CLINICAL ROLE - THE “MASSIVE RESPONSIBILITY” OF THE ROLE OF THE ICU NURSE

5.2 DISCUSSION OF FINDINGS

5.2.1 THE “MASSIVE RESPONSIBILITY” OF THE ROLE OF THE ICU NURSE

5.2.1.3 CLINICAL ROLE

Participants raised clinical issues relating to the intensive care nurse’s role in antimicrobial stewardship. These were the ongoing monitoring of the critically ill patient in order to identify early signs of infection, the correct administration of antimicrobial therapy and infection prevention and control. All participants viewed monitoring of the patient’s condition as including the ongoing assessment of the clinical parameters of the patient. This is seen as a primary function of nurses by Kutney-Lee, Lake and Aiken (2009) who identify the components of monitoring as ongoing observation and assessment, recognition of changes and the significance of these changes and decision-making and is enhanced by educational background, clinical experience and specialist competencies. Little attention has been given to those aspects of clinical nursing practice that may contribute to the development of antimicrobial resistance (Edwards, Loveday, Drumright et al. 2011).

Nursing participants said that a large part of their responsibilities was the daily monitoring of microbiology reports, infective markers and blood cultures by shift leaders to identify infections. Risk factors for infection in ICU include an impaired host defence mechanism due to severe illness, malnutrition, immune compromise and invasive devices. Other risk factors are the inappropriate use of antimicrobial therapy, prolonged length of stay, mechanical ventilation and lack of adequate infection control and antimicrobial protocols (Perovic, 2011). The monitoring of antibiotic ‘days’, invasive line ‘days’ and endotracheal tube ‘days’

was identified by participants as an important part of the ICU nurse’s role in antimicrobial stewardship (Vasuthevan, 2012). Invasive lines such as central and arterial lines and urinary catheters were monitored to determine days of insertion and potential for infection. Daily rounds were conducted by the shift leaders to ensure compliance with record keeping and appropriate interventions by the floor nurses such as prompt removal of invasive lines when possible.

Nursing participants stated that daily monitoring of infective markers such as PCT were part of routine care with ill patients in the unit. The monitoring of infective markers in critically ill patients is essential to guide antimicrobial therapy (Kollef and Micek, 2012). C-reactive protein (CRP) levels are no longer regarded as useful indicators of infection and are seen to be misleading as surgical interventions result in an increased CRP. Procalcitonin (PCT) levels have been found to show a better correlation with clinical severity and are useful in guiding antimicrobial therapy in the ill patient (Schuetza, Raadb and Aminc, 2013). It is important to differentiate between an inflammatory response and the infective process. The immune response generally results in a rise in temperature but fever and leucocytosis are signs of an inflammatory response and not necessarily an indication of infection. If a PCT is low, antibiotics are not indicated but a raised PCT along with a rise in white cell count and leucocytes is a reliable indication that an infective process is occurring in the patient with levels rising swiftly within two to four hours and normalizing with recovery (Hayashi and Paterson, 2011). However, features of sepsis that continue several days following the antibiotic intervention may mean that there has been inadequate source control (Richards, 2010).

Nursing participants stated that specimens for MC&S were taken by the floor nurse on insertion of invasive lines and on intubation of the patient in order to monitor for nosocomial infections. South African microbiologists Wasserman, Boyles and Mendelson (2014), have

provided guidelines for taking specimens in order to minimise specimen contamination which might lead to unnecessary antibiotics. Recommendations are also that “sterile site” cultures, such as blood cultures, are more reflective of true infection than “non sterile site” cultures such as a positive endotracheal aspirate, wound or urine culture which are more likely to be contaminated or colonized (Katsios, Burry, Nelson et al. 2012). Nursing participants said that blood cultures were taken when indicated however one nursing participant said that this had to be discussed with the shift leader and the specialist managing the patient. Blood stream infections occur in approximately 15% of critically ill patients (Afshari, Pagani and Harbarth, 2012). ‘Surviving Sepsis Campaign’ recommendations include 6 care elements necessary to reduce morbidity and mortality from severe infection. One of these is that blood cultures need to be taken before antibiotics are commenced (Dellinger, Levy, Rhodes et al. 2012). All participants noted that the floor nurse caring for a patient received the laboratory reports for that particular patient and that the nurse had a duty of care to read and understand these reports and to communicate positive finding to the relevant doctors. Antibiogram results were closely monitored for appropriate response to microbial sensitivity and this was seen by both nursing and non-nursing participants as an important aspect of the nurses’ monitoring role.

