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Shamshiri M, Fuh Suh B, Mohammadi N, Nabi Amjad R. A Survey of Adherence to Guidelines to Prevent Healthcare-Associated Infections in Iranian Intensive Care Units. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e27435. [PMID: 27621932 PMCID: PMC5004621 DOI: 10.5812/ircmj.27435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 01/13/2016] [Accepted: 03/06/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) are acquired by patients while receiving care. The highest incidence of HAIs has been documented in admissions to intensive care units. Adherence to evidence-based practices is the most important step for preventing HAIs. OBJECTIVES To determine the rate of adherence to evidence-based post-insertion recommended care practices after admission into the intensive care unit for the following devices: central line catheter, indwelling urinary catheter, and mechanical ventilator. PATIENTS AND METHODS A structured observational cross-sectional research design was used. Data were collected using a checklist and a self-report questionnaire. The minimum sample size required for this study was 276 post-insertion care episodes, and 332 episodes were observed. The ANOVA test was used to identify any significant differences among the mean scores of the three devices. RESULTS Overall observed adherence rates were 18.3%, 59.1%, and 43.1% for central line catheters, indwelling urinary catheter, and mechanical ventilator, respectively. Of the observed episodes of device care, only in 9.4% of the episodes was regular oral care performed for patients on mechanical ventilators and only in 19.3% of the episodes were indwelling urinary catheters properly secure after insertion. More so, in none (0.0%) of the episodes was the central line catheter hub disinfected before being accessed. CONCLUSIONS Evidence-based post-insertion recommended care practices were not consistently and uniformly implemented in the intensive care units. Establishment of a program for the surveillance of adherence to recommended guidelines is required for improving compliance by health professionals and the quality of preventive care.
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Affiliation(s)
- Mahmood Shamshiri
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, IR Iran
| | - Boudouin Fuh Suh
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences-International Campus, Tehran, IR Iran
| | - Nooredin Mohammadi
- Department of Critical Care Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, IR Iran
| | - Reza Nabi Amjad
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran
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Hamishehkar H, Vahidinezhad M, Mashayekhi SO, Asgharian P, Hassankhani H, Mahmoodpoor A. Education alone is not enough in ventilator associated pneumonia care bundle compliance. J Res Pharm Pract 2014; 3:51-5. [PMID: 25114937 PMCID: PMC4124680 DOI: 10.4103/2279-042x.137070] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: Ventilator-associated pneumonia (VAP) described as a secondary and preventable consequence in mechanically ventilated patients, emerges 48 h or more after patients intubation. Considering the high morbidity and mortality rate of VAP and the fact that VAP is preventable, it seemed necessary to evaluate care bundle compliance rate and effect of education on its improvement. Methods: This observational study was conducted on 10 Intensive Care Units (ICUs) of four university affiliated hospitals in three steps. In the first step, VAP care bundle compliance including head of bed (HOB) elevation, endotracheal cuff pressure (ETCP), mouthwash time, utilizing close suction systems, subglottic secretion drainage, type of suction package, and hand wash before suctioning was evaluated. In the second and third steps, ICU staffs were trained and its effect on VAP care bundle compliance was investigated. Finally, an inquiry from nurses was conducted to evaluate the obtained results. Findings: A total of 552 checklists consisting of 294 observations in the pre-education group and 258 observations in the posteducation group were filled. Mean VAP care bundle compliance in pre-education and posteducation stages was 36.5% and 41.2%, respectively (P > 0.05). Except for patients' mouth washing, there were no improvement in HOB elevation (>30°), hand washing and ETCP after education. Based on the results of questionnaire received from nurses at the end of study, more than 90% of nurses believed that lack of rigid monitoring of VAP care bundle is a main reason of low adherence for VAP care bundle compliance. Conclusion: The adherence to VAP care bundle was inappropriate. Education seems to be ineffective on improving VAP care bundle compliance. Frequent recall of the necessity of the VAP care bundle and the continuous supervision of ICU staffs is highly recommended.
