Effectiveness of Suction Protocol on Nurse's and Patient's Outcome in ICU

Sachdeva Seema¹*, Koul Pity², Batra Kiran³

¹Nursing Tutor, College of Nursing, AIIMS, Delhi

²Director and Professor, School of Health Sciences, IGNOU, Maidan Garhi, New Delhi

³Principal and Professor, Silver Oaks College of Nursing, Punjab

*Corresponding Author Email:sachdevaaiims@gmail.com

ABSTRACT:

Background: Critical ill patients are at high risk of complications due to severity of medical conditions and invasive procedures like suctioning and multiple treatments modalities. Airway suction is also associated with significant complications like trauma, nosocomial infections like ventilator associated pneumonia (VAP). Objectives: The present study aimed to assess the nurse’s outcome in terms of knowledge and practices on endotracheal/ tracheal suctioning before and after implementation of protocol and to assess the patient’s outcome in terms of complications related to endotracheal/ tracheal suctioning before and after implementation of protocol and finally to find the association of nurse’s and patient’s outcome with selected variables. Methods: The study followed 'Quasi experimental with non equivalentpre testpost test control group design'. The study was conducted in a selected hospital of NCR, Delhi from May 2014 to December 2014. The sample size was 60 for nurses and 145 for patients divided in control and experimental group. The tools used were 'Nurse Outcome Measurement Sheet' (Knowledge questionnaire and objective performance evaluation checklist on endotracheal suction practices) and 'Patient Outcome Measurement Sheet' (2 complications related to endotracheal suctioning: Tracheobronchial haemorrhage and ventilator associated pneumonia). Protocol on 'Suction Procedure' and was developed and validated before actual intervention. After pre test (May to August 2014) done in both groups, the intervention i.e protocol on suctioning was administered to experimental group subjects through structured teaching program over the period of 1 week. The post test was done on nurses and patients in both groups after a gap of 1 month of intervention (October to December 2014). P value <0.05 was considered statistically significant. Results: It revealed that there was significant increase in knowledge scores in all domains (Significant in hand washing, suction management and overall knowledge scores). The performance (compliance rate to the procedure steps) also improved from 52% in control group to 77% in experimental group after the intervention. There was a significant association of nurses outcome with demographic variables like education and experience at the level p<0.05. For patients' outcomes, experimental group subjects had lesser number of complications than control group (tracheobronchial hemorrhage and VAP) with p<0.05, after administration of protocol. VAP rate decreased significantly from 35.2 to 15.87 per 1000 ventilator days. Patient's outcome had a significant association with duration of invasive ventilation, suction duration and frequency of suction at the level p<0.05. Conclusion: The protocol was effective in improving both nurse's and patient' outcome.

KEYWORDS: Nurse outcome, Patient Outcome, Endotracheal/ Tracheal Suctioning, Ventilator Associated Pneumonia (VAP)

INTRODUCTION:

Mechanical ventilation is commonly used in intensive care units to assist in breathing in a variety of conditions. Mechanical Ventilation is achieved through placement of Endotracheal tube or tracheostomy tube in situ.¹

Airway suction plays a keen role to keep this tube patent and help the patient in receiving humidified air and oxygen.²However the research has revealed that suction once considered a ‘surprisingly simple technique’ is associated with numerous complications like tracheobronchial edema, ulceration and denudation of epithelium. These areas of mucosal damage increase the risk of infection and bleeding.³ Additionally the use of ventilator increases the risk of nosocomial infections to 6-21 times and risk of contracting pneumonia trauma increases to 1-3% with each additional day on ventilator.^4,5Most of literature describes endotracheal suction should only be performed as necessary⁶. Correct suctioning technique and performing suction only when indicated can reduce the risk of trachea bronchial trauma and infections as reported in different studies^7-9. The emphasis on evidence based nursing practices, has resulted in production of policies, protocols and guidelines.¹⁰Many standard suction protocols are developed by different experts in order to help the nurses to become proficient in suction procedure. To improve standards of care, nurses must be aware of current research recommendations which is possible by regular education and training programmes.¹¹

NEED OF THE STUDY:

Unfortunately the large number of errors in ICU goes unnoticed in regard to complication of suctioning which increases to morbidity, mortality and hence increase hospital stay for patient. In order to reduce these sentinel events or complications, a synchronization of education and repetitive training sessions are recommended to improve quality care.¹² Few studies have been done in India, to assess the nurse’s and patient’s outcome altogether in terms of suction procedure. The present study aimed to develop and implement suctioning protocol by training of nurses in small groups and further evaluating in terms of nurse’s and patient’s outcomes.

