Type 2 Diabetes Mellitus: Relationships Between Preoperative Physiologic Stress, Gastric Content Volume and Quality, and Risk of Pulmonary Aspiration.

Pulmonary aspiration is a potentially fatal anesthetic complication occurring when gastric contents enter the respiratory system. Fasting guidelines aim to decrease the risk of pulmonary aspiration by recommending a timeframe in which patients abstain from food and drink before surgery. Fasting guidelines recommended for healthy individuals fail to account for patients with type 2 diabetes mellitus (T2DM). Gastroparesis, a common condition associated with T2DM, is exacerbated during stress such as an impending surgery. This study sought to determine whether a relationship exists between stress levels and gastric contents in fasting patients with T2DM presenting for an elective surgical or diagnostic procedure. The quality and quantity of gastric contents and preoperative stress were evaluated using gastric ultrasonography and salivary α-amylase levels. No relationship existed between preoperative stress and gastric contents; however, glycated hemoglobin levels of 7% or greater were associated with increased gastric fluid, which was the most significant finding in this study. In addition, there was a significant difference between the mean gastric volume in healthy individuals and patients with T2DM. Performance of gastric ultrasonography preoperatively provides objective data that could influence the anesthetic plan and decrease the risk of pulmonary aspiration in patients with T2DM.

[The Triangular Relationship Among Swallowing Disorders, Aspiration Pneumonia, and Poor Oral Hygiene].

Persons with dysphagia have difficulties chewing and swallowing food because of functional, structural, or psychological reasons. Dysphagia may cause choking or the inhalation of food into the trachea and lungs. Patients with dysphagia often induce the coughing reflex when drinking water and brushing teeth and tend to suffer from gum bleeding. As a result, their caregivers tend to reduce the frequency of or discontinue teeth brushing, which promotes the spread of periodontal disease, dental caries, and oropharyngeal secretions colonizing in the oral cavity or throat. When a patient suffers a choking attack or aspiration, bacteria is inhaled into the trachea and lungs, causing aspiration pneumonia. Furthermore, patients with choking issues are often be fitted with nasogastric tubes to facilitate the delivery of nutrients and water. Long-term use of nasogastric tubes also significantly increases the risk of aspiration pneumonia. Adjusting eating posture, improving food texture, conducting swallowing rehabilitation, providing training, and practicing proper oral care are an effective approach to preventing the onset of chewing and swallowing disorders and aspiration pneumonia.

Nursing oral suction intervention to reduce aspiration and ventilator events (NO-ASPIRATE): A randomized clinical trial.

AIM: The primary aim of this study is to compare an oropharyngeal suction intervention versus usual care on microaspiration in intubated patients. Secondary aims are to evaluate the intervention on ventilator-associated condition rates, time to occurrence and compare tracheal-oral α-amylase ratios between groups. DESIGN: Prospective randomized clinical trial. METHODS: The study received funding from the National Institutes of Health in February 2014 and Institutional Review Board approval in July 2013. Over 4 years, a convenience sample of 600 orally intubated, ventilated adult patients will be enrolled within 24 hr of intubation. The target sample is 400 participants randomized to the two groups. The intervention involves enhanced suctioning of the mouth and oropharynx every 4 hr, while the usual care group receives a sham suctioning. The research team will deliver usual oral care to all patients every 4 hr and collect oral and tracheal specimens every 12 hr, to quantify α-amylase levels to detect aspiration of oral secretions. Study completers must be enrolled at least 36 hr (baseline and three paired samples). Outcomes include α-amylase levels, percent of positive specimens, ventilator-associated conditions, length of stay, ventilator hours, and discharge disposition. DISCUSSION: Enrolment has closed, and data analysis has begun. Subgroup analyses emerged, contributing to future research knowledge. IMPACT: Standardized interventions have reduced but do not address all risk factors associated with ventilator-associated conditions. This study provides the potential to reduce microaspiration and associated sequelae in critically ill, intubated patients.

[Measuring nursing sensitive outcomes in publicly funded hospitals in the Veneto Region, Italy: the development of a regional policy]. / Misurare gli esiti dell'assistenza infermieristica nelle Aziende Ospedaliere e Socio Sanitarie Locali della Regione del Veneto: sintesi dell'esperienza di sviluppo di una policy regionale.

