Physicians' and nurses' opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey

Contains fulltext : 89741.pdf (publisher's version ) (Open Access)INTRODUCTION: Use of selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) in intensive care patients has been controversial for years. Through regular questionnaires we determined expectations concerning SDD (effectiveness) and experience with SDD and SOD (workload and patient friendliness), as perceived by nurses and physicians. METHODS: A survey was embedded in a group-randomized, controlled, cross-over multicenter study in the Netherlands in which, during three 6-month periods, SDD, SOD or standard care was used in random order. At the end of each study period, all nurses and physicians from participating intensive care units received study questionnaires. RESULTS: In all, 1024 (71%) of 1450 questionnaires were returned by nurses and 253 (82%) of 307 by physicians. Expectations that SDD improved patient outcome increased from 71% and 77% of respondents after the first two study periods to 82% at the end of the study (P = 0.004), with comparable trends among nurses and physicians. Nurses considered SDD to impose a higher workload (median 5.0, on a scale from 1 (low) to 10 (high)) than SOD (median 4.0) and standard care (median 2.0). Both SDD and SOD were considered less patient friendly than standard care (medians 4.0, 4.0 and 6.0, respectively). According to physicians, SDD had a higher workload (median 5.5) than SOD (median 5.0), which in turn was higher than standard care (median 2.5). Furthermore, physicians graded patient friendliness of standard care (median 8.0) higher than that of SDD and SOD (both median 6.0). CONCLUSIONS: Although perceived effectiveness of SDD increased as the trial proceeded, both among physicians and nurses, SOD and SDD were, as compared to standard care, considered to increase workload and to reduce patient friendliness. Therefore, education about the importance of oral care and on the effects of SDD and SOD on patient outcomes will be important when implementing these strategies. TRIAL REGISTRATION: ISRCTN35176830

Airway management and respiratory tract colonization in intensive care patients

Background The majority of patients admitted to Intensive Care Units (ICUs) require an artificial airway and mechanical ventilation (MV). An important aspect of airway management in these patients is to remove secretions by endotracheal suctioning. Multiple use closed suction systems (CSS) are increasingly replacing single-use open suction system (OSS) to perform this invasive procedure. However, recommendations for the routine use of CSS remained controversial because of inconclusive study results. Objective The objective was to determine effectiveness of closed and open suction systems with respect to (1) reducing the incidence of cross-transmission and acquisition with Gram-negative bacteria in intensive care units, (2) reducing changes in cardiorespiratory variables, and (3) costs. Furthermore, based upon the microbiological results in this study, we determined (4) risk factors for acquiring respiratory tract colonization with Gram-negative bacteria, (5) acquisition of antibiotic resistance, and (5) the population structure of P. aeruginosa isolated from intensive care patients as compared with isolates from cystic fibrosis patients. Results In a prospective crossover design with fixed periods in which either of both systems was used for all patients in the intensive care unit, 37% of the patients acquired respiratory tract colonization with at least one of the selected Gram-negative bacteria in each of the study periods. Overall acquisition rates were 35.5 and 32.5 per 1000 patient days at risk during CSS and OSS, respectively. Cross-transmission rates with Pseudomonas aeruginosa, Acinetobacter species and Enterobacter species were low: 5.7 and 4.5 per 1000 patient days at risk with any of these pathogens during CSS and OSS, respectively. The physiological consequences of CSS and OSS were investigated in an observational study nested within the crossover trial. Changes in heart rate and mean arterial pressure appeared minor and were comparable when using either CSS or OSS. Only changes in peripheral oxygen saturation appeared higher after using OSS as compared to CSS, but differences were very small (98.2% and 97.5%) and therefore clinically not relevant. In the UMC Utrecht, the price of using OSS was € 5 and of CSS €11,20 per patient per day (price level the Netherlands, 2009), and using OSS instead of CSS would save over €60,000 per year. Conclusion Based upon the results, both CSS and OSS can be considered equally safe in mechanically ventilated ICU patients. We could not demonstrate a difference in overall cross transmission, nor in overall acquisition of respiratory tract colonization. Furthermore, no clinically relevant differences in cardiorespiratory variables were found. The implications of the results for clinical practice are rather straightforward: the choice of the ES system to be used can be based on costs and personal preference

Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: a qualitative interview study.

