Ventilator-Associated Pneumonia and Pressure Ulcer Prevention as Targets for Quality Improvement in the ICU

Crit Care Nurs Clin N Am 18 (2006) 453–467

Ventilator-Associated Pneumonia and Pressure Ulcer Prevention as Targets for Quality Improvement in the ICU Kathleen M. Vollman, MSN, RN, CCNS, FCCM ADVANCING NURSING LLC, 17139 Victor Drive, Northville, MI 48168, USA

In today’s critical care environment, clinicians and nurses face a difficult but essential task. They must provide comprehensive, compassionate, complex, technologic care without causing harm to patients. To create a patient-safe environment they must examine care practices and the processes around care to reduce the chance of error. With patient safety serving as the overriding goal there are a number of driving forces to help create risk- or error-free environments within critical care (Box 1). Patient safety: drivers of clinical practice change The initial driver is scientific. The evidencebased practice movement has assisted practitioners with strategies to move newly acquire science into practice. Evidence-based practice is the conscientious explicit and judicious integration of the best available evidence from systematic research with individual clinical expertise and patient preference [1]. The challenge faced in the current culture is the misrepresentation of evidence-based practice. Often evidence-based practice is seen only as the implementation of double-blind, placebo-controlled, randomized clinical trials. That is a very restrictive view. Failure to implement other levels of evidence that are superior to tradition-based practice results in inferior care. For example, the lowest level of systematic research is case-control studies. Traditional care or case-control studies provide clinicians with a direction on how to deliver the care, and how to choose the evidence over tradition. E-mail address: [email protected]

A second driver of change is economic and social forces. There are organizational and regulatory bodies that are driving patient safety initiatives within critical care. The document that placed patient safety as a significant agenda item in health care reform 5 years ago is called ‘‘To Err is Human,’’ published by the Institute of Medicine [2]. The Institute of Medicine reported that over 95,000 people die a year because of medical errors. The top four medical errors include (1) medications, (2) nosocomial infections, (3) injury related to falls, and (4) pressure ulcers. The Joint Commission on Accreditation of Hospitals Organization (JCAHO) is a regulatory body that has aligned its surveying processes to hold hospitals accountable for key patient safety goals [3]. Two quality improvement organizations, the Institute for Health Care Improvement and the Volunteer Hospitals of America, focus on creating and testing change technology that makes it easier to move evidence into practice. They design working collaboratives where health care organizations can receive coaching on how to implement the evidence using this technology to impact care practices and measure the results [4,5]. The final driver of change toward greater patient safety is a professional driver. The profession of nursing is refocusing on the implementation of basic care practices using evidence to affect the top four errors in this country. How did medications, hospital-acquired infections, falls, and pressure ulcers become the top four errors? When one examines the care practices that significantly reduce these errors it is clear most fall within nursing’s autonomous scope of practice. For the past 20 years in the acute care

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Box 1. Driving forces of change Scientific driver Evidence-based practice movement Economic and social drivers Institute of Medicine Leap Frog Group Institute for Health Care Improvement and Volunteer Hospitals of America Joint Commission Accrediting Hospital Organization Professional driver Back to the basics using evidence Courtesy of Advancing Nursing, Dearborn, MI; with permission.

environment there has been limited reinforcement, reward and recognition, or reprimand for the presence or absence of basic nursing care. Without any reward, recognition, or reinforcement structure built into the care environment, according to Skinner [6], the behavior does not continue because it has not been reinforced. The disease-focus model of diagnosis and treatment has been the care delivery model within acute care environments. Prevention has been absent. Most nurses are aware when they make a medication error, or when they do not follow a doctor’s order, and are aware of patient-family satisfaction data, because satisfaction of the customer is a major focus of most health care systems. Before patient safety focused initiatives, however, most critical care nurses were unaware of their unitbased pressure ulcer incident rate, ventilator-associated pneumonia (VAP) rate, and bloodstream infection rates. These indicators are nurse-sensitive outcomes for the quality of care nurses delivered [7]. Florence Nightingale over 140 years ago faced a similar challenge that critical care nurses face today. She wrote, ‘‘Nursing has been limited to signify little more than the administrations of medicines and the application of poultices (treatments). It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet, all at the least expensive the vital power to the patient’’ [8]. She believed the role of nursing was to place the patient in the best condition for nature to heal them. It is time for the profession to get back to the basics of nursing, using evidence to drive the change. This article focuses on providing

