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Bundle de prevenção da pneumonia associada à ventilação mecânica: uma construção coletiva
| Content Provider | Scilit |
|---|---|
| Author | Silva, Sabrina Guterres Da Nascimento, Eliane Regina Pereira Do Salles, Raquel Kuerten De |
| Copyright Year | 2012 |
| Abstract | This article reports on a qualitative convergent care research, which was aimed at the collective construction of a bundle to prevent ventilator-associated pneumonia by nursing and physiotherapy professionals at the intensive care unit of a public teaching hospital in Santa Catarina. The data collection occurred from May to December 2011 and included individual interviews and discussion groups, with the participation of 25 and 14 professionals, respectively. For the data analysis, Morse and Field's reference framework was adopted. The construction of the bundle was guided by the evidence-based practice criteria and consists of four preventive care acts: oral hygiene with 0.12% chlorhexidine; headboard elevated (30-45º); endotracheal cuff pressure between 20-30 cmH2O; and care with the aspiration of tracheal secretions. The implementation of these recommendations can support healthcare practice, contributing to reduce ventilator-associated pneumonia rates. Descriptors: Intensive care units. Ventilator-associated pneumonia. Nursing care. Nursing assessment. RESUMEN Se trata de un estudio cualitativo de tipo convergente asistencial, que tuvo por objetivo construir colectivamente un bundle para evitar la neumonía asociada a ventilación mecánica por profesionales de enfermería y fisioterapia en la unidad de cuidados intensivos de un hospital público de enseñanza en Santa Catarina. La recolección de datos tuvo lugar entre mayo y diciembre de 2011 por medio de entrevistas individuales y grupos de discusión, que incluyeron la participación de 25 y 14 profesionales respectivamente. Para el análisis de los datos se utilizó el referencial de Morse y Field. La construcción del bundle se guió por los criterios de Práctica Basada en la Evidencia y compuesto por cuatro cuidados preventivos: higiene oral con clorexidina 0,12%, alta cabecera (30-45º); presión del cuff endotraqueal entre 20-30 cm H2O; y el cuidado con la aspiración de secreciones traqueales. Se cree que la aplicación de estas recomendaciones puede ayudar a la práctica asistencial, contribuyendo a la reducción de las tasas del neumonía asociada a ventilación mecánica. Descriptores: Unidades de cuidados intensivos. Neumonía asociada a ventilación mecánica. Cuidados de enfermería. Evaluación de enfermería. INTRODUCTION Ventilator-Associated Pneumonia (VAP) is an infectious process of the pulmonary parenchyma that affects patients submitted to endotracheal intubation and Mechanical Ventilation (MV) for more than 48-72h and for whom infection was not the reason to start the ventilation. 1-3 Considered as the most recurrent Healthcare Related Infection (HCRI) at Intensive Care Units (ICUs), VAP plays a considerable role in morbidity and mortality rates and entails potential health damage for individuals affected by this complication. In addition, its occurrence leads to a significant increase in hospitalization times and care costs for health institutions. 4 Risk factors for VAP are diverse and "can vary depending on the hospital, type of ICU and study population". 5:39 This indicates the need for continuing local surveillance and specific conducts to prevent and control these adverse events. A strategy that has been adopted successfully to prevent VAP is the creation of protocols in ICUs, applied in a multidisciplinary form and audited by Hospital Infection Control Services. 3 Applying protocols in care practice represents a challenge though. Studies suggest that these should be dynamic and put in practice together with the health team, so that all stakeholders are motivated, permitting the continuous assessment of care delivery and the creation of clear therapeutic measures. 6-8 Nowadays, Care Bundles have been frequently used, which join a small group of interventions that, when implemented jointly, result in substantial healthcare improvements. 2 Differently from conventional protocols, in care bundles, not all possible therapeutic strategies need to be included, as this model does not serve as a comprehensive reference framework of the available therapeutic arsenal, but as a small and simple set of evidence-based practices that, when executed jointly, improve the outcomes for the patients. The choice of what interventions to include in a bundle should consider cost, ease of implementation and adherence to these measures. The bundle approach is aimed at the joint execution of all elements in an "all or nothing" strategy. With a view to a successful implementation, there cannot be any "more or less", there is not partial credit for doing some of the steps. Results are only effective if all care actions are accomplished at all times. 2 In this perspective, with a view to effective actions for the control and reduction of these HCRI, we sought an answer to the following question: what care do nursing and physiotherapy professionals consider relevant for inclusion in a bundle to prevent ventilator-associated pneumonia? To answer this inquiry, the collective construction, with nursing and physiotherapy professionals, of a prevention bundle for ventilator-associated pneumonia was set as the study objective, with a view to promoting care that is based on the safety and quality of healthcare delivery to patients under artificial ventilation. METHOD A qualitative Convergent-Care Research (CCR) was undertaken, whose main characteristics are: subjects' active participation, intentional solution and/or minimization of problems and introduction of innovations in care practice. 