INTRODUCTION: The indicators used in the Italian National Outcome Strategy does not include measurement of nursing care outcomes so these have not yet been assessed systematically in our country but only in the context of specific research projects. Positive and negative outcomes of nursing care have been documented in the literature, the latter associated with missed nursing care, a phenomenon that occurs when conditions are such that nurses are unable to deliver planned care to patients. OBJECTIVES: To describe the rationale, methodology and main results achieved to date in the development of a regional policy aimed at establishing a panel of indicators for monitoring nursing care-sensitive outcomes hospitals in publicly funded hospitals in the Veneto Region (northern Italy). METHODS: A plurennial, multi-method project based on [1] identification of selection criteria for a Minimum Data Set of indicators; [2] a rapid review of the literature and of the policies established internationally to measure nursing care-sensitive outcomes; [3] the establishment of an initial panel of indicators and evaluation of any critical issues with the chosen indicators, and [4] identification of the most appropriate tool for measuring missed nursing care. RESULTS: The medical and surgical units were considered to be the most suitable settings for the pilot study. Following the literature review, indicators that were already being monitored in the current regional information system were chosen, with the intent to prevent an additional administrative burden to nurses. By using a progressive consensus process, five outcome indicators (functional status, falls, pressure sores, urinary tract infections, aspiration pneumonia) and one process indicator (missed nursing care) were selected., and the tools for measuring the above-mentioned indicators and their related risks, were identified. A regional policy was then established to measure these indicators in a pilot phase, with the intent of implementing them as stable indicators to be measured in the new computerized hospital information system. CONCLUSIONS: An initial panel of nursing-sensitive outcome indicators has been defined to be used in Internal Medicine and General Surgery units of hospitals in Italy's Veneto Region. Despite its limitations, the project represents the first effort to create a regional policy to measure the contribution of nursing care to the health outcomes of patients and that will also the identification of potential relations with other variables such as personnel staffing and/or skill mix.

The impact of aspiration pneumonia and nasogastric feeding on clinical outcomes in stroke patients: A retrospective cohort study.

AIMS AND OBJECTIVES: To determine presence of clinical complications related to dysphagia and to explore their operational outcomes. BACKGROUND: Dysphagia is a common complication of stroke. The management of poststroke dysphagia is multidisciplinary with nurses playing a key role in screening for dysphagia risk, monitoring tolerance of food and fluids and checking for the development of complications such as fever, dehydration and change in medical status. Dysphagia often results in further complications including aspiration pneumonia and the need for nasogastric feeding. Dysphagia-related complications have been shown to have a significant impact on morbidity and mortality, length of stay and cost of admission. DESIGN: Retrospective cohort study. METHODS: A total of 110 patients presenting with an ischaemic stroke were chart-audited. RESULTS: Aspiration pneumonia poststroke was found to be significantly associated with increased overall length of stay, poorer functional outcomes poststroke as well as being associated with a high risk of mortality. The presence of a nasogastric tube was also associated with reduced functional outcomes poststroke and increased risk of death. CONCLUSION: High prevalence and cost of complications associated with stroke highlight the complexity of providing nursing and allied health care to this patient population. This provides a snapshot of dysphagia-related complications experienced by stroke patients. RELEVANCE TO CLINICAL PRACTICE: This paper highlights that poststroke complications can significantly impact on patient outcomes and operational factors such as cost of admission; therefore, poststroke care requires a multidisciplinary approach to management. Furthermore, preventing and managing complications poststroke is a key element of nursing care and has the potential to significantly reduce incidence of mortality, length of stay and cost of hospital admission.