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Affiliation(s)
- Hadi Hamishehkar
- Department of Clinical Pharmacy, Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahdi Vahidinezhad
- Iranian Evidence Based Medicine Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Simin Ozar Mashayekhi
- The Liver and Gastrointestinal Research Center, Tabriz University of Medical sciences, Tabriz, Iran
| | - Parina Asgharian
- Student Research center committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Hassankhani
- Department of Nursing, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology and critical care, Tabriz University of Medical Sciences, Tabriz, Iran
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3
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Günlemez A, Atasay B, Güriz H, Aysev D, Arsan S. Multi-resistant viridans streptococcal pneumonia and sepsis in the ventilated newborn. ACTA ACUST UNITED AC 2013; 24:253-8. [PMID: 15479576 DOI: 10.1179/027249304225018993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Mechanical ventilation increases the frequency of nosocomial infections. This study describes the frequency of multi-resistant viridans streptococcal colonisation, the clinical course of nosocomial sepsis and ventilator-associated pneumonia in mechanically ventilated neonates in the neonatal intensive care unit of Ankara University Hospital. Seventy-nine ventilated newborns were enrolled. Broncho-alveolar lavage culture and blood cultures were positive in 44 (56%) and 17 (22%) patients, respectively. The most predominant micro-organisms in broncho-alveolar lavage cultures were multi-resistant viridans streptococci (29, 66%). Viridans streptococci were also one of the predominant organisms in blood cultures (5/17, 29%). In 29 patients with broncho-alveolar lavage positive for viridans streptococci, nine (31%) had colonisation, 15 (52%) had ventilator-associated pneumonia and five (17%) had sepsis owing to viridans streptococcus. Ventilator-associated pneumonia was encountered in 52/1000 ventilation days. Mortality was caused by infection in three (10%) of them. Mechanically ventilated neonates in our neonatal intensive care unit had a high rate of both multi-resistant viridans streptococcus airway colonisation and subsequent ventilator-associated pneumonia and sepsis.
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Affiliation(s)
- Ayla Günlemez
- Division of Neonatology, Ankara University School of Medicine, Ankara, Turkey.
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Silva LTRD, Laus AM, Canini SRMDS, Hayashida M. Evaluation of prevention and control measures for ventilator-associated pneumonia. Rev Lat Am Enfermagem 2011; 19:1329-36. [DOI: 10.1590/s0104-11692011000600008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 02/24/2011] [Indexed: 11/21/2022] Open
Abstract
This study aimed to evaluate the quality of health care delivered in an Intensive Care Unit, concerning the use of pneumonia prevention and control measures in high-risk patients on mechanical ventilation. In this descriptive and exploratory research, 839 observations of patients under invasive ventilation care were carried out, between November 2009 and January 2010, using the Indicator of Evaluation of Adherence to Prevention and Control Measures in High-risk Patients (IRPR). Some isolated measures that compose the mentioned indicator reached rates close to 100%, but the general compliance rate with all prevention and control measures of ventilator-associated pneumonia was 26.94%. It is concluded that, although the evaluated practices are accomplished at the unit, systematic evaluations of the interventions is needed so as to permit the discussion and practice of other educational strategies by the health team.
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Affiliation(s)
| | - Ana Maria Laus
- Universidade de São Paulo; WHO Collaborating Centre for Nursing Research Development, Brazil
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Yeung KY, Chui YY. An exploration of factors affecting Hong Kong ICU nurses in providing oral care. J Clin Nurs 2011; 19:3063-72. [PMID: 21040012 DOI: 10.1111/j.1365-2702.2010.03344.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM AND OBJECTIVES This paper aims to explore the factors that affect Hong Kong intensive care unit nurses in providing oral care. BACKGROUND The literature shows that evidence-based oral care prevents ventilator-associated pneumonia. Nevertheless, not all intensive care unit nurses provide such care. Although several studies have been undertaken to identify factors that affecting the provision of oral care, none of these studies looked at the situation in Hong Kong. DESIGN An exploratory qualitative design was adopted, with audio-taped interviews. METHODS A convenience sample of 10 registered nurses with 3-14 years of intensive care unit working experience was recruited from the intensive care unit of one regional hospital in Hong Kong. Transcribed interviews were analysed by means of content analysis. RESULTS The participants' descriptions of their oral care practices covered oral health assessment, cleansing the oral cavity and care of the surrounding areas. Findings revealed the following significant factors that influenced intensive care unit nurses in providing oral care: their perceptions of the purpose of oral care; their fears about providing it; the priority of oral care; and inadequate support for oral care. CONCLUSIONS The findings indicate that nurses' oral care practices were not evidence based. Factors that affected the provision of oral care were consistent with those found in previous studies. RELEVANCE TO CLINICAL PRACTICE Study findings indicate that present oral care training should be revised. The findings also highlight the influence of ward culture on nurses' priorities in providing oral care. Appropriate materials, adequate staffing levels and the establishment of an evidence-based oral care protocol may facilitate the provision of oral care in the intensive care unit.
