The Conceptual Framework
6.5 Potential Developments of HPIM
improve outcomes.” Nurses discussion focused mainly around the patients’ vulnerability, management of constipation, inconti- nence care, pain management, and mobility [39]. Even if, at present, there are no available data about their effectiveness, the APN-led nursing rounds were found “extremely valuable” by over 60% of surveyed nurses, finding an extensive implementa- tion in other hospital’s acute care areas [39].
Moreover, constipation is an independent risk factor for mor- tality in critically ill patients [43]. Data from observational stud- ies revealed the significant increasing of 12% (p < 0.001) in mortality, and of 32% (p < 0.001) in acquired bacterial infec- tions between mechanical ventilated patients with late opening of bowel (after the fifth day of ICU stay) [44].
At present, constipation in critically ill patients remains an open issue due to the lack of studies evaluating the efficacy of bowel management protocols implementation, and the impor- tant limitations of the published research, often related to small samples or to inclusion criteria [45]. Furthermore, some authors speculated that bowel management protocol failure could be due to the lack of adherence clinicians [46]. Hence, this issue assumes a high value in term of nursing outcomes and interven- tions, requiring energies to spend in the research and in clinical practice improvement.
Currently, as for bowel management, there are no evidence- based practice guidelines to optimize the conditions of sleep and rest for patients in ICUs [47]. Nevertheless, promoting sleep and rest for patients remains an open issue for ICU nurses because of the important consequences and complications caused by sleep deprivation [48], and it should have a place in the IPHM. The sleep in critically ill patients is mainly characterized by severe fragmentation, equally distributed between day and night, increased time in stage 1 sleep, decreased time in stages 2, 3, 4, REM stage, and increased arousals and awakenings [49]. From an epidemiologic point of view, sleep disturbance in critically ill patients is difficult to estimate, due to the variation in its definition provided in literature. However, studies from literature suggest that high percentages of ICU patients are affected by poor sleep quality, prolonged sleep latency, and frequent arousals/awaken- ings [50]. Some authors report that 38% of ICU patients had dif- ficulties to fall asleep, and almost 70% of cancer patients admitted in ICU had serious sleep disturbances [50].
Factors affecting the architecture and quality of sleep in ICU patients are [48, 49, 51, 52]:
• Environmental noise, i.e., staff conversations and monitoring alarms
• Prolonged exposure to low levels of artificial light, lighting practices
• Pain or illness and consequent psychosocial stress
• Anxiety
• Psychosis
• Patient care activities, i.e., vital signs, medication administra- tion, and diagnostic testing
• Dyssynchrony with mechanical ventilation
• Inflammatory mediators
• Pharmacological agents, i.e., sedative, opioids, benzodiaze- pines, and inotropes
• Increased cortisol release
• Decreased endogenous melatonin levels
• Preexisting sleep disorders
At present there is no clear evidence about the relationship between sleep deprivation and mortality in ICU. Researches per- formed on animals showed that lack of sleep was associated with increasing in mortality rates, offering the basis to hypothesize an association to be proved by large observational studies [51].
However, sleep deprivation produces multisystem conse- quences in critically ill patients, summarized in Table 6.2.
The approach to prevention of sleep disturbance in ICU is clearly multi-professional and needs a strong contribution from nurses, with simple basic interventions [53].
Some authors have developed a clinical practice guideline (CPG) to promote sleep and rest in ICU patients, using the consultation with healthcare personnel to overcome the lack of evidence from research [47]. The CPG leading principles were provide optimal conditions for nighttime sleep, optimize circa- dian rhythm, manage pain well, and provide a daytime rest period [47]. The components of rest and sleep CPG were
“optimize the environment,” “rest and sleep interventions,”
and, only at last, “consider sleep-promoting medication” [47].
The nursing interventions provided for the “optimize the envi- ronment” were [47]:
• Report faulty equipment and fittings.
• Quiet shoe rule.
• Environmental cleaning during daylight hours only.
• Quiet conversation.
• Lightings appropriate for the time of day.
The “rest and sleep interventions” were [47]:
• Manage pain well.
• Optimize normal circadian rhythm.
• Rest period during daytime hours.
• Provide optimal conditions for nighttime sleep.