Most of the nursing participants and two non-nursing participants identified infection control in an ICU as an essential part of the antimicrobial stewardship programme in order to actively address the problem of hospital-acquired infections (Best Care Always, 2011). Infection control in the private healthcare sector in South Africa is often seen as an area that is the specific concern of nurses. This should be an area of collective responsibility (Mendelson, Whitelaw, Nicol et al. 2012). Surveillance, hand hygiene compliance, isolation precautions, environmental cleaning, auditing, measuring of compliance and feedback and positive reinforcement have been promoted by FIDSSA (2012) as part of the role of the infection control practitioner within an antimicrobial stewardship programme.

Infection control has become part of general hospital management and nurses recognize this as being an integral part of intensive care protocol with a dedicated infection prevention and control nurse allocated to these programmes. The patient who requires admission into an ICU is often compromised by trauma, extensive surgery or chronic disease such as HIV or tuberculosis and is vulnerable to opportunistic infections and hospital-acquired infections.

Contributing factors to infection in the critically ill patient are poor nutrition, hypotension, ischaemia and reperfusion, trauma and therapy with corticosteroids or immune suppressives

(Mer, 2003). ICUs can be ‘hot spots’ for infection if infection control is not carefully implemented (Rice, 2003) and infection control practices need to be closely scrutinized for the purpose of identification of resistant pathogens within the unit environment (Essack, 2006). The increasing number of hospital-acquired infections and antibiotic resistance is linked to the indiscriminate use of antibiotics which ‘exerts a detrimental selective pressure on the broader bacterial ecology’ (Dryden, Cooke and Davey, 2009:1). Antimicrobial resistance emerges in the intensive care environment through selective pressure from antibiotic use and nosocomial transmission by healthcare workers (Majumdar and Padiglione, 2012) and those patients who develop infections from resistant pathogens generally require prolonged medical treatment (Edwards, Loveday, Drumright et al. 2011).

Ventilator-associated pneumonia (VAP) was identified by nursing participants as a common hospital-acquired infection in ICU. Risk factors for ventilator-associated pneumonia include age over 70 years, chronic lung disease, aspiration and previous antibiotic exposure and is the second leading cause of nosocomial infection in ICU following urinary tract infections (Afshari, Pagani and Harbarth, 2012). It is defined as a pneumonia occurring between 2 and 3 days after a patient is placed on mechanical ventilation (Gillespie, 2009) and results in increased levels of morbidity and a mortality of 70% (Freeman, 2010). Care bundles for the prevention of ventilator-associated pneumonia initially included the elevation of the head of the bed to 30 degrees at all times to minimize micro-aspiration of secretions, daily sedative interruption and evaluation of readiness for extubation, peptic ulcer prophylaxis and venous thromboembolism prevention (Majumdar and Padiglione, 2012). Revised VAP care bundles have replaced the latter two interventions with subglottic secretion drainage, the use of chlorhexidine in mouth care and initiation of early enteral feeding to minimize translocation of gastrointestinal organisms (Best Care Always, 2012).

A nursing participant felt that ventilator-associated pneumonia was linked with the aspiration of secretions from the mouth. There has been widespread concern that nasopharyngeal secretions seep down into the lungs past the endotracheal cuff (Lawrence and Fulbrook, 2011) and strategies for preventing ventilator-associated pneumonia include reducing colonization and aspiration (Majumdar and Padiglione, 2012). Control of gravitational seepage of these secretions by using a sub-glottic device that provides a continuous suction is seen to minimize aspiration of bacterial contaminated secretions that accumulate above the cuff of the endotracheal tube (Perovic, 2011). This device has been shown to reduce the

incidence of ventilator-associated pneumonia but not length of stay in ICU or mortality (O’Grady, Murray and Ames, 2012). Oral care, the avoidance of accumulation of secretions and adequate cuff pressure are the three goals of prevention of micro aspiration (Blot, Poelaert and Kollef, 2014).

