ABSTRACT
BACKGROUND: Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations. OBJECTIVE: To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support. METHODS: In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023. RESULTS: Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care. CONCLUSION: The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.
Subject(s)
Chlorhexidine , Respiration, Artificial , Chlorhexidine/analogs & derivatives , Chlorhexidine/therapeutic use , Chlorhexidine/adverse effects , Chlorhexidine/administration & dosage , Humans , Male , Female , Anti-Infective Agents, Local/therapeutic use , Anti-Infective Agents, Local/administration & dosage , Adult , Middle Aged , Aged , Critical Care Nursing/standards , Oral Hygiene/methods , Oral Hygiene/nursing , Intensive Care Units , Aged, 80 and over , Mouthwashes/therapeutic use , Administration, OralABSTRACT
BACKGROUND: Evidence-based practice (EBP) is a major concept threaded throughout nursing education, yet competencies are not clearly identified in The Essentials. PURPOSE: Nurse leaders' EBP competency expectations for professional practice were explored to inform competency-based education for students and practicing nurses. A secondary aim explored potential effects of misinformation on EBP. METHODS: Descriptive qualitative inquiry was performed with a focus group of 6 clinical nurse leaders. RESULTS: EBP expectations were identified, discriminating between novice entry level and advanced-level nurses. Participants emphasized asking questions, linking evidence to practice, and acknowledging that evidence changes over time. All advanced-level nurses were expected to apply, lead, and teach EBP. Post pandemic, nurses need to reclaim evidence-based practices, critically appraise evidence, and educate patients and families to address misinformation. CONCLUSIONS: Information learned will inform competency-based EBP education for students and nurses in academic and clinical settings.
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AIMS: This article explored the publication impact of evidence-based healthcare terminology to determine usage and discuss options for low usage terms. BACKGROUND: A plethora of terms describe the scholarship of evidence-based healthcare. Several terms are synonyms, creating redundancy and confusion. The abundance and overlap of terms may impede the discovery of evidence. DESIGN: This discursive article explored and discussed publication impact of evidence-based healthcare terms. METHODS: Evidence-based healthcare terms were identified, and their 10-year (2013-2022) publication impact was assessed in the CINAHL and Medline databases. A card sort method was also used to identify terms with low usage. RESULTS: A total of 18/32 terms were included in the review. The terms evidence-based practice, quality improvement, research and translational research were the most highly published terms. Publication data were presented yearly over a 10-year period. Most terms increased in publication use over time, except for three terms whose use decreased. Several terms related to translational research have multiple synonyms. It remains unknown whether these terms are interchangeable and possibly redundant, or if there are nuanced differences between terms. CONCLUSION: We suggest a follow-up review in 3-5 years to identify publication trends to assess context and terms with continued low publication usage. Terms with persistent low usage should be considered for retirement in the reporting of scholarly activities. Additionally, terms with increasing publication trends should be treated as emerging terms that contribute to evidence-based healthcare terminology. IMPLICATIONS FOR NURSING: Confusion about the use of appropriate terminology may hinder progress in the scholarship of evidence-based healthcare. We encourage scholars to be aware of publication impact as it relates to the use of specific terminology and be purposeful in the selection of terms used in scholarly projects and publications.
Subject(s)
Terminology as Topic , Humans , Evidence-Based Practice , Publishing/trends , Publishing/statistics & numerical dataABSTRACT
INTRODUCTION: Non-ventilator-associated hospital-acquired pneumonia is a preventable health care-associated infection accounting for 1 in 14 hospital deaths. Clinical factors influencing this condition include oral health and bacteria and oral care. This case report addresses diagnostics and clinical variables related to non-ventilator-associated hospital-acquired pneumonia and emphasizes the importance of prevention. CLINICAL FINDINGS: A 90-year-old woman was admitted to the hospital with shortness of breath and generalized weakness from new-onset atrial fibrillation and suspected heart failure exacerbation. During the hospitalization, her oral health status declined and oral bacterial colonization shifted, with Neisseria becoming the most common oral bacterial genus around the time of development of probable non-ventilator-associated hospital-acquired pneumonia. DIAGNOSIS: The patient had new respiratory symptoms and a chest radiograph positive for pneumonia on day 4 and was subsequently diagnosed with probable non-ventilator-associated hospital-acquired pneumonia. INTERVENTIONS: Intravenous antibiotic treatment was initiated. Oral care was completed on only 2 of 7 days. The patient received limited ambulation assistance and encouragement from staff and family members. No dysphagia screening was documented. OUTCOMES: On day 6, the patient was discharged with oral antibiotics to her independent living facility with home health care. CONCLUSIONS: Consistent oral care, early and frequent physical activity, and measures aimed to reduce aspiration risk are key interventions for all hospitalized patients to prevent non-ventilator-associated hospital-acquired pneumonia. Further research is warranted to assess shifts in oral bacteria and general oral health during hospitalization, which could provide clinically meaningful data on risk for non-ventilator-associated hospital-acquired pneumonia.
