| Background and Objection:Intensive Care Unit (ICU) is a clinical area where they place a person who is in very critical condition so he/she can be monitored closely and treated timely and effectively. Professional knowledge, skills and equipment are fixed in ICU. Mechanical ventilator has become a common medicine skill and live support method for lung function. Now, mechanical ventilator is used popular in ICU. Esteban et al surveyed412medical-surgical ICUs and showed that39%patients received mechanical ventilation. But there may be some ventilation associated complication during mechanical ventilation, one of which is ventilator-associated pneumonica (VAP).As the rearch on mechanical ventilation, intervention on reduction of ventilation associated complication and promotion of withdrawl bring benefit to critical ill patients. But the rate of VAP remains at high level. Meta analysis showed that8-28%of the patients receiving mechanical ventilation occurred VAP, and the mortality rate for VAP varied between24%and76%. VAP lead to increase mechanical ventilation long10-32days, length of stay9days, and adds an estimated cost of more than $40000per patient.Recently, It focus on How to prevent or reduce the VAP. VAP associated guideline were published by many organization or association. Such as, Canadian Critical Care Society an Critical Care Trials Group published "Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia" in2004. As the spread of evidence-based medicine, evidence-based practice guideline has become more and more important in health care area. Evidence-based nurse could decrease VAP efficiently with practicable, safe and low cost care item. But the evidence-based knowledge did not bring about the ideal improvent of clinical practice. On the status of poor evidence-based practice compliance, researchers started some study to try to find out the effect factor of practice. But most of the researches surveyed the common factor subjectively, without systematic assessment based on theory.In China, there are few reports and researches on the current evidence-base cognition and practice for reducing VAP in ICU, especially on the gap between cognition and behavior and the influencing factors. The purpose of this study was to analysis the status of evidence-based knowledge and practice for reducting VAP in nurse and explore influencing factors of evidence-based practice with system evaluation, to study the nursing countermeasures, so as to provide evidence for improving clinical practice.Methods1, For assessing the evidence-based practice of units for reducting VAP in China, a self-designed questionnaire was developed. Evidence-based clinical practice guidelines published by the Centers for Disease Control and Prevention, the American Thoracic Society and Canadian Critical Care Society were reviewed as an standard for developing the questionnaire on VAP practice evaluation. We also searched Medline database for systematic reviews, Meta analyses and randomized controlled trials to summarize the best practices, following the questionnaire under Chinese clinical culture. The questionnaire was send to ICU via Email. The address was searched though the Chinese journal database in which ICU nurses’thesis was collected.For assessing the practice of reducting VAP in ICU nurses, a self-designed questionnaire similar to the former one was send to every nurse in ICU by mail. The setting for this part of study was choosen in Guangdong Province. The22units from Guangzhou, Shenzhen, Zhuhai, Foshan, Shantou, Zhanjiang, Qingyuan, Yangjiang were selected by convenient sampling method. The feature of clinical was analysiscd and gap between clinical practice and nursing quality standard in ICU was discussed.2, For assessing the evidence-based knowledge of nurses for reducting VAP in ICU, a self-designed questionnaire was developed, according to evidence-based guidline for reducing VAP and "Critical care nurses" knowledge of evidence-based intervention for preventing VAP" Questionnaire from foreign research. Convenience sampling was used and all nurses in an intensive care unit of Zhujiang Hospital in Guangzhou were chosen. The self-designed questionnaire was send by researcher.To compare the evidence-based knowledge and practice in ICU nurse, two item which were mastered well by nurse were chosen to monitor:head-of-bed and endotracheal tube cuff pressure. The critical patients in the ICU same as in the nurse knowledge research were chosen. The researcher assessed the monitoring item for6-7patients by objective equipment on workday anytime. The protractor and piezometer were used.3, We searched Medline, PsyARTICLES, Nursing