Table 6.2 Consequences of sleep disturbance on ICU patients [53]
System Consequences
Neurological Agitation
Delirium
Post-traumatic stress disorder Continued sleep disruption Reduced tolerance of pain Neurocognitive disfunction Respiratory Weakness of upper airway muscles
Delayed ventilator weaning Apnea and hypopneas
Decreased hypercapnic and hypoxic responsiveness
Cardiovascular Arrhythmias
Nocturnal hypertension Worsening heart failure Death
Immune Delayed healing
Reduced ability to fight infections Altered tissue repair
The keyword emerging from this project was “sleep hygiene”
[47]. Therefore, this issue seems naturally to claim the right to enter in the Interventional Patient Hygiene Model.
Take Home Messages
• Basic nursing care interventions, if constantly performed, can exert a positive influence on patients outcomes and prevent complications.
• At present, the components of IPHM are bathing and inconti- nence management, patient mobility, oral care, dressing change, surgical site infection care, hand hygiene, skin anti- sepsis, and urinary catheter care.
• HPIM provides for evidence-based nursing interventions and nursing-sensitive outcomes assessment.
• HPIM gives a conceptual framework to strengthen the nurs- ing priorities.
References
1. Vincent JL. Critical care - where have we been and where are we going? Crit Care. 2013;17:S2. https://doi.org/10.1186/cc11500.
2. Bambi S, Lucchini A, Solaro M, Lumini E, Rasero L. Interventional Patient Hygiene Model. A critical reflection on basic nursing care in intensive care units. Assist Inferm Ric. 2014;33:90–6. https://doi.
org/10.1702/1539.16815.
3. Burns SM, Day T. A return to the basics: “Interventional Patient Hygiene” (a call for papers). Intensive Crit Care Nurs. 2012;28:193–6.
https://doi.org/10.1016/j.iccn.2012.05.004.
4. Savitz LA, Jones CB, Bernard S. Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005. http://
www.ncbi.nlm.nih.gov/books/NBK20600/. Accessed 05 Dec 2015.
5. Vollman KM. Interventional patient hygiene: discussion of the issues and a proposed model for implementation of the nursing care basics.
Intensive Crit Care Nurs. 2013;29:250. https://doi.org/10.1016/j.
iccn.2013.04.004.
6. Camporota L, Brett S. Care bundles: implementing evidence or com- mon sense? Crit Care. 2011;15:159. https://doi.org/10.1186/cc10232.
7. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1–45.
8. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health Organization; 2009. http://apps.who.int/
iris/bitstream/10665/44102/1/9789241597906_eng.pdf. Accessed 5 Dec 2015.
9. Wip C, Napolitano L. Bundles to prevent ventilator-associated pneu- monia: how valuable are they? Curr Opin Infect Dis. 2009;22:159–66.
https://doi.org/10.1097/QCO.0b013e3283295e7b.
10. Bouadma L, Wolff M, Lucet JC. Ventilator-associated pneumonia and its prevention. Curr Opin Infect Dis. 2012;25:395–404. https://doi.
org/10.1097/QCO.0b013e328355a835.
11. Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, et al.
epic3: national evidence-based guidelines for preventing healthcare- associated infections in NHS hospitals in England. J Hosp Infect.
2014;86:S1–70. https://doi.org/10.1016/S0195-6701(13)60012-2.
12. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009.
Infect Control Hosp Epidemiol. 2010;31:319–26. https://doi.
org/10.1086/651091.
13. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis.
2011;52:1087–99. https://doi.org/10.1093/cid/cir138.
14. Shah HN, Schwartz JL, Gaye L, Cullen DL. Bathing with 2% chlorhex- idine gluconate. evidence and costs associated with central line–associ- ated bloodstream infections. Crit Care Nurs Q. 2016;39:42–50. https://
doi.org/10.1097/CNQ.0000000000000096.
15. Anderson DJ, Podgorny K, Berríos-Torres SI, Bratzler DW, Dellinger EP, Greene L, et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol.
2014;35:605–27. https://doi.org/10.1086/676022.
16. National Collaborating Centre for Women’s and Children’s Health (UK). Prevention and treatment of surgical site infection. NICE Clinical Guidelines. London: RCOG Press; 2008.
https://www.nice.org.uk/guidance/cg74/evidence/full-guideline- 242005933. Accessed 3 Oct 2016.