Participants did not mention managing endotracheal cuff pressure when discussing infection control aspects of the nurse’s role in antimicrobial stewardship. The maintenance of an adequate cuff pressure is important for adequate tidal volumes and ventilation but also to prevent pharyngeal secretions from seeping down into the lungs and starting an infective process. In a South African survey carried out by Jordan, van Rooyen and Venter (2012), poor cuff practice was noted in private ICU and this was attributed to the high levels (36%) of agency nurses which are used to augment permanent staff. Current practice in South African ICUs is to measure the cuff pressure several times over the course of a 12 hour nursing shift. A worrying variation in endotracheal cuff pressures was noted when pressures were measured continuously and occurred both with patient movement and during nursing and other healthcare staff interventions and were not identified with routine intermittent measuring (Memela and Gopalan, 2014).

Nursing participants reported that hand washing and care bundles were used primarily in this ICU as the basis of its infection control. Infection control and hygiene are integral to control the spread of bacterial resistance (Paterson, 2007). Strategies used for infection prevention can be placed in two main groups; vertical interventions which monitor, screen and treat for a specific important pathogen, such as MRSA, and horizontal interventions which aim to avoid all infections and include hand hygiene, chlorhexidine bathing, and care bundles. The former are costly and the latter require compliance from healthcare workers in order to be effective (Edmond and Wenzel, 2013). Although hand washing was known to be important and training was reported to be ongoing, concern was expressed by some of the nursing participants that this was not happening as it should.

Hand washing has been shown by extensive studies to be the most important evidence-based intervention for the prevention of transmission of pathogens as a result of direct contact but despite widespread education healthcare workers do not wash/ spray their hands with compliance found to be only 40% in ICUs in South Africa (Brink, Feldman, Duse et al.

2006). In an earlier South African study Candida albicans was found on the hands of 39% of

ICU staff (Mer, 2003). Acceptance of poor standards of hygiene in intensive care units may contribute to blood stream infections with pathogens such as Pseudomonas aeruginosa, Acinetobacter species, Stenotrophomonas maltophilia and Candida species which result from hand contamination of central lines by healthcare workers (Mer, 2006).

A study into the control of carbapenem-resistant Pseudomonas aeruginosa showed that hand washing correlated with a reduction in this pathogen and confirmed the importance of infection control measures as part of antimicrobial stewardship programmes (Dos Santos, Jacoby, Machado, Lisboa, Gastal, Nagel, Kuplich, Konkewicz and Lovatto, 2011).

Monitoring and tracking poor infection control in a unit by healthcare workers has been identified as an important way of providing feedback to the antimicrobial stewardship team and can contribute to decision-making regarding the need to audit behaviour and plan further educational programmes. Poor hand washing in particular can be confirmed by strain typing and will then confirm the need for education focused on infection control in that particular area (Essack, 2006; Deege and Paterson, 2011).

Another clinical aspect identified by participants as part of the role that the ICU nurse plays in antimicrobial stewardship was the coordination of antimicrobial therapy, ordering antibiotics from the pharmacy and the correct administration of antibiotics. Nursing participants indicated that a collection of original antibiotics was kept in ICU to reduce ‘hang time’ when starting a patient on an antibiotic. This was a new initiative in the ICU and was felt to be necessary because of prolonged delays in the delivery of stock from pharmacy.

Guidelines for the management of patients with septic shock or severe sepsis are that broad spectrum antibiotics are given within an hour of diagnosis. These should be available in clinical areas to prevent delay in administration (Peel, 2008). There may be a misunderstanding currently regarding this one hour period with the misconception that all patients in ICU who have been prescribed antibiotic treatment must have this within one hour. This is part of the Surviving Sepsis Campaign Guidelines (SSC) and refers specifically to patients in a clinical crisis due to infection (Dellinger, Levy, Rhodes et al. 2013). Hranjec and Sawyer, (2013) suggest that withholding antibiotics while waiting for more information about the infection may not be necessarily harmful to patients who do not fall into the categories described by the SSC guidelines.

Dalam dokumen Exploring the role of the intensive care nurse in the antimicrobial stewardship team at a private hospital, eThekwini, South Africa. (Halaman 86-92)