the rationale for and the evidence to support changes in key nursing care practices to reduce two of the top four errors seen in critical care units: VAP and pressure ulcers. Basic nursing and hygiene care: making it a priority Many of the key care strategies that help reduce VAP and pressure ulcers fall within the context of basic nursing and hygiene care. To most critical care nurses hygiene and mobility are significantly lower on a priority list for care delivery when compared with titrating vasoactive drips, monitoring a left ventricular assist device, or administering some of the latest pharmacologic advancements. Placing evidence-based hygiene and mobility strategies within the context of a comprehensive program to reducing error helps to move it higher on the priority list of care activities for critical care nurses. Webster’s dictionary defines hygiene as the science and practice of the establishment and maintenance of health [9]. The goal is to intervene with nursing actions that focus on using evidence-based hygiene strategies to reduce two of the top four errors in the United States. The term ‘‘interventional patient hygiene’’ was created as a conceptual framework for using evidence-based nursing care guidelines directly focused on fortifying a patient’s host defenses. It is actualized in hygienic and care activities that include oral cleansing, mobility, hand washing, the bathing process, and incontinence management targeted to reduce the incidence of hospital-acquired pneumonia and pressure ulcers [10]. The key is proactive intervention. The body is built with sufficient defenses to fight against infection and injury. Some of the external barriers to prevent infection and injury include an acidic pH, normal flora, cilia, bactericidal secretions, and skin [11,12]. In the average critical care environment, the patient’s host defense is significantly altered with insertion of central lines, administration of broad-spectrum antibiotics, placement of endotracheal and nasogastric tubes, maintenance of a supine position, inappropriate sedation, and delayed nutrition. The impact on the host defense can be reduced by implementing nursing care strategies that fortify this defense. Targeting ventilator-associated pneumonia VAP is seen as a second leading medical error in the United States. Most cases of VAP occur

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within 3 to 10 days of intubation in the ICU. The accrual mortality is approximately 10% to 40% [13,14]. The median rate of VAP ranges between 2.4 and 14.7 per thousand ventilator days [15]. An increase in the median ICU length of stay is 6 days, with the range being 10 to 32 days [16,17]. Single VAP can cost approximately $30,000 to $40,000 [13,18]. VAPs cost the United States health care system annually about $2 billion dollars. There are two global risk factor categories for the development of nosocomial pneumonia: factors that increase bacterial burden or colonization and factors that increase the risk for aspiration [14,19]. The focus is placed on nursing activities that can reduce these two categories of risk factors. Nursing care interventions to reduce the risk of bacterial colonization There are multiple factors that increase bacterial burden or colonization that places a mechanically ventilated patient at risk for the development of pneumonia (Box 2). Baseline risk rate rarely begins at zero secondary to age and number of comorbidities. Intubation and placement on a mechanical ventilator results in a 6 to 21 times higher risk for acquiring VAP [14,20,21]. The endotracheal tube is a direct portal for microorganisms to the upper respiratory tract. It removes the normal filter mechanisms facilitating entry while decreasing the clearance of secretions and bacteria [14,22,23]. A bacterial biofilm develops along the inner lining

Box 2. Risk factors for the Increase in bacterial burden and colonization  Extreme age, severe underlying condition, or immunosuppression  Administration of antibiotics  Agents that raise the gastric pH  Withholding gastric feeding  Mechanical ventilation  Lack of oral care  Poor infection control practices  Contaminated respiratory equipment or contaminated condensate  Saline administration  Immobility Courtesy of Advancing Nursing, Dearborn, MI; with permission.

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of the endotracheal tube, resulting in colonization and potential shedding [24–26]. Management of oral colonization The oral cavity becomes a significant source of bacterial colonization. Within 48 hours of admission to the critical care area, the normal oral flora changes to include respiratory pathogens not normally found in healthy individuals [27,28]. In a study examining 89 critically ill patients, microbiologic colonization of the oropharynx was examined throughout the patient’s ICU stay. The study compared pathogens in the oral cavity with pathogens causing VAP using pulsed field gel electrophoresis to compare chromosomal DNA. Out of 31 VAPs, 28 patients revealed an identical DNA match of the pathogen in the oral cavity to the pathogen causing the pneumonia [29]. Using a similar methodology, a recent study by El-Solh and coworkers [30] examined baseline dental plaque scores and microorganisms within the dental plaque of 49 elderly nursing home residents admitted to the hospital. Fourteen of the 49 patients developed pneumonia. Ten of the 14 patients showed an identical match of pathogens in the oral cavity and the organism causing the pneumonia by DNA analysis. Salivary flow is a natural host defense in facilitating the removal of plaque and microorganisms. Mechanical ventilation often promotes dry mouth or reduced salivary flow, contributing to plaque accumulation and decreased production of salivary immune factors [31,32]. The major immune factor in saliva is IgA. Its role is to protect the upper airway by limiting the absorption and penetration of microorganisms [11]. The equipment used to remove oral secretions and suctioning of the endotracheal tube may contribute to the colonization of the oral cavity. In a study examining equipment used to suction excess secretions from the oral cavity, 94% of tonsil suction devices were colonized within 24 hours [33]. In a recent study 80% of the tonsil suctions yielded cultures with one or more pathogens with a percentage being resistant organism [34]. Before the current patient safety initiatives, the routine practice of oral care in the critically ill patient was sporadic. Many nurses mixed their own solutions or used tap water or mouthwash with a sponge to clean the oral cavity. Lemon glycerin swabs are still in use and have been found to damage the oral cavity by overstimulating the salivary gland and drying out the mouth [35–38].

