A rapid evaluation of quality of sedation and ventilation care processes for critically ill patients in Vietnam

Abstract

Background Sedation assessment, spontaneous awakening and breathing trials are evidence-based practices which can minimise harm from ventilation and sedation of critically ill patients. There are known difficulties in implementing these processes which are likely to be exacerbated in low-resource settings. This study aimed to describe current delivery of these care processes in three intensive care units in Vietnam; identify barriers and facilitators to their delivery; and describe local capacity for improvement. Methods We conducted a prospective rapid evaluation between 01/11/2021 and 31/12/2023 comprising registry-enabled measurement of daily care processes, process mapping, observations, focus group discussions, semi-structured interviews and a structured assessment of local capacity for improvement. Contextual determinants of care quality were analysed using the Consolidated Framework for Implementation Research. Organisational capacity for improvement was analysed using the Model for Understanding Success in Quality. Results Sedation was assessed qualitatively rather than using systematic tools. Spontaneous Awakening and Breathing Trials were both performed according to individual doctors’ clinical judgement in a non-protocolised manner. Barriers to delivering these processes included the lack of locally-adapted protocols, perceived safety concerns exacerbated by staffing shortages and lack of familiarity due to confusing terminology. Facilitators to improvement included quality improvement champions, registry-enabled audit and feedback, training, and partnerships within and between hospitals. Conclusion We identified opportunities to improve sedation and ventilation in the three study settings in Vietnam. The barriers to delivering the care processes we studied echoed those reported in high-income countries, but were exacerbated by local contextual factors such as staffing shortages and differences in professional roles. We developed recommendations for future improvement projects: implementing setting-adapted protocols, standardising terminology to improve documentation, engaging clinical staff with feedback, identifying champions, educate staff regarding the clinical processes and quality improvement and leverage existing internal expertise. These recommendations may have applicability to other care processes and/or settings.