MATERIAL AND METHODS:

Research Design:

The study used 'Quasi-experimental research design' with 'Non equivalent control group before after intervention design'. It involves the intervention to experimental group (administration of protocol) and comparing both control and experimental group outcome variables in pre intervention and post intervention phase. The study design is described in table no 1

Table 1: Research Design for the Study

Group	Pre test	Intervention	Post test
Control group	O1 O2	---	O1 O2
Experimental group	O3 O4	X	O3 O4

O1: Observation of nurse's outcome in control group

O2: Observation of patient's outcome in control group

O3: Observation of nurse's outcome in experimental group

O4: Observation of patient's outcome in experimental group

X: Intervention (administration of protocol)

Sample and Ethical Consideration:

The study involved all 60 nurses (28 in experimental and 32 in control group) as sample size who were providing direct patient care in tertiary care hospital, NCR, Delhi, India during May 2014 to December 2014. The sample size was for patients was 160 (80 subjects in each group) but due to attrition the sample size dropped to 145. The sampling technique employed for nurses was total enumeration sampling and for patients was simple random sampling technique. The inclusion criteria for nurses was staff nurses providing direct patient care in ICU and for patients this inclusion criteria was limited to those who were newly admitted to ICU within 24-48 hrs and had endotracheal/ tracheal tube in place for > 24 hrs. Participants were given information about the study and informed written consent was taken from study participants. Permission was taken from institutional ethical committee to conduct the study.

Development of Study Intervention Tool and Protocol:

The intervention strategy i.e. ‘Suction protocol’ was developed using evidence based guidelines on suctioning, VAP management and infection control measures.^13-15It was validated by expert from medical and nursing fields. It was implemented in small groups using teaching sessions followed by demonstrations among experimental group subjects over the period of 1 week. The tools used for the study were 'Nurse Outcome Measurement Sheet’ (subject data sheet, Knowledge questionnaire and objective performance evaluation checklist) and 'Patient Outcome Measurement Sheet' (subject data sheet, complications related to suction). There were total 25 items in knowledge questionnaire divided under 5 subheadings like hand washing (2 items), gloves management (2 items), suction management (7 items), ventilator management and oxygenation (8 items), and miscellaneous interventions (6 items) related to suction. For objective performance evaluation, a procedure checklist was prepared with 25 items. Subjects were evaluated as per performance or non performance of the step in checklist. For patient outcome measurement sheet, the outcome was observed in terms of complications like incidence of tracheobronchial haemorrhage and ventilator associated pneumonia. Content validity of the tool and protocol were established by eleven experts and necessary modification was made. The study reliability was confirmed using Crohnbach’s alpha(r value=0.84).The VAP rate was calculated in both groups before and after intervention. The VAP rate of targeted patients was calculated using CDC guidelines (2003) and clinical pulmonary infection scale (CPIS) (Fartoukh et al., 2003)¹⁵ which was designed to indicate VAP at a score of 6 or higher. It was calculated as follows: no of patients connected to ventilator >48 hrs who developed pneumonia X 1000/ no of patients on ventilator >48 hrs during that time period.

Data Collection:

The pilot study was conducted before actual study and it was found feasible. For pre test, both control and experimental group were observed for outcome variables over the period of 3 months. The responses were filled by nurses as asked in Knowledge questionnaire. For objective performance evaluation, the researcher had done direct observation to measure the suction procedure performance using checklist. Scores were given based upon the correct response/ step of the procedure. For patient assessment, subjects were observed for their complications throughout their intubation period using direct observations and records analysis method. The suctioning complication was measured in terms of their frequency, as listed in tool. The intervention was done in experimental group following pre test and the post intervention assessment for nurses and patients outcome was started after a gap of 1 month in both groups. However the patients changed from pre intervention to post intervention in both groups due to short ICU stay.