Subject(s)
Cross Infection , Pneumonia, Ventilator-Associated , Female , Humans , Aged, 80 and over , Pneumonia, Ventilator-Associated/prevention & control , Cross Infection/drug therapy , Anti-Bacterial Agents/therapeutic use , Hospitalization , HospitalsSubject(s)
Nursing Staff, Hospital , Working Conditions , Humans , Personnel Staffing and Scheduling , Workplace , WorkforceABSTRACT
BACKGROUND: Cleansing and storage practices for reusable feeding tube stylets are varied and lack consensus guidelines. Almost 40% of critical care nurses do not cleanse reusable stylets. Our proof-of-concept study aimed to identify potential microbial contamination of stylets before and after cleansing with 70% isopropyl alcohol to establish practice standards. METHODS: This prospective, exploratory pilot study sampled reusable feeding tube stylets using three different stylet sample sets. Set 1 included human participant stylets sampled for microbiome profile precleansing, and postcleansing and reinsertion into feeding tubes (n = 4). Sets 2 and 3 included stylets stored at the bedside. Set 2 included precleansed stylets for microbiome profiles (n = 5). Set 3 included precleansed and postcleansed stylets sampled for quantitative cultures (n = 5). Careful handling and storage protocols were used. Microbiome profiling used 16s ribosomal RNA gene amplicon sequencing. RESULTS: Bacterial species identified on stylets were primarily common microflora and opportunistic pathogens, including Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas fulva, Cutibacterium acnes, Prevotella melaninogenica, and Lactobacillus paracasei. Microbiological culturing of stylet samples (set 3) did not yield growth for 9/10 samples; Staphylococcus capitis was identified in one postcleansed sample. Mean bacterial species diversity (alpha diversity) decreased following alcohol cleansing (M = 2.54 pre, M = 1.5 post; P = 0.006). CONCLUSION: The abundance of several potentially opportunistic pathogens indicated plausible risk for gut contamination secondary to reinsertion of stylets into small-bore feeding tubes. Stylet cleansing with 70% isopropyl alcohol reduced bacterial burden on the stylets, although viability was unknown. Careful cleansing, handling, and storage protocols for reusable stylets are necessary to minimize contamination.
Subject(s)
2-Propanol , Microbiota , Humans , Prospective Studies , Pilot Projects , Bacteria , Critical CareABSTRACT
AIM: This study explored relationships between enteral feeding and tracheal pepsin A. BACKGROUND: Mechanically ventilated (MV) patients receiving enteral feeding are at risk for microaspiration. Tracheal pepsin A, an enzyme specific to gastric cells, was a proxy for microaspiration of gastric secretions. METHODS: Secondary analysis of RCT data from critically ill, MV adults was conducted. Microaspiration prevention included elevated head of bed, endotracheal tube cuff pressure management, and regular oral care. Tracheal secretions for pepsin A were collected every 12 h. Microaspiration was defined as pepsin A ≥ 6.25 ng/mL. Positive pepsin A in >30 % of individual tracheal samples was defined as abundant microaspiration (frequent aspirator). Chi-squared, Fisher's Exact test, and generalized linear model (GLM) were used. RESULTS: Tracheal pepsin A was present in 111/283 (39 %) mechanically ventilated patients and 48 (17 %) had abundant microaspiration. Enteral feeding was associated with tracheal pepsin A, which occurred within 24 h of enteral feeding. Of the patients who aspirated, the majority received some enteral feeding 96/111 (86 %), compared to only 15/111 (14 %) who received no feeding. A greater number of positive pepsin A events occurred with post-pyloric feeding tube location (55.6 %) vs. gastric (48.6 %), although significant only at the event-level. Frequent aspirators (abundant pepsin A) had higher pepsin A levels compared to infrequent aspirators. CONCLUSIONS: Our findings confirmed the stomach as the microaspiration source. Contrary to other studies, distal feeding tube location did not mitigate microaspiration. Timing for first positive pepsin A should be studied for possible association with enteral feeding intolerance.