9 The research was developed at the general ICU of a public hospital in Santa Catarina and involved 25 health professionals, 21 from the nursing team and four from the physiotherapy team. The nursing and physiotherapy staff at the ICU under study consists of 82 professionals, including 17 nurses, 59 nursing technicians and six physiotherapists. The research universe comprised all professionals who agreed to participate in the research in advance and complied with the following inclusion criteria: being a nursing or physiotherapy professional, working at the sector for at least six months, authorizing the use of a recorder and permitting the dissemination of results, with the preservation of anonymity. To determine the end of data collection, the information saturation principle was used. All participants signed the Informed Consent Form. The research received approval from the Ethics Committee for Research Involving Human Beings at Universidade Federal de Santa Catarina (Process 1922/11), in compliance with the recommendations of National Health Council Resolution 196/96. 10 Data were collected between May and December 2011 in two phases. The first included semistructured individual interviews, held in a private room at the ICU. To guarantee reliability, the information was registered on a micro-recorder, with the interviewees' consent, and then fully transcribed. The second phase involved discussion groups. All professionals who participated in the interviews were invited to the meetings. Three groups were organized, each including different members, based on the participants' preferred times and availability. The mean duration of each group meeting was 60 minutes. To analyze and interpret the data, the reference framework by Morse and Field 11 was adopted, suggested by the authors of the CCR method, 9 which consists of four phases: apprehension, synthesis, theorization and recontextualization. The apprehension phase included information collection and organization, based on the careful reading of each interview, with a view to getting familiar with what the participants expressed. The synthesis phase involves the study of the collected information, analyzing associations and variations. Seventeen care actions to prevent VAP emerged from this phase, which were grouped in five categories, and then analyzed in the light of Evidence-Based Practice (EBP), which corresponded to the initial phase of theorization. In EBP, evidence levels are organized according to classification system, which in general "are characterized hierarchically, depending on the research design". 12:5 Most classifications are designed in few items, about three or four. In this study, the classification of the American Thoracic Society 4 was adopted, which organizes evidence levels into: level I (high): well-conducted evidence, randomized clinical trials; level II (moderate): well-conceived evidence, controlled trials without randomization (including cohort, patient series and case-control studies). This level also includes any large sample in which systematical analysis and reports on new therapies were not collected in a randomized manner; and level III (low): evidence from case studies and expert opinions. After ranking the care actions' evidence levels, this were taken to group discussions to socialize the results obtained in the interviews and jointly selecting the care actions for inclusion in the VAP prevention bundles, taking into account the professionals' opinions, care-related evidence and the feasibility of applying these practices in the care context. The final VAP prevention bundles, which comprised the final phase of theorization, resulted from the combination of the care actions chosen by the professionals who participated in the three group meetings. During the meetings that followed on the first group, participants received no information on what care actions the preceding group had selected, so as to avoid bias and/or induced answers, thus permitting the authenticity of each group. RESULTS AND DISCUSSION In the first research phase, which involved individual interviews, 25 professionals participated, eight of whom were nurses, 13 nursing technicians and four physiotherapists. Nineteen of the participants were women. Fourteen professionals participated in the group meetings, 13 of whom were women. The first group included six members (two nurses, one physiotherapist and three nursing technicians), the secon |
| Related Links | http://www.scielo.br/pdf/tce/v21n4/en_14.pdf http://www.scielo.br/scielo.php?script=sci_pdf&pid=S0104-07072012000400014&lng=pt&nrm=iso&tlng=en |
| Ending Page | 844 |
| Page Count | 8 |
| Starting Page | 837 |
| ISSN | 01040707 |
| e-ISSN | 01040707 |
| DOI | 10.1590/s0104-07072012000400014 |
| Journal | Texto & Contexto - Enfermagem |
| Issue Number | 4 |
| Volume Number | 21 |
| Language | English |
| Publisher | FapUNIFESP (SciELO) |
| Publisher Date | 2012-12-01 |
| Access Restriction | Open |
| Subject Keyword | Enfermagem |
| Content Type | Text |
| Resource Type | Article |
| Subject | Advanced and Specialized Nursing |