RESULTS:

For data analysis, SPSS version 15 was used. Nurses and patients general characteristics were compared in both groups using chi square for frequency, percentile and homogeneity. To compare the difference of knowledge and performance scores of nurses between the groups and within the group, independent t test and paired t test was used. To find the association ANOVA was used. To compare the VAP occurrence rate before and after intervention log rank test was used. P value <0.05 was considered statistically significant. The data was analysed in 2 parts: Nurse’s outcome analysis and patient’s outcome analysis.

Part I: Nurse's outcome analysis:

a). Socio demographic Variables of Nurses:

The majority of subjects were females in both groups (71% in control group and 80% in experimental group) and majority in age group of 31-40 yrs (41% in control group and 50% in experimental group). 66% nurses in control group and 71% nurses in experimental group had GNM nursing as qualification and for professional experience, majority of the subjects (56%) had 1-3 years of experience in both groups. 59% subjects in control group and 54% subjects in experimental group reported 1:3 nurse patient ratio. 33% of nurses in experimental group and 28% in control group had attended educational training related to suctioning. Both the groups were comparable for their demographics with no statistical significant difference at p<0.05.

b). Knowledge Scores of Nursing Subjects:

The knowledge of subjects was assessed and analyzed in five domains like hand washing, gloves Management, suction management, Ventilator management and miscellaneous intervention related to suction procedure as shown in table no 2.

Table 2: knowledge scores of nursing subjects in both groups in pre and post intervention period N=60

Knowledge Domains	Pre- intervention phase		P value#	Post intervention phase		P value#
Knowledge Domains	Control Group n=32	Experimental Group n =28	P value#	Control Group n=32	Experimental Group n =28	P value#
Hand washing (Total items/ scores=2)	0.67± 0.12	0.78±0.60	0.15	0.71± 0.35	1.25±0.27	0.008*
Use of Personal Protective Equipments (Total items/ scores=2)	1.93±0.02	1.89± 0.08	0.37	1.89 ±0.30	1.93±0.02	0.64
Suction management (Total items/ scores=7)	3.12±1.28	4.34±1.94	0.42	4.76±1.54	6.61±0.21	0.02*
Ventilator management and oxygenation (Total items/ score=8)	5.72±1.32	5.67±1.23	0.87	4.98±1.09	7.21±0.15	0.73
Miscellaneous interventions (Total items/ score=6)	2.28±1.02	2.67±1.04	0.78	2.50±0.67	5.94±0.03	0.021*
Total knowledge scores (Total items/ score=25)	13.72±1.12	14.57±0.03	0.46	13.13±1.31	21.69±1.08	0.002*

# Independent t test, p value<0.05 significant

Figure 1: Performance Scores of nursing subjects in both groups

Table 3: Observation Checklist for Suction Procedure in Control and Experimental group N=60