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Affiliation(s)
- Ka Yi Yeung
- Nethersole School of Nursing, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.
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Jones DJ, Munro CL, Grap MJ, Kitten T, Edmond M. Oral care and bacteremia risk in mechanically ventilated adults. Heart Lung 2010; 39:S57-65. [PMID: 20598375 PMCID: PMC2995009 DOI: 10.1016/j.hrtlng.2010.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 04/12/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Transient bacteremia occurs in healthy populations from toothbrushing. With the high incidence of bacteremia in the intensive care unit and toothbrushing as an oral care method, this study examined the incidence and clinical significance of transient bacteremia from toothbrushing in mechanically ventilated adults. METHODS Prospective pre- and post-test with all subjects (N = 30) receiving a toothbrushing intervention twice per day (up to 48 hours). The planned microbial analysis used DNA typing to identify organisms from oral and blood cultures collected immediately before, 1 minute, and 30 minutes after the interventions. RESULTS Seventeen percent of subjects had oral cultures that were positive for selected pathogens before the first toothbrushing intervention. None of the subjects had evidence of transient bacteremia by positive quantitative blood cultures before or after the toothbrushing interventions. Patient characteristics were not statistically significant predictors for systemic inflammatory response syndrome, length of hospital stay, or length of intubation. CONCLUSION The toothbrushing intervention did not induce transient bacteremia in this patient population.
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Affiliation(s)
- Deborah J Jones
- University of Texas Health Science Center at Houston School of Nursing, Houston, Texas 77030, USA.
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Sole ML. How I learned my ABCs: Action, back to basics, collaboration, discovery. Am J Crit Care 2010; 19:326-34. [PMID: 20595214 DOI: 10.4037/ajcc2010402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Research is essential to generate the scientific evidence for critical care nursing practice, but it is challenging to conduct research in the busy critical care environment. The challenges are even greater in a setting with limited resources for research and where nurses have not typically conducted independent clinical studies. OBJECTIVES To detail a successful research trajectory for studying the ABCs of patient care in the critically ill: airway, breathing, and circulation. METHODS After initial studies on circulation were conducted, the research was narrowed to focus on airway management. Airway management may be a key factor in preventing ventilator-associated pneumonia because aspiration of colonized oral, gastric, and tracheal secretions is the primary cause of ventilator-associated pneumonia. Multiple descriptive, pilot, and interventional studies have been conducted; findings from each have contributed to future studies. RESULTS Other ABCs were critical to this research success: action, back to basics, collaboration, and discovery. It is important for researchers to be self-motivated and to take initiative to develop skills and resources for conducting clinical studies. Several guiding principles help to promote success in research: (1) generate research ideas grounded in observation and clinical practice, (2) collaborate with others, and (3) establish affiliations and partnerships. Discovery occurs in many ways: new findings to guide practice and research, resources to conduct the study, and self-discovery. CONCLUSIONS Nursing research is not easy. However, determination and resources help nursing researchers achieve success.