17. National Institute for Health and Care Excellence. Surgical site infec- tion. Evidence Update June 2013. A summary of selected new evidence relevant to NICE Clinical Guideline 74 ‘Prevention and treatment of surgical site infection’ (2008). Evidence Update 43. Manchester:
National Institute for Health and Care; 2013. https://www.nice.org.uk/
guidance/cg74/evidence/evidence-update-241969645. Accessed 3 Oct 2016.
18. Dayton P, Feilmeier M, Sedberry S. Does postoperative showering or bathing of a surgical site increase the incidence of infection? A system- atic review of the literature. J Foot Ankle Surg. 2013;52:612–4. https://
doi.org/10.1053/j.jfas.2013.02.016.
19. Karki S, Cheng AC. Impact of non-rinse skin cleansing with chlorhexi- dine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review. J Hosp Infect. 2012;82:71–84. https://doi.org/10.1016/j.jhin.2012.07.005.
20. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2006;2:CD004985. https://doi.org/10.1002/14651858.CD004985.
pub2.
21. Beeckman D, Schoonhoven L, Verhaeghe S, Heyneman A, Defloor T. Prevention and treatment of incontinence-associated dermatitis: lit- erature review. J Adv Nurs. 2009;65:1141–54. https://doi.
org/10.1111/j.1365-2648.2009.04986.x.
22. Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:410–
6. https://doi.org/10.7326/0003-4819-158-5-201303051-00008.
23. Agency for Healthcare Research and Quality’s (AHRQ). Preventing pressure ulcers in hospitals. A Toolkit for improving quality of care.
http://www.ahrq.gov/sites/default/files/publications/files/putoolkit.pdf.
Accessed 3 Dec 2015.
24. Duncan CN, Riley TV, Carson KC, Budgeon CA, Siffleet J. The effect of an acidic cleanser versus soap on the skin pH and micro-flora of adult patients: a non-randomised two group crossover study in an inten- sive care unit. Intensive Crit Care Nurs. 2013;29:291–6. https://doi.
org/10.1016/j.iccn.2013.03.005.
25. Powers J, Peed J, Burns L, Ziemba-Davis M. Chlorhexidine bathing and microbial contamination in patients’ bath basins. Am J Crit Care.
2012;21:338–42. https://doi.org/10.4037/ajcc2012242.
26. Johnson D, Lineweaver L, Maze LM. Patients’ bath basins as potential sources of infection: a multicenter sampling study. Am J Crit Care.
2009;18:31–8. https://doi.org/10.4037/ajcc2009968.
27. Vollman K. Back to the fundamentals of care: why now, why us! Aust Crit Care. 2009;22:152. https://doi.org/10.1016/j.aucc.2009.09.001.
28. McGuckin M, Shubin A, Hujcs M. Interventional patient hygiene model: Infection control and nursing share responsibility for patient safety. Am J Infect Control. 2008;36:59–62. https://doi.org/10.1016/j.
ajic.2007.01.010.
29. Kool DR, Blickman JG. Advanced Trauma Life Support®. ABCDE from a radiological point of view. Emerg Radiol. 2007;14:135–41.
https://doi.org/10.1007/s10140-007-0633-x.
30. Monsieurs KG, Nolan JP, Bossaert LL, Greif R, Maconochie IK, Nikolaou NI, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation.
2015;95:1–80. https://doi.org/10.1016/j.resuscitation.2015.07.038.
31. Bambi S. Nursing clinical practice in intensive care unit (ICU) settings.
Dimens Crit Care Nurs. 2012;31:212–3. https://doi.org/10.1097/
DCC.0b013e318253e61f.
32. Farrell GA. From tall poppies to squashed weeds*: why don’t nurses pull together more? J Adv Nurs. 2001;35:26–33.
33. Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Sermeus W, RN4CAST Consortium. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. Int J Nurs Stud.
2013;50:143–53. https://doi.org/10.1016/j.ijnurstu.2012.11.009.
34. Kalisch BJ, Tschannen D, Lee KH. Do staffing levels predict missed nursing care? Int J Qual Health Care. 2011;23:302–8. https://doi.
org/10.1093/intqhc/mzr009.
35. Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Care Nurs. 2004;20:69–76. https://
doi.org/10.1016/j.iccn.2004.01.004.
