International perspectives on the influence of structure and process of weaning from mechanical ventilation.

Background 
Recently, clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation. One such process, use of a weaning protocol, has yielded conflicting results, arguably because of the influence of existing context and processes.

Objective 
To compare international data to assess differences in context and processes in intensive care units that could influence weaning.  

Methods 
Review of existing national data on provision of care for critically ill patients, including structure, staffing, skill mix, education, roles, and responsibilities for weaning in intensive care units of selected countries.

Results 
Australia, New Zealand, Denmark, Norway, Sweden, and the United Kingdom showed similarities in critical care provision, structure, skill mix, and staffing ratios in intensive care units. Weaning in these countries is generally a collaborative process between nurses and physicians. Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care unit’s health care team. Nurses may be excluded from direct management of ventilator weaning in some institutions, as this role is primarily assumed by respiratory therapists guided by medical directives. Availability of critical care beds was highest in the United States and lowest in the United Kingdom.

Conclusion 
Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries. Further quantification of these contextual influences should be considered when translating research findings into local clinical practice and when designing randomized, controlled trials.

Peer Rating for Feedback in Group Projects

The National Student Survey (NSS) in the UK has since 2005 questioned final year
undergraduate students on a broad range of issues relating to their university experience.
Across disciplines and universities students have expressed least satisfaction in the areas of
assessment and feedback. In response to these results many educational practitioners have
reviewed and revised their procedures and the UK Higher Education Academy (HEA) has
produced guidelines of best practice to assist academics in improving these specific areas.
The Product Design and Development (PDD) degree at Queen’s University Belfast is
structured with an integrated curriculum with group Design Build Test (DBT) projects as the
core of each year of the undergraduate programme. Based on the CDIO syllabus and
standards the overall learning outcomes for the programme are defined and developed in a
staged manner, guided by Bloom’s taxonomy of learning domains.
Feedback in group DBT projects, especially in relation to the development of personal and
professional skills, represents a different challenge to that of individual assignment feedback.
A review of best practice was carried out to establish techniques which could be applied to
the particular context of the PDD degree without modification and also to identify areas
where a different approach would need to be applied.
A revised procedure was then developed which utilised the structure of the PDD degree to
provide a mechanism for enhanced feedback in group project work, while at the same time
increasing student development of self and peer evaluation skills. Key to this improvement
was the separation of peer ratings from assessment in the perception of the students and the
introduction of more frequent face to face feedback interviews.
This paper details the new procedures developed and additional issues which have been
raised and addressed, with reference to the published literature, during 3 years of operation.

Juvenile Songbirds Compensate for Displacement to Oceanic Islands during Autumn Migration

To what degree juvenile migrant birds are able to correct for orientation errors or wind drift is still largely unknown. We studied the orientation of passerines on the Faroe Islands far off the normal migration routes of European migrants. The ability to compensate for displacement was tested in naturally occurring vagrants presumably displaced by wind and in birds experimentally displaced 1100 km from Denmark to the Faroes. The orientation was studied in orientation cages as well as in the free-flying birds after release by tracking departures using small radio transmitters. Both the naturally displaced and the experimentally displaced birds oriented in more easterly directions on the Faroes than was observed in Denmark prior to displacement. This pattern was even more pronounced in departure directions, perhaps because of wind influence. The clear directional compensation found even in experimentally displaced birds indicates that first-year birds can also possess the ability to correct for displacement in some circumstances, possibly involving either some primitive form of true navigation, or 'sign posts', but the cues used for this are highly speculative. We also found some indications of differences between species in the reaction to displacement. Such differences might be involved in the diversity of results reported in displacement studies so far.

Highly regioselective platinum catalyzed hydrometallation of propargylic alcohols

A Pt catalysed hydrometallation reaction has been developed that provides b-metallated products as a single region and geometric isomer. The reaction is incredible tolerant of sterics and actually performs better in more sterically congested stubstrates. We have demonstrated this approach in hydrosilylations, hydrostannylations and hydroboronations. We have shown a wide range of silanes to participate in this reactions and a Denmark type one-pot hydrosilylation-Hiyama coupling has been achieved as a single regioisomer. The regioselectivity has been probed for internal alkynes and we have discovered that the regioselectively is determined by both steric and electronic factors. We can selectively form either the a or b-products as a single regioisomer by altering the steric environment and we have discovered that electronic effects overide the sterics.

Decisional responsibility for mechanical ventilation and weaning: an international survey

Introduction: Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.

Methods: A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.

Results: Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0)). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.

Conclusions: Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.