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In a large multisite study examining oral care practices among nurses, 75% used a sponge or toothette dipped in water or mouthwash every 4 hours, 75% suctioned the oral cavity using a tonsil suction, and 41% rarely or never brushed the teeth of a critically ill patient [39]. Based on the results of a random sample survey, less than 50% of ICUs in the United States had oral care as part of a policy or procedure. Eighty-two percent of the ICUs reported using a single suction canister and tubing for both closed endotracheal suctioning and oral suctioning. Tonsil suctions were used in 89% of the institutions with no policy for rinsing, changing, or storing, and most practitioners stored the tonsil suction back in the original package contributing to greater bacterial colonization. In a study examining the frequency of oral care, nurses identified that 72% of the time they provided intubated patients with oral care five times a day using a sponge, versus a toothbrush. Oral care procedures, however, were documented only 1.2 times per patient a day [40]. When asked to prioritize the importance of oral care using a 100-point scale, nurses rated it at 53.9. In a more recent study of 102 ICUs exploring oral care practices, however, 91% of 556 respondents perceived oral care as a high priority [41]. The Centers for Disease Control and Prevention (CDC) in their recent guidelines on the prevention of health care–associated pneumonia recommended the implementation of a comprehensive oral care program as a care practice to reduce VAP rates [14]. Based on the study the CDC reviewed to make the recommendation, a comprehensive oral care program was defined as brushing the teeth or use of a sponge if risk of bleeding, cleansing every 2 to 4 hours with a 1.5% hydrogen peroxide (H2O2), followed by suctioning any remaining secretions and moisturizing the mouth. Included in the program was deep oral cleansing using a soft-tip catheter every 6 hours and use of a closed tonsil suction system to provide protected oral suctioning if necessary between cleaning episodes. When the comprehensive oral care program was introduced and all other clinical changes held constant, the VAP rate dropped from 5.6 to 2.2 per thousand ventilator days. The cost savings identified was approximately $30,000 per incident [18]. Garcia and coworkers [42] conducted a 48-month preinterventional and postinterventional study and demonstrated a statistically significant reduction in the VAP rates with the implementation of

a comprehensive oral care program. The VAP rate dropped from 8.5 to 3.8 per 100 ventilator days or a 42% reduction. The oral care program included brushing the teeth twice daily, cleansing of the oral cavity every 4 hours, followed by oral suctioning and moisturizing. Deep oral cleansing was performed every 6 hours and a yankauer used for oral suctioning in between cleansing was kept covered and changed every 24 hours. A Y connector at the suction canister was implemented to allow two lines to prevent disconnection of the suction tubing to perform oral care. Repetitive opening of a ‘‘closed suction system’’ may result in contamination of the suctioning device and surrounding surfaces with pathogenic bacteria [43]. Brushing is an essential component of an effective oral care program. Foam swabs are limited in their ability to remove plaque from sheltered areas or between teeth. Brushing enables cleaning of the approximal sites and crevices [44]. Brushing with commercial fluoride toothpaste in mechanical ventilated patients may have limited effectiveness. Sodium bicarbonate helps to dissolve mucus, allowing saliva to remove debris more effectively [42,45]. Sodium bicarbonate also reduces oral acidity and is superior in the removal of plaque shown in a 1-minute brush test when compared with toothpaste preparations including commercial fluoride toothpaste [46]. For cleansing in-between brushing with H2O2 helps reduce gingivitis and plaque formation. It is effective against gram-positive and gram-negative organisms [47]. A less than 1% dilution solution has shown no benefit in plaque removal and a solution strength greater than 3% causes harm to the oral mucosa [48]. In a study examining the safety and efficacy of a 1.5% H2O2 and baking soda dentifrice, all groups demonstrated a significant reduction in gingival index, no disruption of the normal flora, and no pathologic or antiplastic changes [49]. Although having beneficial antibacterial properties, mouthwashes frequently contain alcohol, which can dry the oral tissues. The use of 0.2% chlorhexidine oral rinse twice daily is being used in place of a comprehensive oral care program in many institutions. There are conflicting studies as to the impact of chlorhexidine oral rinse on VAP rates [50–52]. Chlorhexidine oral rinse has been shown significantly to reduce gram-negative, gram-positive, and virus colonization of the oral cavity for a sustained period of time up to 6 hours [53]. In a recent multicenter, double-blind, randomized trial, Fourrier and colleagues [50] examine the

