Terry L. Jones, Professor, Clinical Nursing, University of Texas at Austin, Austin, TX, USA.
Worldviews Evid Based Nurs. 2011 Mar;8(1):40-50. doi: 10.1111/j.1741-6787.2010.00183.x.
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.
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.
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).
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.
目前，成人呼吸窘迫综合征（ARDS）和急性肺损伤（ALI）的机械通气方法包括将关键的患者-通气机参数维持在既定的肺保护目标范围内。监测是护理过程的一部分，被认为可以指导治疗干预并促进对这些目标的遵守。监测、治疗干预和遵守这些实践指南之间的经验关系尚未得到充分探讨。
采用回顾性观察设计，探讨了 ARDS 或 ALI 患者队列中监测强度、治疗干预强度与遵循机械通气肺保护理念之间的关系。肺保护目标的依从性通过记录的医疗记录中的氧饱和度、肺泡扩张压和潮气量在推荐指南范围内的时间比例来衡量。监测强度和治疗干预强度基于记录的评估和干预在医疗记录中的频率。
监测强度与疾病严重程度（r=0.39）和治疗干预强度（r=0.30）呈正相关，与肺保护指南的依从性（CLPG）呈负相关（r=-0.34）。包括监测强度、疾病严重程度、腹内高压风险和 CLPG 的回归模型具有统计学意义（p=0.02），但对肺保护参数依从性的方差解释很小（R2=0.13）。
在没有标准化监测和干预方案的情况下，建议使用肺保护参数的依从性不理想。初步证据表明，监测与疾病严重程度和治疗干预之间存在正相关关系。需要控制护理和医生实践的变异性，以排除监测和绩效偏差对协作实践结果的影响。建议制定明确的标准化协议，解决评估和干预的频率以及治疗目标，以用于协作实践指南。
