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A prospective cluster-randomized quality improvement trial was conducted to evaluate whether a structured nurse education program on ventilator waveform interpretation and alarm management reduces patient-ventilator asynchrony in the pediatric intensive care unit. Two PICU units within the same hospital were randomized to either an Education group or a Control group. Nurses in the Education group received multimodal training, reference cards, and support for real-time waveform review. The primary outcomes were asynchrony index (%) and ventilator alarm frequency (alarms/day). Secondary outcomes included ventilator days, cumulative sedation dose, withdrawal symptoms, nurse accuracy in identifying asynchrony, and nurse workload.
Patient-ventilator asynchrony (PVA) is common in mechanically ventilated children and is associated with impaired gas exchange, increased sedation exposure, prolonged mechanical ventilation, and higher morbidity. Recognition and management of asynchrony require real-time waveform interpretation, yet bedside nurses' ability to identify it varies widely.
This prospective cluster-randomized quality improvement study was conducted in two pediatric intensive care units within the same tertiary children's hospital. The two PICUs were randomized 1:1 to either the Education group or the Control group. Children aged 1 month to 18 years who required at least 48 hours of invasive mechanical ventilation were eligible.
In the Education group, bedside nurses participated in a structured, multimodal training program including face-to-face teaching, case-based waveform analysis, alarm management principles, and a mobile platform for sharing ventilator screenshots with an asynchrony review team. Reference pocket cards summarizing common asynchrony patterns and recommended responses were provided. Nurses performed routine waveform checks and communicated suspected asynchrony to the clinical team; ventilator settings were changed only by physicians.
The Control group followed the existing standard of care without nurse-specific training. Asynchrony was quantified using 24-hour waveform recordings exported from the ventilator.
Primary outcomes were asynchrony index (%) and total ventilator alarm frequency (alarms per ventilator day). Secondary outcomes included mechanical ventilation duration, cumulative sedation dose (mg/kg), withdrawal symptoms measured using the WAT-1 score, nurse accuracy before and after training, and nurse workload assessed using the NASA-TLX tool.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Education Group | Experimental | Bedside nurses received a structured multimodal education program on ventilator waveform interpretation, recognition of patient-ventilator asynchrony, and ventilator alarm management. The training included face-to-face sessions, case-based waveform discussions, reference pocket cards, and real-time waveform sharing with an asynchrony review team. Nurses conducted routine waveform checks and communicated suspected asynchrony to physicians; ventilator adjustments were performed only by physicians. |
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| Control Group | No Intervention | Patients received standard care in accordance with existing mechanical ventilation and alarm management protocols. No nurse-specific training on ventilator waveforms or patient-ventilator asynchrony was provided. Asynchrony was assessed using 24-hour ventilator waveform recordings exported for analysis. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Nurse Education on Ventilator Waveform and Alarm Management | Behavioral | A structured multimodal education program delivered to bedside nurses, including face-to-face teaching, case-based ventilator waveform interpretation, recognition of common patient-ventilator asynchrony patterns, ventilator alarm management principles, reference pocket cards, and real-time waveform sharing with an asynchrony review team. Nurses performed routine waveform checks and reported suspected asynchrony to physicians; ventilator adjustments were performed only by physicians. |
| Measure | Description | Time Frame |
|---|---|---|
| Asynchrony Index (%) | The proportion of asynchronous breaths divided by total breaths, expressed as a percentage. Asynchrony is quantified using 24-hour ventilator waveform recordings. | Within the first 24 hours of invasive mechanical ventilation |
| Ventilator Alarm Frequency (alarms/day) | The total number of ventilator alarms per ventilator day, including pressure, volume, and flow-related alarms. | Within the first 24 hours of invasive mechanical ventilation |
| Measure | Description | Time Frame |
|---|---|---|
| Duration of Mechanical Ventilation (days) | Number of days from initiation of invasive mechanical ventilation to successful extubation or transition to noninvasive ventilation. | Up to 28 days or until discontinuation of invasive mechanical ventilation, whichever comes first. |
| Cumulative Sedation Dose (mg/kg) |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Hasan Agin, Prof.Dr. | Dr. Behcet Uz Children's Hospital | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Behcet Uz Children's Hospital - Pediatric Intensive Care Unit | Izmir | Turkey (Türkiye) |
This study does not plan to share individual participant data.
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| ID | Term |
|---|---|
| D000097742 | Patient-Ventilator Asynchrony |
| ID | Term |
|---|---|
| D012131 | Respiratory Insufficiency |
| D012120 | Respiration Disorders |
| D012140 | Respiratory Tract Diseases |
| D012818 | Signs and Symptoms, Respiratory |
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Two pediatric intensive care units were randomized as clusters to Education vs Control groups.
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Total cumulative dose of sedative medications administered during mechanical ventilation, normalized to patient weight. |
| Up to 28 days or until discontinuation of invasive mechanical ventilation, whichever comes first. |
| Nurse Accuracy in Identifying Asynchrony (%) | Proportion of correctly identified asynchrony patterns on pre-training and post-training waveform tests. | Within the first 24 hours of invasive mechanical ventilation |
| Withdrawal Severity (WAT-1 Score) | Maximum Withdrawal Assessment Tool-1 (WAT-1) score recorded during mechanical ventilation and weaning. | Up to 48 hours after extubation following a period of mechanical ventilation. |
| D012816 | Signs and Symptoms |
| D013568 | Pathological Conditions, Signs and Symptoms |