Objective To explore whether nurses in hospital settings experience moral distress when involved in potentially life-prolonging treatments in adults with a short life expectancy. Methods A qualitative study using semi-structured interviews. Results 23 Registered nurses working in inpatient or outpatient hospital settings participated. The nurses stated they were often not involved in decisions regarding life-prolonging treatments. They reported signs of moral distress such as feeling powerless when they when they were not being listened to in the decision-making process and when confronted with negative treatment outcomes. Nurses felt frustrated when their own values were not reflected in the decision-making or when physicians created unrealistic expectations. Conclusions Hospital nurses experience moral distress when they are involved in life-prolonging treatment because of the patient’s advanced condition and their own lack of involvement in the decision-making process about the treatment. In these situations, moral distress is characterised by feelings of powerlessness and frustration. Practice implications Nurses need to be empowered by training programmes that focus on an active role in the decision-making process. Further research is needed to evaluate effective tools and training programmes that help nurses in shared decision-making processes

Interruptions during intravenous medication administration: a multicenter observational study.

Aims: To determine the frequency and cause of interruptions during intravenous medication administration, which factors are associated with interruptions and to what extent interruptions influence protocol compliance. Background: Hospital nurses are frequently interrupted during medication administration, which contributes to the occurrence of administration errors. Errors with intravenous medication are especially worrisome, given their immediate therapeutic effects. However, knowledge about the extent and type of interruptions during intravenous medication administration is limited. Design: Multicenter observational study. Methods: Data were collected during two national evaluation studies (2011/2012 and 2015/2016). Nurses were directly observed during intravenous medication administration. An interruption was defined as a situation where a break during the administration was needed or where a nurse was distracted but could process without a break. Interruptions were categorized according to source and cause. Multilevel logistic regression analyses were conducted to assess the associations between explanatory variables and interruptions or complete protocol compliance. Results: In total, 2526 intravenous medication administration processes were observed. During 291 (12%) observations, nurses were interrupted 321 times. Most interruptions were externally initiated by other nurses (19%) or patients (19%). Less interruptions occurred during the evening (Odds Ratio: 0.23, (95%‐Confidence Interval: 0.08‐0.62). Do‐not‐disturb vests were worn by 61 (2%) nurses. No significant association was found between being interrupted and complete protocol compliance. Conclusion: An interruption occurred in every eight observed intravenous medication administration, mainly caused by other nurses or patients. One needs to critically consider which strategies effectively improve safety during the high‐risk nursing‐task of intravenous medication administration

Feasibility and effectiveness of tools that support communication and decision making in life-prolonging treatments for patients in hospital: a systematic review.

Objective Patients with advanced diseases and frail older adults often face decisions regarding life-prolonging treatment. Our aim was to provide an overview of the feasibility and effectiveness of tools that support communication between healthcare professionals and patients regarding decisions on life-prolonging treatments in hospital settings. Design Systematic review: We searched PubMed, CINAHL, PsycINFO, Embase, Cochrane Library and Google Scholar (2009–2019) to identify studies that reported feasibility or effectiveness of tools that support communication about life-prolonging treatments in adult patients with advanced diseases or frail older adults in hospital settings. The Mixed Methods Appraisal Tool was used for quality appraisal of the included studies. Results Seven studies were included, all involving patients with advanced cancer. The overall methodological quality of the included studies was moderate to high. Five studies described question prompt lists (QPLs), either as a stand-alone tool or as part of a multifaceted programme; two studies described decision aids (DAs). All QPLs and one DA were considered feasible by both patients with advanced cancer and healthcare professionals. Two studies reported on the effectiveness of QPL use, revealing a decrease in patient anxiety and an increase in cues for discussing end-of-life care with physicians. The effectiveness of one DA was reported; it led to more understanding of the treatment in patients. Conclusions Use of QPLs or DAs, as a single intervention or part of a programme, may help in communicating about treatment options with patients, which is an important precondition for making informed decisions

Self-Management support in patients with incurable cancer: how confident are nurses?

Objectives: To explore how nurses perceive their self-efficacy and performance in supporting self-management among patients with incurable cancer, and whether these perceptions differ between community and hospital nurses. Sample & setting: 222 hospital nurses (n = 94) and community nurses (n = 128) working with adult patients with incurable cancer. Methods & variables: An online survey included the Self-Efficacy and Performance Into Self-Management Support instrument. Possible differences in age, gender, work setting, and additional training in oncology between groups were explored. Results: Nurses felt confident about their self-efficacy, particularly in assessing patients’ knowledge and beliefs and in advising about their disease and health status. Nurses felt less confident in their performance, particularly in the use of technology (arranging follow-up care), but also in agreeing on collaborative goals and assisting patients in achieving these goals. Compared to hospital nurses, community nurses reported significantly higher scores on self-efficacy and performance. Implications for nursing: More effort is needed to increase nurses’ confidence in providing self-management support, with a focus on arranging follow-up care with the use of technology and on collaborating with patients in setting and achieving goals