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Affiliation(s)
- Mary Lou Sole
- Mary Lou Sole is a professor in the School of Nursing at the University of Central Florida in Orlando
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A Survey of Physiotherapists' Current Practice with Closed Suction Systems in Adult Patients. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/14038190120851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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O'Keefe-McCarthy S, Santiago C, Lau G. Ventilator-Associated Pneumonia Bundled Strategies: An Evidence-Based Practice. Worldviews Evid Based Nurs 2008; 5:193-204. [DOI: 10.1111/j.1741-6787.2008.00140.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Nursing Staff Perceptions of Methicillin-Resistant Staphylococcus aureus and Infection Control in a Long-Term Care Facility. J Am Med Dir Assoc 2008; 9:342-6. [DOI: 10.1016/j.jamda.2008.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 02/06/2008] [Accepted: 02/06/2008] [Indexed: 11/19/2022]
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Oral care and the risk of bloodstream infections in mechanically ventilated adults: A review. Intensive Crit Care Nurs 2008; 24:152-61. [PMID: 18403205 DOI: 10.1016/j.iccn.2008.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 01/29/2008] [Accepted: 01/31/2008] [Indexed: 12/20/2022]
Abstract
RATIONALE Bacteraemia, defined as the presence of viable bacteria in the circulating blood can result in bloodstream infection, which is one of the most frequent and challenging hospital-acquired infections. Bacteraemia occurs in healthy populations with manipulation of the oral mucosa, including toothbrushing. Oral care is commonly administered to mechanically ventilated patients, it is important to determine whether this practice contributes to the incidence of bacteraemia. This paper reviews the literature on the link between the manipulation of the oral cavity and the development of bacteraemia in mechanically ventilated adults. METHODS Searches were conducted using Medline, CINAHL, and the Cochrane Library databases. Article inclusion criteria were (1) a focus on mechanical ventilation and critical illness, (2) human subjects, (3) adult subjects, and (4) publication in English (or available English translation). RESULTS Nine articles met inclusion criteria and were critiqued. All relied upon clinical data as outcome measures; many were retrospective. The three organisms most often associated with nosocomial bloodstream infections were Staphylococcus aureus, coagulase negative staphylococci, and Enterococcus species. Establishing the origin of bacteraemia was problematic in most studies. CONCLUSIONS Additional research is needed to understand the relationship of oral care practices to bacteraemia in mechanically ventilated adults.
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Cason CL, Tyner T, Saunders S, Broome L. Nurses’ Implementation of Guidelines for Ventilator-Associated Pneumonia From the Centers for Disease Control and Prevention. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.1.28] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Ventilator-associated pneumonia accounts for 47% of infections in patients in intensive care units. Adherence to the best nursing practices recommended in the 2003 guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention should reduce the risk of ventilator-associated pneumonia.
• Objective To evaluate the extent to which nurses working in intensive care units implement best practices when managing adult patients receiving mechanical ventilation.
• Methods Nurses attending education seminars in the United States completed a 29-item questionnaire about the type and frequency of care provided.
• Results Twelve hundred nurses completed the questionnaire. Most (82%) reported compliance with hand-washing guidelines, 75% reported wearing gloves, half reported elevating the head of the bed, a third reported performing subglottic suctioning, and half reported having an oral care protocol in their hospital. Nurses in hospitals with an oral care protocol reported better compliance with hand washing and maintaining head-of-bed elevation, were more likely to regularly provide oral care, and were more familiar with rates of ventilator-associated pneumonia and the organisms involved than were nurses working in hospitals without such protocols.
• Conclusions The guidelines for the prevention of ventilator-associated pneumonia from the Centers for Disease Control and Prevention are not consistently or uniformly implemented. Practices of nurses employed in hospitals with oral care protocols are more often congruent with the guidelines than are practices of nurses employed in hospitals without such protocols. Significant reductions in rates of ventilator-associated pneumonia may be achieved by broader implementation of oral care protocols.