S.No	Steps of the procedure	Post intervention phase		P value#
S.No	Steps of the procedure	Control group n=32 F (%)	Expt. Group n=28 F (%)	P value#
1	Need of suction verified	15 (47)	23 (82)	0.001*
2	Procedure explained to patient	5 (16)	17 (61)	0.02*
3	Assemble all the required articles	24 (89)	26 (93)	0.12
4	Hand washing done thoroughly	6 (19)	14 (50)	0.02*
5	Baseline vitals (HR, SpO2) checked	19 (59)	22 (78)	0.04*
6	Supine position given to patient	27 (84)	25 (89)	0.48
7	Suction pressure set at 80-100mm Hg	22 (69)	25 (89)	0.07
8	Correct suction catheter selected	32 (100)	28 (100)	0.78
9	Pre oxygenated with 100% oxygen	18 (56)	23 (82)	0.001*
10	Personal protective measures used (Gloves and mask) in sterile manner	17 (53)	20 (71)	0.51
11	Suction catheter opened and attached with suction tube in sterile manner	23 (72)	26 (93)	0.04*
12	Correct length of suction catheter introduced in endotrachel/ tracheal tube	30 (94)	28 (100)	0.69
13	Suction pressure not applied during insertion of catheter	29 (91)	27 (96)	0.32
14	Catheter withdrawn in rotating motion by applying intermittent suction	19 (59)	24 (86)	0.03*
15	Secretions cleared in a sterile bottle of normal saline	27 (84)	25 (89)	0.61
16	The duration of suction was maintained < 15 seconds per cycle	24 (81)	26 (93)	0.06
17	Chest physiotherapy performed in b/w subsequent suction	26 (81)	23 (82)	0.97
18	At least 1 min gap was maintained between each suction	15 (47)	19 (68)	0.003*
19	Suction repeated till airway cleared and secretion removed	32 (100)	28 (100)	0.84
20	Oral suction/ nasal suction done followed by ET suction	29 (91)	28 (100)	0.73
21	Sterile technique maintained throughout the procedure	10 (31)	16 (57)	0.002*
22	Reset of patient FiO2 done	16 (50)	20 (71)	0.03*
23	Disposal of articles done as per biomedical waste management	32 (100)	28 (100)	0.91
24	Documentation of the procedure done	11 (34.3)	26 (93)	0.000*
25	Extra sterile suction catheter kept for emergency at bed side	9 (28)	20(71)	0.002*

# Independent t test, p value<0.05 significant.

The above table illustrates that after the intervention, higher number of nursing subjects followed the steps of procedure in expt. group than control group. The difference was found significant (p<0.05) for the steps like assessing the need of suction, explaining the procedure, hand washing, checking baseline vitals, pre oxygenation, maintain adequate gap b/w 2 suction, maintaining sterile technique and documentation.

d). Association of nurse’s outcome with selected variables

The association of nurse’s outcome (performance scores) was observed with selected variables like gender, education, in service training, and other selected suction procedure variables. The knowledge and skill was found significant with experience and in service training in both groups at p<0.05 using ANOVA test.

Part II: Patient's outcome analysis:

For patient’s analysis, the patients changed from pre intervention phase to post intervention phase in both groups because of short ICU stay (average 7.8 days). Therefore there were 4 independent groups of patients (N=145) which were comparable for their clinical characteristics. (Chi square test).

a) Socio Demographic Variables of Patients:

Majority of patients in all groups were male, within age group of 21-40 years. Majority of patients were admitted to ICUs with Head injury (24-37%) followed by respiratory system disorders (21-29%), cardio vascular (12-15%) and central nervous system disorders (9-13%). Majority of patients had GCS between 3-8 (78%), co morbid illness as hypertension (35%) and diabetes (29%) in both groups. The average duration of invasive ventilation was 5.6 days (median value) and average ICU stay was 7.8 days (median value) in both groups.

b) Patient's outcome in terms of complications:

Patient's outcome was measured in terms of complications of suction procedure like Incidence of tracheobronchial hemorrhage and ventilator associated pneumonia as shown in table no 4.

Table 5: Association of patient's outcome with duration of invasive ventilation

Patient's Complications	Groups	Duration of invasive ventilation			P value#
Patient's Complications	Groups	<24-72 hrs	>72 hrs to 1 week	>1 week	P value#
Tracheo-bronchial haemorrhage	Control Group (n=13)	1	4	8	0.003*
Tracheo-bronchial haemorrhage	Experimental Group (n=7)	0	3	4	0.018*
Ventilator associated pneumonia	Control Group (n=7)	0	2	5	0.041*
Ventilator associated pneumonia	Experimental Group (n=3)	0	1	2	0.032*

# ANOVA test, p<0.05 Significant

Table 6: Association of patient's outcome with suction duration and frequency of suction

Patient's Complications	Groups	Suction duration		P value	Frequency of suction		P value
Patient's Complications	Groups	<15 sec	>15 sec	P value	<2 hrs	>2- 4 hrs	P value
Tracheobronchial haemorrhage	Control Group (n=13)	0	13	0.001*	8	5	0.03*
Tracheobronchial haemorrhage	Experimental Group (n=7)	0	7	0.001*	5	2	0.002*
Ventilator associated pneumonia	Control Group	3	4	0.73	4	3	0.068
Ventilator associated pneumonia	Experimental Group	1	2	0.41	2	1	0.07

The table 6 shows that the with the increase in suction duration to >15 sec and by decreasing the frequency of suction to < 2 hrs, higher number of patients had tracheal haemorrhage in both groups with significant p value of <0.05. Similarly incidence of VAP increased with the increase in suction duration to >15 seconds and by decreasing the frequency of suction to < 2 hrs but it was not found statistically significant in both groups.