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effect of a 0.2% chlorhexidine oral rinse gel given three times a day versus a placebo. Although significantly reducing oral colonization there was no difference in VAP rates between the chlorhexidine oral rinse group (13.3 per 1000 ventilator days) and the placebo group (13.2 per 1000 ventilator days). According to the CDC guidelines, the only recommendation for the use of chlorhexidine is for it to be part of a comprehensive oral care program and for use only with post–open-heart patients [14]. If chlorhexidine oral rinse is used, the rinse should occur after tooth brushing and swallowing should be avoided [42]. Hand washing, suctioning, and mobility: three core nursing care activities to reduce colonization Additional factors that have the potential for increasing the bacterial burden or colonization include poor hand washing practices, saline administration during endotracheal suctioning, and the stationary supine position. Insufficient or ineffective hand hygiene contributes significantly to the spread of microorganisms and a greater bacterial burden within the care environment [14]. An increase in bacterial contamination of the hands occurs with patient care activities that take a longer time to complete and airway management can be a time-laden activity [54]. Performance improvement programs designed to improve the quality of hand washing in the clinical environment over the past 20 years have not been successful. To date, the only strategy shown to reduce the microorganisms spread by poor hand hygiene is the use of alcohol-based hand washing [55]. CDC guidelines on hand hygiene recommend that when hands are visibly soiled, they should be washed with both a non-antimicrobial or antimicrobial soap and water. When washing with soap and water, the hands should first be wet, soap should be applied with vigorous rubbing for 15 seconds, followed by rinsing and drying. A paper towel should then be used to turn off the faucet. If the hands are not visibly soiled or after removing gloves, an alcohol-based hand solution should be used for routine decontamination of the hands in all clinical situations. Housekeeping-dispensed hand lotion or lotion within the alcohol-base hand solution should be provided for health care workers to reduce the occurrence of irritant contact dermatitis [55]. The administration of saline into the endotracheal tube to help facilitate secretion removal has

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been a routine practice in the critical care environment. Over the past 20 years, a significant amount of research has shown that this practice may have a negative impact. The only demonstrated physiologic benefit to administering saline is that it helps the patient cough. Saline administration does not thin or liquefy secretions. Rather, it creates a decrease in oxygen saturation and has the potential to increase colonization in the upper respiratory tract [56]. Hagler and Traver [57] demonstrated that saline administration during suctioning resulted in a greater dislodgment of viable bacteria from the endotracheal tube. Saline rinses the endotracheal tube of any bacteria biofilm resulting in a large inoculation of bacteria to the upper respiratory tract. In patients with thick secretions, sufficient hydration, adequate humidification of air, and effective mobilization of the patient are key strategies for effective secretion removal. Although closed suction systems were created to reduce the incidence of bacterial colonization of the upper respiratory tract and VAP, to date the research demonstrates no difference in infection rates between open and closed suctioning with some increase in colonization of ventilator tubing with use of a closed suction system [58]. Immobility is a major factor in the development of atelectasis and VAP. The average critical care patient spends most of their time in the supine position and it is an independent risk factor for mortality in mechanically ventilated patients [59]. Krishnagopalan and coworkers [60] demonstrated that during an 8-hour time frame, less than 3% of critically ill patients were turned the standard every 2 hours. Close to 50% of patients during that same time period had no body position change. What impact does the stationary supine position have on lung physiology? Anzueto and coworkers [61] examined the impact of every 2-hour turning on healthy mechanically ventilated adult baboon lungs. By study conclusion at 11 days, the lung pathology in the baboons turned every 2 hours showed areas of bronchiolitis with five out of the seven animals demonstrating surrounding bronchopneumonia. Lying in a supine position contributes to a reduction in mucociliary clearance and functional residual capacity because of the position of the heart within the chest wall and the pressure of the abdominal contents on the diaphragm. Malbouisson and coworkers [62] showed that when lying supine 17% of the lung tissue rests under the compression forces of the heart altering pleural

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pressures resulting in alveolar collapse. In patients with enlarged hearts that influence can be as great as 36%. In the prone position only 4% of the lung tissue rests under the compression forces of the heart. In spontaneously breathing individuals in the supine position, the diaphragm acts as a shield against the pressure exerted by the abdominal contents, preventing those contents from interfering with lower lung expansion. When patients are mechanically ventilated with positive-pressure breaths, sedated, or paralyzed, the shielding function of the diaphragm is lost, resulting in a cephalad displacement of the diaphragm. This allows abdominal pressures to impact dependent lung volume inflation and functional residual capacity [63]. The literature supports the notion that if the standing upright position is not maintained, sitting straight up is the next best position to breathe if the lungs are in fairly good health [64,65]. During hospitalization, especially during the immediate phase of a critical illness, the sitting upright position cannot be tolerated because of the effect on the cardiovascular system. Often patients have limited self-movement because of their disease, treatment, or medications being administered. As a result, alternative strategies for body position must be used to benefit gas exchange and prevent the development of VAP [66]. Positioning therapies have been targeted to meet specific lung pathology. What position is best for patients at significant risk for VAP? That determination is made based on the severity of the patient’s lung disease and critical illness. For a large number of patients, turning every 2 hours is not enough to preserve the oxygenating ability of the lungs or to prevent pneumonia [67]. Many hospitals use rotation therapy when caring for critically ill patients who are at risk for pneumonia. Table-based rotation beds or kinetic therapy turns the patient on a platform to achieve a rotational arc of 62 degrees when in its full lateral position. The term ‘‘kinetic therapy’’ first appeared in the literature and was associated with tablebased rotation that achieves a 62-degree angle turn [68]. Later it was associated with the use of oscillating beds that rotate greater than 40 degrees. The term ‘‘kinetics’’ as defined by Webster’s dictionary is to put in motion [69]. All rotational therapies put the patient in motion. The term ‘‘kinetic therapy’’ should be used as originally intended to describe platform-based rotation and continuous lateral rotation therapy when rotation is achieved by oscillating beds through the inflation and deflation of cushions.