36. Feider LL, Mitchell P, Bridges E. Oral care practices for orally intu- bated critically ill adults. Am J Crit Care. 2010;19:175–83. https://doi.
org/10.4037/ajcc2010816.
37. McGuckin M, Torress-Cook A. Interventional patient hygiene for the wound care professional. Adv Skin Wound Care. 2009;22:416–20.
https://doi.org/10.1097/01.ASW.0000360257.38099.68.
38. Carr D, Benoit R. The role of interventional patient hygiene in improv- ing clinical and economic outcomes. Adv Skin Wound Care.
2009;22:74–8. https://doi.org/10.1097/01.ASW.0000345281.97908.24.
39. Mahanes D, Quatrara BD, Shaw KD. APN-led nursing rounds: an emphasis on evidence-based nursing care. Intensive Crit Care Nurs.
2013;29:256–60. https://doi.org/10.1016/j.iccn.2013.03.004.
40. Mostafa SM, Bhandari S, Ritchie G, Gratton N, Wenstone R. Constipation and its implications in the critically ill patient. Br J Anaesth. 2003;91:815–9.
41. Nassar AP Jr, da Silva FM, de Cleva R. Constipation in intensive care unit: incidence and risk factors. J Crit Care. 2009;24:630.e9–12. https://
doi.org/10.1016/j.jcrc.2009.03.007.
42. McPeake J, Gilmour H, Macintosh G. The implementation of a bowel management protocol in an adult intensive care unit. Nurs Crit Care.
2011;16:235–42. https://doi.org/10.1111/j.1478-5153.2011.00451.
43. de Azevedo RP, Rezende Freitas FG, Ferreira EM, Ribeiro MF. Intestinal constipation in intensive care units. Rev Bras Ter Intensiva.
2009;21:324–31.
44. Gacouin A, Camus C, Gros A, Isslame S, Marque S, Lavoué S, et al.
Constipation in long-term ventilated patients: associated factors and impact on intensive care unit outcomes. Crit Care Med. 2010;38:1933–
8. https://doi.org/10.1097/CCM.0b013e3181eb9236.
45. Bambi S, Lumini E. “Back to basic”: starting again from the “basics”
of nursing to improve patient outcomes. Scenario. 2012;29:5–7.
46. Knowles S, McInnes E, Elliott D, Hardy J, Middleton S. Evaluation of the implementation of a bowel management protocol in intensive care:
effect on clinician practices and patient outcomes. J Clin Nurs.
2014;23:716–30. https://doi.org/10.1111/jocn.12448.
47. Elliott R, McKinley S. The development of a clinical practice guideline to improve sleep in intensive care patients: a solution focused approach.
Intensive Crit Care Nurs. 2014;30:246–56. https://doi.org/10.1016/j.
iccn.2014.04.003.
48. Pisani MA, Friese RS, Gehlbach BK, Schwab RJ, Weinhouse GL, Jones SF. Sleep in the intensive care unit. Am J Respir Crit Care Med.
2015;191:731–8. https://doi.org/10.1164/rccm.201411-2099CI.
49. Weinhouse GL, Schwab RJ. Sleep in the critically ill patient. Sleep.
2006;29:707–16. https://doi.org/10.1164/rccm.201411-2099CI.
50. Matthews EE. Sleep disturbances and fatigue in critically ill patients.
AACN Adv Crit Care. 2011;22:204–24. https://doi.org/10.1097/
NCI.0b013e31822052cb.
51. Delaney LJ, Van Haren F, Lopez V. Sleeping on a problem: the impact of sleep disturbance on intensive care patients - a clinical review. Ann Intensive Care. 2015;5:3. https://doi.org/10.1186/s13613-015-0043-2.
52. Friese RS. Sleep and recovery from critical illness and injury: a review of theory, current practice, and future directions. Crit Care Med.
2008;36:697–705. https://doi.org/10.1097/CCM.0B013E3181643F29.
53. Tembo AC, Parker V. Factors that impact on sleep in intensive care patients. Intensive Crit Care Nurs. 2009;25:314–22. https://doi.
org/10.1016/j.iccn.2009.07.002.
177
© Springer International Publishing AG, part of Springer Nature 2018 I. Comisso et al., Nursing in Critical Care Setting,
https://doi.org/10.1007/978-3-319-50559-6_7