Subject(s)
Bodily Secretions , Critical Illness , Enteral Nutrition , Pepsin A , Respiratory Aspiration of Gastric Contents , Trachea , Adult , Bodily Secretions/chemistry , Bodily Secretions/metabolism , Critical Illness/therapy , Enteral Nutrition/adverse effects , Humans , Infant, Newborn , Intubation, Intratracheal , Pepsin A/analysis , Pepsin A/metabolism , Respiratory Aspiration of Gastric Contents/etiology , Respiratory Aspiration of Gastric Contents/metabolism , Trachea/metabolismABSTRACT
BACKGROUND: Hospital-acquired pneumonia accounts for 25% of all health care-associated infections and is classified as either ventilator-associated or non-ventilator-associated pneumonia. Hospital-acquired pneumonia most frequently results from aspiration of oropharyngeal secretions into the lungs. Although preventive measures for ventilator-associated pneumonia are well established, few preventive measures exist for the nonventilator type. OBJECTIVE: To (1) explore oral microbes associated with ventilator-associated and non-ventilator-associated pneumonia in acutely ill, adult hospitalized patients, and (2) provide evidence-based recommendations for measures to prevent pneumonia in hospitalized patients. METHODS: A literature search was conducted using CINAHL, Academic Search Premier, Medline, and the Cochrane Library. RESULTS: Ten studies were found that identified common oral microbes in ventilator-associated and non-ventilator-associated pneumonia, including Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, S aureus, and Streptococcus pneumoniae. Collectively, oral colonization with E coli, P aeruginosa, methicillin-resistant S aureus, and S aureus increased the risk of nonventilator pneumonia. Findings also suggested microaspiration of colonized oral microbes into the lungs. Non-ventilator-associated pneumonia had similar colonization rates of gram-positive and gram-negative bacteria, whereas ventilator-associated pneumonia had greater colonization with gram-negative bacteria. The literature did not indicate a standard of oral care effective in all patient populations. DISCUSSION: Oral care is an effective intervention to prevent hospital-acquired pneumonia by reducing pathogenic oral microbial colonization. The impact of different methods and timing of oral care on oral microbes should be further explored, particularly in patients not receiving mechanical ventilation. CONCLUSIONS: Findings reaffirm the importance of consistent oral care in hospitalized patients. In addition, practices should be different in patients receiving mechanical ventilation versus patients not receiving ventilation. Results may also provide knowledge to inform future preventive measures for pneumonia, particularly for nonventilator pneumonia.
Subject(s)
Methicillin-Resistant Staphylococcus aureus , Pneumonia, Ventilator-Associated , Adult , Anti-Bacterial Agents/therapeutic use , Escherichia coli , Gram-Negative Bacteria , Gram-Positive Bacteria , Hospitals , Humans , Pneumonia, Ventilator-Associated/microbiology , Pneumonia, Ventilator-Associated/prevention & controlABSTRACT
Publishing is a measure of faculty performance, yet barriers often include getting started, time management, and difficulty finishing. Manuscript submissions also lack deadlines, which creates additional challenges. Writing accountability groups (WAGs) are associated with increased faculty writing productivity. The purpose of this paper is to provide an overview of WAGs, including the process, participants, writing productivity outcomes, benefits, challenges, and unintended consequences. To maintain our writing progress during the COVID-19 pandemic, we moved our WAG sessions to a virtual platform. Our WAG protocol (both face-to-face and virtual) is shared to help other faculty members or doctoral students implement writing accountability groups. We also advocate for hybrid WAG sessions to promote attendance. In addition to facilitation of scholarly writing and improved writing habits, our WAG created opportunities for scholarly communication and networking with colleagues.
Subject(s)
COVID-19 , Pandemics , Faculty , Humans , SARS-CoV-2 , Social Responsibility , WritingABSTRACT
BACKGROUND: The evidence-based practice (EBP) process was challenged during the early phase of the COVID-19 pandemic by factors such as a novel disease, rapidly changing guidelines, shortage of personal protective equipment, and other health care supplies. OBJECTIVES: Our aims were to (1) explore sources of evidence sought by critical care nurses during a pandemic and (2) explore nurses' perceptions of EBP. METHODS: A qualitative exploratory study was conducted using deidentified data from the American Association of Critical-Care Nurses (ACCN) open-access Facebook page, January 28 to April 30, 2020. RESULTS: Two major themes were identified: (1) "sharing and seeking evidence," that is, nurses used both formal and informal sources to explore evidence supporting evolving clinical practices, and (2) "concerns about evidence," that is, nurses expressed concerns about lack of evidence and mistrust of evolving evidence. DISCUSSION: Initially, there was a mismatch in nurses' expectations of the American Association of Critical-Care Nurses Facebook page. A major limitation of Facebook is the lack of a repository for quick retrieval of information. Despite these limitations, and fear and mistrust of changing guidelines, social media was used to communicate, collaborate, and share evidence to support clinical practice. Critical care nurses seemed to value evidence to support patient management and their personal safety during this evolving health crisis. CONCLUSIONS: Social media played a large role in dissemination of timely evidence-based information during the early pandemic. Our results show that current EBP models should be revised to prepare for future crises and include direction for dealing with limited health care resources, and lack of and/or rapidly changing evidence.
Subject(s)
COVID-19 , Social Media , Critical Care , Humans , Pandemics , SARS-CoV-2ABSTRACT
AIM: This qualitative study explored de-implementation of feeding tube auscultation practice in adult patients by critical care nurses. BACKGROUND: Despite years of evidence suggesting inaccuracy and harm, auscultation (air bolus method) continues to be used by the majority of critical care nurses to verify small-bore feeding tube placement in adults. DESIGN: This descriptive qualitative study used thematic analysis with telephone interview data. METHODS: Fourteen critical care nurses from four stratified groups within the United States (by hospital type and auscultation practice) participated in telephone interviews. RESULTS: Two major themes of individual influence and organizational leadership emerged from the data. Categories identified key components required for auscultation de-implementation. CONCLUSIONS: Nurses feel obligated to follow hospital policies and expressed less accountability for their own practice. Organizational leadership involvement is recommended to facilitate de-implementation of this tradition-based, low-value practice and mitigate harm events.