Kinetic therapy and continuous lateral rotation therapy reduces the incidence of VAP, atelectasis, time on the ventilator, and length of stay in the ICU. In most studies patients were rotated greater than 18 hours a day to achieve maximum benefit and the therapy was initiated as early as possible. Research has not yet determined whether the degree or the frequency of rotation is the crucial factor [70–76]. Ahrens and coworkers [77] randomized 234 medical-surgical trauma patients to receive rotation therapy or standard care and measure the impact on VAP, lobar atelectasis, and length of stay. The results showed a significant reduction in VAP and lobar atelectasis but no impact on length of stay. A potential reason for no change in length of stay may be related to the inability to control variables that impact time on the ventilator and stay in the ICU, such as sedation or weaning protocol use. There are three published systematic reviews of the literature on rotational therapy that have found similar results [71,78,79]. The most recent showed a significant improvement in reducing VAP in patients using rotational therapy regardless of the rotational degree achieved with a trend toward reduced ventilator days (P ¼ .08) (Fig. 1). In a recent multicenter randomize trail, Guerin and coworkers [80] assigned patients to the prone or supine position for 8 hours per day. Although no difference in mortality was noted, a significant reduction in VAP rates in the prone position was seen (85 of 413 prone and 91 of 378 supine, P ¼ .045). Once the patients is able hemodynamically to tolerate other forms of mobilization, every attempt should be made progressively to mobilize the patient to dangle, chair, weight-bearing, and ambulation positions to decrease the severe muscle wasting that occurs in critically ill patients [81]. One of the major factors that prevent mobility in the critically ill patient is hemodynamic instability. Hemodynamic instability during turning may occur because of spending prolonged lengths of time in a stationary position or the establishment of a ‘‘gravitational equilibrium.’’ A lessening of the carotid-cardiac baroreflex responsiveness is caused by prolonged bed rest and correlates with orthostatic hypotension and syncope [82]. When individuals change their gravitational reference from a laying to sitting position the body goes through a series of physiologic adaptations to maintain cardiovascular homeostasis [83]. Critically ill patients may experience a similar adaptation when turned laterally. With changes in

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Fig. 1. Pooled analysis of ventilator associated ammonia in studies evaluating the use of rotational therapy. P ¼ 0.82 for heterogeneity. P O.00001 for overall affect. (From Hess DR. Patient positioning and ventilator-associated pneumonia. Respir Care 2005;50:895; with permission.)

gravitational plane (position change) the stretch receptors read the shift in plasma volume and respond by sending information to the autonomic nervous system to constrict the vasculature [84]. Astronauts, as an example, must adapt to changes in gravity to maintain an effective circulating volume. Training is done to ensure tolerance of gravitational changes on baroreflex and vestibular or inner ear response. This ensures that the astronauts achieve cardiovascular adaptation in space. A similar mechanism may be important in critically ill patients. If nurses assist them to turn and prevent extended lengths of time in a stationary position and reduce the speed at which the patient is turned, less instability with position change may result. Continuous lateral rotation therapy can be used as a strategy gradually to retrain the patient to tolerate turning [85]. Nursing care interventions to reduce the risk of aspiration The major nursing care interventions to reduce the risk of aspiration include monitoring for risk factors, location of the endotracheal and gastric tube, and appropriate positioning of the head of the bed. Changes in level of consciousness can alter a patient’s capacity to control the airway and their ability to swallow. It must be assessed on a routine basis to reduce the risk of aspiration. Research using healthy subjects found that 45% aspirated during sleep and this was significantly greater in patients with impaired level of consciousness and inability to protect their airway [86]. These are also independent risk factors for the development of hospital-acquired pneumonia [87]. Ensuring that the endotracheal tube is secured properly prevents accidental extubations.