Carga de trabajo y cumplimiento por parte de las enfermeras de las medidas no farmacológicas para la prevención de la neumonía asociada a la ventilación mecánica. Estudio piloto / Nursing workload and adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia. A pilot study

Objetivo: Analizar si el cumplimiento de las medidas no farmacológicas para la prevención de la neumonía asociada a la ventilación mecánica (NAV) se asocia a la carga de trabajo de las enfermeras. Método: Estudio observacional prospectivo llevado a cabo en una UCI médico-quirúrgica. Se evaluó a las enfermeras a cargo de pacientes con soporte ventilatorio. Variables: cuestionario de conocimiento, aplicación de las medidas no farmacológicas de prevención de la NAV, carga de trabajo medida mediante el Nine Equivalents of Nursing Manpower Use Score. Fases: 1) las enfermeras realizaron un programa educativo, basado en conferencias de 60 min sobre medidas no farmacológicas para la prevención de NAV, completando al finalizar un cuestionario de conocimiento; 2) periodo de observaciones; 3) cuestionario de conocimiento. Resultados: De un total de 67 enfermeras de UCI, 54 completaron el programa formativo y fueron incluidos en el estudio. Se llevaron a cabo un total de 160 observaciones de 49 enfermeros/as. El correcto conocimiento de las medidas de prevención se confirmó tanto en el cuestionario inicial como final. La aplicación de las medidas de prevención varió desde el 11% para el lavado de manos preaspiración hasta el 97% para el uso de sonda de aspiración estéril. La puntuación del Nine Equivalents of Nursing Manpower Use Score fue de 50±13. No se observaron asociaciones significativas entre el grado de conocimiento y la aplicación de medidas de prevención, ni entre la carga de trabajo y la aplicación de dichas medidas. Conclusiones: El conocimiento de las enfermeras de las medidas de prevención de la NAV no se traslada necesariamente a la práctica diaria. En la población estudiada, la falta de aplicación de estas medidas no está sujeta a la falta de conocimiento ni a la carga de trabajo, sino probablemente a los factores contextuales (AU)

Objective: To analyse whether adherence to non-pharmacological measures in the prevention of ventilator-associated pneumonia (VAP) is associated with nursing workload. Methods: A prospective observational study performed in a single medical-surgical ICU. Nurses in charge of patients under ventilator support were assessed. Variables: knowledge questionnaire, application of non-pharmacological VAP prevention measures, and workload (Nine Equivalents of Nursing Manpower Use Score). Phases: 1) the nurses carried out a educational programme, consisting of 60-minute lectures on non-pharmacological measures for VAP prevention, and at the end completed a questionnaire knowledge; 2) observation period; 3) knowledge questionnaire. Results: Among 67 ICU-staff nurses, 54 completed the educational programme and were observed. A total of 160 observations of 49 nurses were made. Adequate knowledge was confirmed in both the initial and final questionnaires. Application of preventive measures ranged from 11% for hand washing pre-aspiration to 97% for the use of a sterile aspiration probe. The Nine Equivalents of Nursing Manpower Use Score was 50±13. No significant differences were observed between the association of the nurses' knowledge and the application of preventive measures or between workload and the application of preventive measures. Conclusions: Nurses' knowledge of VAP prevention measures is not necessarily applied in daily practice. Failure to follow these measures is not subject to lack of knowledge or to increased workload, but presumably to contextual factors (AU)

Assessment of Airway Defenses in the Neurologically Impaired Patient.

Impairment of cough and swallow is a potential consequence of neurological dysfunction that places affected patients at increased risk for respiratory compromise and death. Nurses are critical to early identification and frequent screening of airway defense mechanisms to reduce aspiration risk and improve clinical outcomes in patients with neurological impairment.

Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting.

Oral care is a crucial routine for patients with dysphagia that, when completed routinely, can prevent the development of aspiration pneumonia. There is no standardised protocol for oral care within government hospitals in South Africa. This study aimed to investigate the outcome of an oral care protocol. Participants were patients with oropharyngeal dysphagia, with either stroke or traumatic brain injury as the underlying medical pathology, and nurses. All participants were recruited from one tertiary level government hospital in Gauteng, South Africa. 139 nurses participated in the study and received training on the oral care protocol. There were two groups of participants with oropharyngeal dysphagia. Group one (study group, n = 23) was recruited by consecutive sampling, received regular oral care and were not restricted from drinking water; however, all other liquids were restricted. Group two (comparison group, n = 23) was recruited via a retrospective record review, received inconsistent oral care and were placed on thickened liquids or liquid restricted diets. Results showed that a regimen of regular oral care and free water provision when combined with dysphagia intervention did prevent aspiration pneumonia in patients with oropharyngeal dysphagia. The article highlights two key findings: that regular and routine oral care is manageable within an acute government hospital context and a strict routine of oral care can reduce aspiration pneumonia in patients with oropharyngeal dysphagia. An implication from these findings is confirmation that teamwork in acute care settings in developing contexts must be prioritised to improve dysphagia management and patient prognosis.