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Affiliation(s)
- Carolyn L. Cason
- The School of Nursing, University of Texas at Arlington (clc), Parkland Memorial Hospital, Dallas, Tex (tt), RHD Memorial Hospital, Dallas, Tex (ss), and Baylor Regional Hospital, Plano, Tex (lb)
| | - Tracy Tyner
- The School of Nursing, University of Texas at Arlington (clc), Parkland Memorial Hospital, Dallas, Tex (tt), RHD Memorial Hospital, Dallas, Tex (ss), and Baylor Regional Hospital, Plano, Tex (lb)
| | - Sue Saunders
- The School of Nursing, University of Texas at Arlington (clc), Parkland Memorial Hospital, Dallas, Tex (tt), RHD Memorial Hospital, Dallas, Tex (ss), and Baylor Regional Hospital, Plano, Tex (lb)
| | - Lisa Broome
- The School of Nursing, University of Texas at Arlington (clc), Parkland Memorial Hospital, Dallas, Tex (tt), RHD Memorial Hospital, Dallas, Tex (ss), and Baylor Regional Hospital, Plano, Tex (lb)
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Ho RP, Boyle M. Non-invasive positive pressure ventilation in acute respiratory failure: providing competent care. Aust Crit Care 2006; 13:135-7, 139-43. [PMID: 16948204 DOI: 10.1016/s1036-7314(00)70641-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Non-invasive positive pressure ventilation (NPPV) has been used as an alternative strategy to provide ventilatory support for patients with acute respiratory failure. Most studies demonstrate that the use of NPPV in acute respiratory failure results in a reduction in the need for endotracheal intubation and an overall survival advantage. However, current evidence, in the form of randomised controlled trials, suggests that these benefits may be restricted to patients suffering from acute exacerbation of chronic obstructive pulmonary disease (COPD). The clinical application of NPPV involves the development of competence in delivering the particular intervention. Clinical outcomes and thus valid comparisons with alternate methods of ventilatory support can only be made if attention is paid to the clinical indications for the application of NPPV and patient subgroups it is used to treat and the level of competence of care givers in its application and delivery. One essential element of competence is the establishment of an appropriate knowledge base and the development of clinical practice guidelines. This literature review identifies the current indications for NPPV and the relevant information for developing clinical practice guidelines for the management of this form of ventilatory support.
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Affiliation(s)
- R P Ho
- Concord Repatriation General Hospital, Sydney
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Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Care Nurs 2004; 20:69-76. [PMID: 15072774 DOI: 10.1016/j.iccn.2004.01.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intensive care unit (ICU) patients have complex oral care needs. Inadequate oral care may predispose ICU patients to nosocomial infections. Recent initiatives have sought to improve the quality and evidence base of ICU oral care provision. OBJECTIVES To describe the current priority given to oral care, the knowledge and practice of oral needs assessment and oral care methods, and adherence to the local ICU oral care protocol of ICU nurses working in one hospital. METHOD Self-administered questionnaire survey of all nurses working in adult ICU ( n = 160 ). RESULTS Replies were received from 103 (response rate 64.5%). On average, oral care was given a similar priority to other aspects of personal care. 13.5% nurses rated oral care as a low priority. Whilst 98% nurses routinely performed an oral needs assessment, only 26% used a written assessment tool. Toothbrushes were used at least once a day by 85.5% nurses and chlorhexidine products were routinely used by 50.5% nurses. The oral care practices of most nurses matched the local ICU protocol. 23.5% nurses had received no training in oral care and 58% nurses requested initial/further training. CONCLUSIONS Most oral care methods were appropriate, based on the available evidence. A small minority of nurses gave oral care a low priority and were not using evidence-based oral care methods recommended in the local ICU protocol. Encouraging the general use of oral needs assessment tools is a priority, and further oral care training is required.