The act of reintubation is a significant risk factor for VAP [88]. Nasotracheal intubation and placement of a nasogastric tube may contribute to VAP [14,89–91]. Large-bore tubes placed in the nasal cavity for any period block effective drainage of the sinuses resulting in sinusitis and a higher level of gastroesophageal reflux. With inconsistent cuff inflation of the endotracheal tube, secretions are able to drain in an unobstructed manner into the upper respiratory tract [23]. Sinusitis is associated with a threefold increase in risk for the development of pneumonia [89,92]. The position of the head of the bed at 30 degrees is a key process indicator used by JCAHO for the ICU core quality measure of preventing VAP. Torres and coworkers [93] examined 19 mechanically ventilated patients to determine the amount of microbial aspiration that occurred in the supine position and when the head of the bed was elevated at 45 degrees over a 2-day period. Gastric contents were radiographically labeled so they could be tracked. Higher radioactive gastric contents were noted in the endobronchial secretions when the patient was supine. The amount of time spent in the position correlated with greater levels of aspiration. Even with the head of the bed elevated, there was a small amount of microaspiration evident. In a recent study, 86 mechanically ventilated patients were randomly assigned to the supine position or head of the bed at 45 degrees and monitored for microbiologically confirmed VAP. Nosocomial pneumonia was significantly lower in a semirecumbent group (2 [5%] of 39) versus the supine position (11 [23%] of 47) [94]. Supine position and enteral nutrition were independent risk factors for the development of VAP. The use of semirecumbent positioning in the clinical arena has

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had its challenges. When measured in actual practice the average head of bed elevation ranged from 19.2 to 22.9 [95,96]. Barriers to the use of semirecumbency include contraindications, hemodynamic instability, increased risk of pressure ulcers, reduced comfort, and resources [95]. Education and monitoring for compliance are effective strategies to ensure correct head of bed elevation for mechanically ventilated patients. Targeting pressure ulcers Pressure ulcer injuries are the fourth leading preventable medical error in the United States [2]. In addition to pain and suffering, one pressure ulcer adds a minimum of 4 days to the length of stay independent of other risk factors. Pressure ulcers increase a patient’s risk of developing a hospitalacquired infection by 25% [97]. Based on the results of a national survey conducted from 1999 to 2004, the percentage of hospital-acquired pressure ulcers has remained constant between 6.8% and 8.6% [98]. In the Nursing Quality Indicator Database, the facility-acquired pressure ulcer rates for critical care are between 7.14 and 14.45% [99]. Is nurses knowledge regarding prevention strategies a factor in the ability to reduce hospital-acquired pressure ulcers? Critical care nurses from an urban teaching hospital were administered a reliable and valid 47-item true-false test to assess their knowledge level of pressure ulcer prevention and staging. Test scores were not affected by experience, educational level, or when nurses last read an article on pressure ulcers. Sixty-seven percent of the nurses scored below 90% on items focused on prevention [100]. Most health care institutions perform daily systematic risk assessment for skin breakdown using such tools as the Braden or Norton scales. If risk is identified, the nurse is directed to initiate evidence-based strategies to minimize or eliminate the risk. The current validated tools do not always capture all the risk factors of critically ill patients. Additional risk factors in critically ill patients are low perfusion states; receiving catecholamines; hemodynamic instability with turning; greater number of tubes and lines; severe agitation; and longer periods on non–pressure-reducing surfaces while in the field, operating room, or emergency room. Education and process change around hygienerelated activities that fortify the patient’s skin to protect against pressure and exposure to caustic substances are essential in reducing the incidence of pressure ulcers [10].

Bathing process: the first line of defense The bathing process is more than just the opportunity to clean the patient. It can serve as an early warning system for skin injury, a chance to assess progress in the patients healing process, and improve tone and elasticity of the skin while potentially reducing the spread of microorganisms [101]. Early detection and communication of skin issues during the bathing process helped one organization reduce the number of hospital-acquired pressure ulcers. By identifying skin problems during the bath, they were able to apply prevention strategies more quickly and prevent skin problems from progressing [102]. If assistive personal are performing the bath, communication regarding the condition of the skin should be required. Establishing effective communication among licensed and unlicensed caregivers helps support the JCAHO communication patient safety goal [3]. The registered nurse needs to consider performing the bathing process with nursing personnel to perform additional assessments and ensure professional expertise in identifying problems early and begin finding solutions. In addition to cleaning and assessment of the skin, the bath is an opportunity to examine a patient’s muscle tone and strength, fatigue factor, range of motion, and ability to participate in activities of daily living both from a physical and psychologic perspective [103,104]. Bathing also enables assessment of a patient’s pain level during activity and rest and promotes active listening to explore the patient’s ability to cope with their illness. These assessments are lost when assistive nursing personal performs the bath independently of the nurse. The type of bath can influence multiple factors including condition of the skin, oxygen consumption, nurse satisfaction, and spread of microorganisms. In most acute care facilities, bedridden patients unable to provide self-care are given baths by nursing personnel using a basin of warm water, soap, and washcloths. The traditional method of a bed bath can result in excessive drying of the skin, an increased oxygen demand, greater nursing time, and the potential for microorganism spread within the environment [101, 105–109]. Larson and coworkers [106], in a study comparing traditional basin bath with prepackaged disposable bathing sponges, found that the disposable bath took less time; fewer products were used with a reduction in overall cost. With less time spent during the bath, maximizing comfort, efficiency, and time may result in a lower