DISCUSSION:

In present study, the nurse's outcome improved after the intervention, in terms of increase in knowledge and performance for endotracheal/ tracheal tube suction. The knowledge significantly improved in area of hand washing, suction management and other miscellaneous interventions related to documentation, assessing the need for suction, disposal of articles etc. The results are comparable with another study (Dubbert et al, 1990)¹⁶where information training, education and feedback improved the suctioning performance of nurses. The objective evaluation of performance showed significant improvement after the intervention from 52% in control group to 77% in experimental group (figure 1). Higher number of nurses followed the steps of suction procedure after the intervention in experimental group (table 3). According to previous studies by Day T et al (2001)¹¹, the similar finding were showed with significant improvement in knowledge and practices following multidimensional interventional program related to suctioning. The present study reported the patient's outcome in terms of complications like tracheal haemorrhage and incidence of VAP which was higher in both groups before the intervention (n=11in control group, n=8 in experimental group for haemorrhage and n=11for control group, n=8 in experimental group for VAP) but the outcome significantly improved after the intervention in experimental group (n=7 for hemorrhage and n=3 for VAP). A significant association (p<0.05) of both complications was found with suction duration and duration of invasive ventilation in both groups. However in different studies, a number of risk factors like depth of suction, negative pressure during insertion, improper size of suction catheter, deeper suction and suction duration>15 sec contributed to incidence of haemorrhage.^4,5Paoulugi O A et al (2006) stated that need based suctioning causes less discomfort and ET trauma as compared to standard 2 hrs suction technique.¹⁷ Another supportive study by Jain M, Miller L, King S. (2006) on bundle of care approach implementation led to decrease in ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p 0.04) and average length of stay in ICU thus decreasing ICU stay cost from $3406 to $2973.¹⁸However the number of studies recommends the use of continuous multidimensional intervention program, training sessions, and information stickers to reduce the nosocomial infection rate with long term impact.^18,19 The present study showed no association of suction duration and frequency of suction with VAP which is contrary to findings by Cordero L (2001) that showed low frequency suction can significantly down the nosocomial infection rates.²⁰

In Conclusion, the implementation of protocol improved the nurse’s outcome in terms of increasing their knowledge and skill and patient’s outcome by decreasing the number of complications as a result of suctioning. The study recommends that multidimensional VAP prevention program, nurses motivation and synchronizing education with training can improve the nurses awareness of evidence based preventive measures. Furthermore it is very important to make the nurses to feel pride that they have contributed in a significant way to bring down VAP in their unit.

ACKNOWLEDGEMENT:

Author express her profound gratitude to respected guides Dr. Pity Koul and Dr. Kiran Batra for their guidance that enabled her to complete this research project which was a part of her PhD thesis. It will be her privilege to express her sincere thanks to Medical Superintendent, Nursing Director to give permission to conduct this study. Finally her sincere thanks to study subjects, statistician and of course to loving family without whom support this work would not have been possible.

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Received on 31.05.2017 Modified on 14.07.2017

Asian J. Nur. Edu. and Research.2017; 7(4): 589-595.

DOI: 10.5958/2349-2996.2017.00115.X

Patient's outcome variables	Control group		Experimental group		P value# (Post intervention phase)
	Pre intervention phase n=35F (%)	Post intervention phase n=35F (%)	Pre intervention phase n=35F (%)	Post intervention phase n=40 F (%)
Tracheobronchial hemorrhage	11 (31)	13 (37)	11 (28.5)	7 (17.5)	0.04*
P value@	0.72		0.03*
Ventilator associated pneumonia (VAP)	8 (23)	7 (20)	7 (20)	3 (8.5)	0.002*
P value@	0.91		0.02*