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Affiliation(s)
- H Jones
- Department of Oral Health Services Research & Dental Public Health, GKT Dental Institute, Caldecot Road, London SE5 9RW, UK
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15
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Abstract
Oral health is influenced by oral microbial flora, which are concentrated in dental plaque. Dental plaque provides a microhabitat for organisms and an opportunity for adherence of the organisms to either the tooth surface or other microorganisms. In critically ill patients, potential pathogens can be cultured from the oral cavity. These microorganisms in the mouth can translocate and colonize the lung, resulting in ventilator-associated pneumonia. The importance of oral care in the intensive care unit has been noted in the literature, but little research is available on mechanical or pharmacological approaches to reducing oral microbial flora via oral care in critically ill adults. Most research in oral care has been directed toward patients’ comfort; the microbiological and physiological effects of tooth brushing in the intensive care unit have not been reported. Although 2 studies indicated reductions in rates of ventilator-associated pneumonia in cardiac surgery patients who received chlorhexidine before intubation and postoperatively, the effects of chlorhexidine in reducing ventilator-associated pneumonia in other populations of critically ill patients or its effect when treatment with the agent initiated after intubation have not been reported. In addition, no evaluation of the effectiveness of pharmacological and mechanical interventions relative to each other or in combination has been published. Additional studies are needed to develop and test best practices for oral care in critically ill patients.
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Affiliation(s)
- Cindy L. Munro
- School of Nursing, Virginia Commonwealth University, Richmond, Va
| | - Mary Jo Grap
- School of Nursing, Virginia Commonwealth University, Richmond, Va
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16
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Abstract
Closed suction catheters (CSC) for removal of bronchial secretions in intubated patients have been used in intensive care units (ICU) for many years. Manufacturers still recommend daily changes of the catheter in order to reduce the incidence of ventilator associated pneumonia (VAP). There is, however, a lack of clinical evidence to support this recommendation. The objective of this study was therefore to compare the incidence of VAP in patients who receive either 24 hourly or 48 hourly changes of the CSC. Eligible patients were randomised to one of the two groups to receive either a 24 hourly change (n = 53) or a 48 hourly change (n = 48) of the CSC. Sputum specimens were sent second daily for quantitative culture. Chest x-rays (CXR) and white blood cell counts were attended daily. A VAP was diagnosed according to previously established criteria. A second set of modified criteria were also used to conduct a further analysis of the results. Of the 158 patients randomised, 101 completed the study. These patients had a mean age of 65 years and a mean APACHE II score of 28.2 in the first 24 hours of the study. The average duration in the trial was 10 days. The two groups were comparable in terms of demographic features. There were no reported cases of VAP in either group using the criteria originally selected in the study design. Using a modified criteria to diagnose VAP there were 10 (19%) patients with VAP in the 24 hour group and 13 (27%) in the 48 hour group. The incidence of VAP between the two groups was not statistically different (p = 0.35). To conclude, there was no difference in the incidence of VAP between the two groups studied. Based on previous studies conducted by Quirke and Kollef and the experience of our study we have changed our clinical practice to a 48 hour change of the CSC. We would, however, suggest further study or a meta-analysis of the available literature before a recommendation is made.
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Affiliation(s)
- Jenny A Darvas
- Intensive Care Unit, Hornsby Ku-ring-gai Hospital, Sydney, NSW
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18
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Grap MJ, Blecha T, Munro C. A description of patients' report of endotracheal tube discomfort. Intensive Crit Care Nurs 2002; 18:244-9. [PMID: 12470014 DOI: 10.1016/s0964339702000654] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this descriptive study was to describe the type, location, and amount of endotracheal tube (ETT) discomfort. Twenty-two subjects (mean age 49.2 years) who had experienced ETT intubation for at least 6 hours (mean: 25.9 hours) after cardiac surgery, completed a 100-mm Visual Analogue Scale related to their experience with the endotracheal tube within 24 hours after extubation. A semi-structured interview was also conducted. There was no relationship between the duration of intubation and the level of discomfort described (r = -0.24; P = 0.29) or between the duration of intubation and whether medications relieved the discomfort (r = 0.34; P = 17). All subjects described some level of discomfort. The majority stated the discomfort was in the throat area. However, 27% (n = 6) described the discomfort as located in the chest. There was no difference in the level of discomfort based on discomfort location (f = -0.14; P = 0.71). The discomfort locations support the notion that ETT irritation occurs at multiple levels (i.e. pharyngeal, laryngeal, and tracheal mucosal areas). In addition, interventions that focus on ETT stability will not be sufficient to reduce discomfort but must re-focus nursing attention on reducing ETT movement as well as the movement of all ventilator tubing.