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oxygen demand. In several studies, traditional bathing has been associated with an increase in oxygen consumption [107,108,110]. As skin changes with aging and dries, the skin roughens in texture and tone and elasticity are reduced; the average hospitalize patient’s skin is at risk for skin breakdown on admission [101]. The bath process should not compound that risk. Washcloths industrially washed and reused become rough in texture and may cause injury. Current soaps used with the traditional bath have a pH greater than 8.5. Cleansing products should have a pH as close to natural’s skins at 4.5 to 5.5 pH because this acid mantle helps reduce the potential for pathogen invasion or environmental irritants [101]. Natural or synthetic surfactants in soap remove the lipid layer during cleansing, compromising the natural infection barrier. In addition, bar soaps may harbor pathogenic organisms [111,112]. The traditional bath requires moisturizing after completion making it a twostep process. Prepackaged disposable bathing products have soft cloths, a cleansing agent that is pH balanced with gentle surfactants, contains lotion, and provides a method for the cloths to retain warmth if the bath process is interrupted. The package usually holds eight cloths to allow cleaning of various parts of the body without reuse of a cloth. With a basin bath there is a potential for the basin to become a reservoir for microorganisms and cross contamination of the immediate environment and health care personnel. Both gram-negative and gram-positive organisms at 105 cfu/mL were identified in patients’ bath water sampled after receiving a soap and H2O basin bath [105]. In a recent systematic review of the literature, 43 waterborne outbreaks were reported with an associated 1400 deaths. The authors recommended that hospitalized patients at high risk for infection avoid exposure to hospital water [113]. In the CDC guidelines for environmental infection control, they make a strong recommendation for the elimination of environmental reservoirs (eg, the bath basin and nebulizer) [114]. Incontinence management: protecting the skin against irritants Patients with fecal incontinence are at a 22 times higher risk for the development of pressure ulcers and the risk increases to 37.5 times when immobility is added. Immobility and fecal incontinence are the most significant risk factors in the development of pressure ulcers [115]. By

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addressing these two risk factors alone, health care practitioners can significantly reduce the number of hospital-acquired pressure ulcers seen in critically ill patients. Strategies for reducing immobility were discussed previously. Exposure to urinary or fecal material contributes to the development of perineal dermatitis, a potential precursor to a pressure ulcer. Up to 33% of all hospitalized patients have perineal dermatitis [116,117]. Perineal dermatitis is an inflammatory response to the injury of the water-protein-lipidmatrix of the skin that is caused by prolonged exposure to urinary or fecal incontinence. Physical signs on the perineum and buttocks include erythema, swelling, oozing, vesiculation, crusting, and scaling [118]. Injury from friction caused by movement against a fixed surface is exaggerated if the skin is moist. Vigorous scrubbing used to remove fecal material can create friction and further injury to the skin. Incontinence can be managed effectively by following the national guidelines, which include cleansing of the skin as soon as soiling occurs, the use of a protective cream or barrier on the skin with every soiling episode, and use of incontinent pad or brief to absorb wetness away from the skin [119]. The ideal cleansing solution should lift irritants from the skin without damaging the acid mantle. Moisture barriers are creams or ointments alone or in combination with the following active ingredients: petroleum, dimethicone, or zinc. Petroleum alone is ineffective against fecal incontinence. Dimethicone, when in combination with zinc or petroleum, serves as an effective barrier against both urine and stool [118]. There are a number of challenges to the current method of cleaning and barrier application. Cleaning and barrier protection usually are done as separate activities. The products are packaged individually and the barrier is not always within reach during the cleaning, leaving the patient unprotected. Seventy-six perineal skin care protocols from 32 different states were analyzed for use of evidencebased practices and compliance related to barrier use with incontinence episodes [120]. Although 75% of the facilities included the use of skin barriers in their protocol, comparison of health care products information service data and urofecal prevalence data suggested underuse of the skin barrier. Clever and coworkers [121] performed a retrospective-prospective quasiexperimental study comparing pressure ulcer incident rates preimplementation and postimplementation of a novel skin protect. The skin protect was a one-step