Risk of aspiration in care home residents and associated factors.

Pneumonia is a prevalent cause of death in care home residents. Dysphagia is a significant risk factor of aspiration pneumonia. The purpose of the current study was to screen for risk of aspiration in care home residents in the Netherlands and assess potential risk factors of aspiration. Five experienced speech-language therapists assessed 203 care home residents (115 primarily physically disabled, 88 primarily cognitively impaired) 60 and older in the first week after admission to a care home. In 43 (21.2%) residents, speech-language therapists assessed risk of aspiration and found no significant difference between physically disabled (26.1%) and cognitively impaired (14.8%) residents. After multivariate logistic regression analysis, the final prediction model for risk of aspiration showed Parkinson's disease as a significant factor (odds ratio = 5.11; 95% confidence interval [1.49, 17.52]) . The authors therefore conclude that risk of aspiration is a relevant care problem among Dutch care home residents and requires further assessment.

Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke.

OBJECTIVES: Dysphagia occurs in approximately 51%-78% of patients with acute stroke. The incidence of pneumonia caused by aspiration in dysphagic patients increases both mortality and the need for hospitalization. The aim of this study was to investigate whether the incidence of aspiration pneumonia could be reduced in such patients by an early screening for dysphagia and intensified oral hygiene. MATERIAL AND METHODS: In this controlled trial, 146 hospitalized acute stroke patients with moderate or severe dysphagia were included in three groups: an intervention group (n = 58), one internal control group (n = 58, retrospectively selected from same clinic), and one external control group (n = 30) from a comparable stroke unit in a neighboring hospital. The intervention consisted of early screening with a clinical method of dysphagia screening, the Gugging Swallowing Screen, and intensified oral hygiene. RESULTS: The incidence of x-ray verified pneumonia was 4 of 58 (7%) in the intervention group compared with 16 of 58 (28%) in the internal control group (p < .01) and with 8 of 30 (27%) in the external control group (p < .05). CONCLUSIONS: Early and systematic dysphagia screening by the Gugging Swallowing Screen method and intensified oral hygiene reduced the incidence of x-ray verified pneumonia.

Gastroesophageal reflux in critically ill patients.

Gastroesophageal reflux (GER) is a common occurrence in critically ill, mechanically ventilated patients. Reflux can lead to pulmonary aspiration of gastric contents and subsequent pneumonia. Several characteristics of patients, interventions provided in the intensive care unit setting, and factors associated with feeding increase a patient's risk for reflux. Critical care nurses and clinical nurse specialists can identify patients at highest risk for GER by utilizing the patient's history, reviewing the medications, and assessing the current status to provide interventions to reduce the risk of GER and its sequelae of aspiration pneumonia. This article reviews the physiology of GER, risk factors, and interventions to decrease GER in the critically ill patient.

Silent aspiration: results of 2,000 video fluoroscopic evaluations.

The purpose of this retrospective study of aspiration and the lack of a protective cough reflex at the vocal folds (silent aspiration) was to increase the awareness of nursing staffs of the diagnostic pathology groups associated with silent aspiration. Of the 2,000 patients evaluated in this study, 51% aspirated on the video fluoroscopic evaluation. Of the patients who aspirated, 55% had no protective cough reflex (silent aspiration). The diagnostic pathology groups with the highest rates of silent aspiration were brain cancer, brainstem stroke, head-neck cancer, pneumonia, dementia/Alzheimer, chronic obstructive lung disease, seizures, myocardial infarcts, neurodegenerative pathologies, right hemisphere stroke, closed head injury, and left hemisphere stroke. It is of high concern that the diagnostic groups identified in this research as having the highest risk of silent aspiration be viewed as "red-flag" patients by the nursing staff caring for them. Early nursing dysphagia screens, with close attention to the clinical symptoms associated with silent aspiration, and early referral for formal dysphagia evaluation are stressed.