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Sole ML, Poalillo FE, Byers JF, Ludy JE. Bacterial Growth in Secretions and on Suctioning Equipment of Orally Intubated Patients: A Pilot Study. Am J Crit Care 2002. [DOI: 10.4037/ajcc2002.11.2.141] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Contamination of equipment, colonization of the oropharynx, and microaspiration of secretions are causative factors for ventilator-associated pneumonia. Suctioning and airway management practices may influence the development of ventilator-associated pneumonia.
• Objectives To identify pathogens associated with ventilator-associated pneumonia in oral and endotracheal aspirates and to evaluate bacterial growth on oral and endotracheal suctioning equipment.
• Methods Specimens were collected from 20 subjects who were orally intubated for at least 24 hours and required mechanical ventilation. At baseline, oral and sputum specimens were obtained for culturing, and suctioning equipment was changed. Specimens from the mouth, sputum, and equipment for culturing were obtained at 24 hours (n = 18) and 48 hours (n = 10).
• Results After 24 hours, all subjects had potential pathogens in the mouth, and 67% had sputum cultures positive for pathogens. Suctioning devices were colonized with many of the same pathogens that were present in the mouth. Nearly all (94%) of tonsil suction devices were colonized within 24 hours. Most potential pathogens were gram-positive bacteria. Gram-negative bacteria and antibiotic-resistant organisms were also present in several samples.
• Conclusions The presence of pathogens in oral and sputum specimens in most patients supports the notion that microaspiration of secretions occurs. Colonization is a risk factor for ventilator-associated pneumonia. The equipment used for oral and endotracheal suctioning becomes colonized with potential pathogens within 24 hours. It is not known if reusable oral suction equipment contributes to colonization; however, because many bacteria are exogenous to patients’ normal flora, equipment may be a source of cross-contamination.
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Affiliation(s)
- Mary Lou Sole
- School of Nursing (MLS, FEP, JFB) and Cardiopulmonary Sciences (JEL), University of Central Florida, Orlando, Fla
| | - F. Elizabeth Poalillo
- School of Nursing (MLS, FEP, JFB) and Cardiopulmonary Sciences (JEL), University of Central Florida, Orlando, Fla
| | - Jacqueline F. Byers
- School of Nursing (MLS, FEP, JFB) and Cardiopulmonary Sciences (JEL), University of Central Florida, Orlando, Fla
| | - Jeffery E. Ludy
- School of Nursing (MLS, FEP, JFB) and Cardiopulmonary Sciences (JEL), University of Central Florida, Orlando, Fla
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O'Neal PV, Brown N, Munro C. Physiologic factors contributing to a transition in oral immunity among mechanically ventilated adults. Biol Res Nurs 2002; 3:132-9. [PMID: 12003441 DOI: 10.1177/1099800402003003003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ventilator-associated pneumonia (VAP), a specific type of nosocomial pneumonia, occurs in approximately 21% of patients in intensive care, and the mortality can be as high as 71%. VAP causes considerable mortality and morbidity, and it exponentially increases health care costs. The incidence of VAP is associated with oropharyngeal colonization of gram-negative bacteria. Within 48 h of hospital admission, the composition of the oropharyngeal flora of critically ill patients undergoes a change from the usual gram-positive streptococci and dental pathogens to a predominant gram-negative flora that includes more virulent organisms, which predispose patients to VAP. Identification and understanding of this oral transition from gram-positive to predominantly gram-negative flora may assist health care professionals in differentiating among oral immune markers that suggest compromised immunity. The purpose of this article is to provide a review of the literature that promotes an understanding of current knowledge about the transition of oral immunity in mechanically ventilated patients.
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Affiliation(s)
- Pamela V O'Neal
- Gordon College, University System of Georgia, Barnesville 30204, USA.
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Ellstrom KE. Breathing Easier in the Intensive Care Unit. Crit Care Nurs Clin North Am 1999. [DOI: 10.1016/s0899-5885(18)30133-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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