consult and The Cochrane Library with the goal of finding article that describe the influencing factor of nursing behavior based on Plan Behavior Theory. Search strategy was defined to ("nurse"OR "nurses" OR "Nursing staff OR "Nursing staffs") And ("Behaviour" OR "intention") AND "Planned Behavior". We also search articles in Chinese dababase. The influencing factor of clinical evidence-based nursing practice were analysis through this system evaluation.4, Focusing on effect of time on clinical evidence-based practice, the nursing workload of all patients admitted in a Chinese ICU in April2011was analysed to propose appropriate manpower resource planning, with the special measure tool NAS. For the comparison between nursing workload and workforce, it was considered the actual number of nurses available in an eight hour shift. The variables of patient, i.e. gender, age, length of stay (LOS), acute physiology and chronic health evaluation II (APAHE II) were analysed to explore the relationship with workload. Especially, mechanical ventilation was considered as an important predict factor of workload to analysis. All data were collected only by a researcher who had experience with using NAS. The NAS data were filled out at8:00daily from admission to discharge from the unit, using information from the patient medical records and daily patient worksheet.5, Focusing on influence of perceived behavior controll on clinical evidence-based practice, the effect of head-of-bed for reducing VAP was analysis to solve knowledge identification. The patients with mechanical ventilator more than24hours admitted in an ICU in April2011was divided into three groups randomly: control (the normal practice in ICU),45°group, and30°group. The angel of bed was monitored by researcher every hour between8:00and18:00everyday. The angle card was used by nurses to maintain angle. In control, the standard protocol was performed with no intervention. In30°group, the head of bed was elevated to30°, with the other care same as control. In45°group, the angle was raised to45°. The study was end when patients were extubated, out of unit or dead.Results:1, The clinical practice of VAP reduction in Units:Only56.5%of respondents had one special nurse for infection control. In oral care,10(21.7%) units used chlorhexidine as oral care solution, while normal saline was most common one (n=39,84.8%). The most common tool used was cotton ball (n=41,89.1%), while only21.7%(n=10) of respondents provided oral care using a toothbrush. A majority (n=25,54.3%) of units practiced oral care every12hours and26.1%(n=12) every8hours. In nasogastric feeding care,76.1%measured gastric residue liquid before each feeding for intermittent feeding patients, while79.5%reported checking gastric residual volumes every4-8hours for continuous feeding patitents. In positional strategies, Semi-Fowler’s position was most commonly used position techniques in our study (n=42,91.3%) and29(63.0%) of respondents put the bed-angle indicator into clinical practice to access the compliance. In endotracheal tube management,34.8%chose multiuse closed system suction catheter, and most respondents (n=21,45.7%) obtained endotracheal tube cuff pressure every8hours. Beside this, one kind of endotracheal tube used for ventilation had a lumen above the endotracheal cuff to drain subglottic secretion, which was used by19(41.3%) ICUs for continuous or intermittent suction. In hand hygiene,91.3%(n=42) of respondents reported that they performed washing hand "always" or "frequently"The clinical practice of VAP reduction in ICU nurses of Guangdong Province: The goodness of fit between clinical practice of ICU nurses and nursing quality standard of ICU unit was divided into5levels.12.5%of respondents reached to level1,and there were25.3%、29.4%、17.4%、8.1%of respondents reached to level2to5respectively. In oral care,30.4%of respondents used chlorhexidine as oral care solution, while55.1%used normal saline. The most common tool used was cotton ball (89.1%) and nurses practiced oral care every12hours mostly. In nasogastric feeding care,97.0%measured gastric residue liquid before each feeding for intermittent feeding patients, while94.8%reported checking gastric residual volumes every4-8hours for continuous feeding patitents. In positional strategies, Semi-Fowler’s position was most commonly used position techniques in ICU nurses (91.5%) and66.6%of respondents put the bed-angle indicator into clinical practice for assessment "always" or "frequently". In endotracheal tube management,31.0%of respondents chose multiuse closed system suction catheter,78.9%practiced suction according to the