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process that included cloths containing a no-rinse cleaning solution and a 3% dimethicone and zinc barrier. Preimplementation, the average monthly incidence rate of pressure ulcers was 4.7%. Postimplementation with an all-in-one cleansing and barrier product resulted in an average monthly pressure ulcer rate of 0.5% or an 89% reduction. Simplifying the care process to ensure that every incontinence episode has a barrier application is crucial to meeting the guidelines of barrier application with each incontinent episode [121,122]. If frequent soiling occurs, care strategies should be initiated for controlling the source of the moisture [119,120]. External management of diarrhea can be achieved through the use of a fetal containment device or bowel management system [123,124]. Whether to use an underpad or diaper to wick away moisture is frequently a choice the nurse needs to make. When nonpolymer diapers were compared with underpads, the pads were superior in reducing the incidence of perineal dermatitis. Nonpolymer diapers are wetter, create more friction, and have higher microbial counts [125]. With the introduction of newer technology of a polymer diaper, the recommendation has changed. In a study comparing underpads, nonpolymer, and polymer diapers, the polymer diapers dramatically decreased the incidence of dermatitis, underpads were second, and nonpolymer diapers had the worse skin injury [126]. Examining the type of product in use to ensure maximum protection is an important nursing consideration. Pads are not the only material placed under patients. In a study examining independent risk factors for pressure ulcer development in critically ill patients, mobility and the number of layers of linen on the bed were found to be significant [127]. More than four layers of linen were associated with an increase risk. This may be attributable to loss of pressure reducing or relieving effect of the mattress. The surface supporting the patient is an important component to reducing the risk for pressure ulcers. There are many types of pressure reducing and relieving surfaces. The clinical trials examining their efficacy are inconclusive as to the type of surface that provides the best benefit for the cost. They are more effective than standard mattresses in reducing pressure. A best practice recommendation is that if a patient is at risk, a low-pressure surface is recommended and a dynamic device with alternating cells should be used if the patient is at high risk [128]. Systematic risk assessment, protocolized skin care prevention strategies, improved support

surface use, documentation enhancements, and use of a comprehensive staff education program significantly reduced the incidence of pressure ulcer development in a 3-year multiphase pressure ulcer prevalence and incidence study [129]. Getting starting: moving the evidence into practice When evidence is moved into practice, a number of barriers are likely to arise. Barriers include research data inaccessible to busy practitioners, lack of skill for appraisal of the literature, and limited organizational and individual support to help implement the evidence. It is clear that passive dissemination of information does not work. The greatest success is seen when multifaceted interventions are aimed at different barriers rather than any single strategy [130–132]. Structures and processes need to be incorporated into current care routines. Auto feedback can be used to keep staff engaged in the change process [133]. There are five steps that can introduce interventional patient hygiene within a unit or organization to reduce VAP and pressure ulcers (Box 3) [10]. Step 1 involves performing an initial assessment of the current practices in oral care, suctioning, mobility, bathing, and incontinence management. Practices that are currently not evidence based should be identified. Step 2 encompasses consolidation of current hygiene and mobility practices under the framework of a comprehensive interventional patient hygiene bundle. Baseline data should be measured using standard definitions for VAP and pressure ulcer incidence rate. The value of these care practices can be highlighted with the staff by sharing the scientific evidence and eliciting their participation in the establishment of protocols and guidelines. Using a shared decision-making model, step 3 contains selecting processes and products that help support compliance of the protocols and help nurses consistently do the right thing in an efficient manner. Step 4 is implementation of the change. Postimplementation rates should be measured after ensuring sufficient compliance with practice changes. Results should then be compared against baseline data and regional and national benchmarks if available. The final step is the continued measurement of compliance on a quarterly basis until the new practice becomes part of the routine. Essential to the success of the process is to ensure ownership and participation of all key practitioners. This allows the change to become real and permanent. The goal is to weave the new

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Summary Box 3. Five-step process for implementation of interventional patient hygiene Step 1  Perform an initial assessment of the current practices in oral care, suctioning, mobility, bathing, and incontinence management  Determine which practices are currently not evidence based Step 2  Consolidation of current hygiene and mobility practices under the framework of a comprehensive interventional patient hygiene bundle  Measure baseline data using standard definitions for VAP and pressure ulcer incidence rate  Build value care practices by sharing the scientific evidence and eliciting their participation in the establishment of protocols and guidelines Step 3  Select processes and products that help support compliance of the protocols using a shared decisionmaking model Step 4  Implement the change  Measure rates postimplementation after ensuring sufficient compliance with practice changes  Compare results against baseline data and regional and national benchmarks if available  Celebrate the success looking for progress, not necessarily perfection Step 5  Continued measurement of compliance on a quarterly basis until the new practice becomes part of the routine Courtesy of Advancing Nursing, Dearborn, MI; with permission.

care practices into the fabric of the unit or organization to create a safer patient environment [134,135].

The health care culture must change. Florence Nightingale wrote [8] ‘‘so deep-rooted and universal is the conviction that to give a medicine is to be doing something, or rather everything and to give air, warmth, cleanliness etc. is to do nothing.’’ Hygiene care practices and mobility activities are fundamental and independent care components in the nursing profession. When implemented using available evidence, they can significantly improve patient outcomes. It is time to reclaim and demonstrate the importance of consistent delivery of the fundamentals of basic nursing care. Interventional patient hygiene is an effective framework to ensure that the basics of nursing care are consistently applied to improve patient outcomes.

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