Practice variation in respiratory therapy documentation during mechanical ventilation

Study objectives: Implementation of new ventilatory strategies such as lung-protective ventilation for ARDS will require a multidisciplinary approach with considerable physician and respiratory therapy (RT) interaction. One of the key factors in this communication is complete and accurate RT documentation of ventilator settings. Few studies have explored the quality and variability of this documentation. Design: Population-based cross-sectional study. Setting: Seventeen adult hospitals in King County, WA. Participants/interventions: We compared the blank RT ICU flow sheet for each institution to the 1992 American Association for Respiratory Care (AARC) clinical practice guidelines (CPGs) for patient-ventilator system checks. We interviewed RT managers at each hospital about their practices. Finally, we reviewed selected charts of patients with acute lung injury (ALI) or ARDS from each hospital to evaluate the documentation. Measurements/results: We found substantial variability in RT documentation practices and in their extent of compliance with the AARC CPGs. Only 15 of 52 items recommended by the AARC CPGs were included on blank RT flow sheets of every hospital in our study, and only 26 of 52 items were found on charts of ALI/ARDS patients at most hospitals (ie, greater than or equal to 10 of 17 hospitals). Only 10 of 17 RT department managers reported using the AARC CPGs as a basis for their documentation policies. Items necessary for the implementation of lung-protective ventilation for ALI/ARDS patients were recorded inconsistently and were not included in the AARC CPGs. Plateau pressure was found on all reviewed charts of ALI/ARDS patients at only 10 of 17 hospitals. Conclusions: Considerable variability exists in RT documentation practices. We suggest that new guidelines be developed for documenting the care of patients receiving mechanical ventilation, in light of recent data on ventilator weaning and the management of ALI/ARDS, and that their effect on practice and outcomes be evaluated.