried out in intersystem interaction.

Implementation of the intersystem patient-care model in clinical practice.

An intrasystem-intersystem model developed by Alfred Kuhn has been integrated into the nursing process model to serve as a model for patient-nurse interaction. In this conceptual model the patient and the nurse represent intrasystems with three components, the detector, selector and effector, which act to supply information about the environment, analyse internal values and preferences and initiate action. The intrasystems are connected through a specified set of relations as the patient and nurse interact to communicate information, transact values and organize a plan of care. An example is presented of how this model can be used to implement the nursing process in the community health setting.