A retrospective exploration of patient-ventilator monitoring intensity, therapeutic intervention intensity, and compliance with lung protective guidelines in a cohort of patients with adult respiratory distress syndrome

Abstract

Background: The current approach to mechanical ventilation for adult respiratory distress syndrome (ARDS) and acute lung injury (ALI) involves maintaining key patient-ventilator parameters within established lung protective targets. Monitoring is part of the processes of nursing care believed to guide therapeutic intervention and facilitate compliance with these targets. Empirical relationships between monitoring, therapeutic intervention, and compliance with these practice guidelines have not been adequately explored.

Methods: A retrospective observational design was used to explore relationships between monitoring intensity, therapeutic intervention intensity, and compliance with a lung protective philosophy of mechanical ventilation in a cohort of patients with ARDS or ALI. Compliance with lung protective targets was measured as the proportion of time oxygen saturation, alveolar distending pressure, and tidal volume were maintained within recommended guidelines as evidenced by medical record documentation. Monitoring intensity and therapeutic intervention intensity were based on the frequency of recorded assessments and interventions in the medical record.

Results: Monitoring intensity correlated positively with both severity of illness (r = 0.39) and with therapeutic intervention intensity (r = 0.30), and was inversely related to compliance with lung protective guidelines (CLPG) (r = -0.34). A regression model including monitoring intensity, severity of illness, risk for abdominal hypertension, and CLPG was statistically significant (p = 0.02) but explained little of the variance in compliance with lung protective parameters (R2 = 0.13).

Discussion and conclusions: Compliance with recommended lung protective parameters in the absence of standardized monitoring and intervention protocols is suboptimal. Preliminary evidence of positive relationships between monitoring and both severity of illness and therapeutic intervention was established. Control for nursing and physician practice variation is needed to rule out the influence of surveillance and performance bias on collaborative practice outcomes. Explicit standardized protocols that address the frequency of assessments and interventions along with therapeutic targets are recommended for collaborative practice guidelines.