patients’need, and68.0%obtained endotracheal tube cuff pressure every4-8hours. Beside this, one kind of endotracheal tube used for ventilation had a lumen above the endotracheal cuff to drain subglottic secretion, which was not used by53.2%of respondents for continuous suction. In hand hygiene,99.2%of respondents reported that they performed washing hand "always" or "frequently"2, The status of evidence-based knowledge about VAP reduction:The mean score of knowledge in nurses was3.39±0.65, with sum score5.97.2%of respondents recognized head-of-bed at an angle of30-45degrees in the absence of medical contraindication. All ICU nurses answered that the endotracheal tube cuff pressure should be maintain at20-30cmH2O. The correct rate of questions about subglottic secretion drainage, gastic residual volume monitoring and ventilator circus management were88.9%,22.2%and13.9%The status of clinical nursing practice, with good evidence-based cognition:The angle of head of the bed was accessed152times, of which74times were for mechanical ventilated patient and78times for non-mechanical ventilated patient. There was no difference between these two groups. In mechanical ventilated patients, the mix angle was10degree, while the max52degree.33.8%of angles fit for the standard, and64.8%was less than30degree.The endotracheal tube cuff pressure was tested122times, of which80times were for mechanical ventilated patients and42times for spontaneous breathing patients with endotracheal tube. In mechanical ventilated patients, the mix pressure was2cmH2O, while the max100CmH2O.40.0%of pressures fit for the standard, as43.8%was insufficient and16.2%out of pressure.3, Systematic review:A total of12articles were identified in the review. There were variations in efficacy of prediction of intention; the R2varied from15.5%to88%. Overall, the frequency-weighted mean R2was53.5%(Number of studies=12, number of nurses=5107).10studies showed that attitude had obvious efficacy of prediction of intention, while the other two reported few efficacy of attitude on care for HIV/AIDS patients and hand hygiene.9studies reported there was predicting efficiency of subjective norms on intention. Subjective norms had weak effect on intention of care for HIV/AIDS or SARS patients and offering smoking cessation advice in accordance with coronary heart disease guidelines. Analysis the efficacy of perceived behavioral control, only one research identified that had no effect on prediction of intention. The model of theory of planned behavior was extended to explain the intention of behavior, which knowledge of nurse, past experience, practice ability, years of working, intensity of activity in the nursing unit were added.4, Countermeasure analysis of time as an effect factor on practice:The patients remained on average9.6(±8.7) days in the ICU, and the mean NAS was56.0(±9.7%). There were14-25patients (mean18.5±2.5)everyday. Analysis of workload, the actual worktime was between187.5to301.2hours everyday. According to the actual number of nurse working everyday, it should increase mean3nurses every shift. High NAS scores were associated with the use of mechanical ventilation (p=0.013). Univariate analysis demonstrated that disease severity (p=0.014), ventilator (p=0.013) and discharge (p=0.006) presented an independent effect in determining nursing demand.5, Effect of head-of-bed on reduction of VAP:A sample of size of44patients was collected.15patients were allocated to the control group,15were to the30°group, while14were to the45°group. Six of the control group (40%) developed VAP, one confirmed and five suspected. Four of the30°group (26.7%) developed VAP, one confirmed and three suspected. Three of the45°group (21.4%) developed VAP, two confirmed and one suspected. There was no stastical difference among three group (p=0.541), the same as the ventilator time, long of stay and morality of patients.Conclusion1, The results of clinical practice of VAP reduction in Units can only be used as reference. Infection control nurse was not universal in ICU. The practice of nasogastric feeding care and hand hygiene were performed well. But oral care had gaps with the international evidence-based guideline; And it should focus on endotracheal tube management and position practice, which should be improved.There was the gap between clinical practice of VAP reduction in ICU nurses of Guangdong province and nursing quality standard in units. The clinical practice status was similar to the result of units survey, but was more close to the international evidence-based guideline.2, The evidence-based nursing knowledge was mastered well. And it should strengthen the nurses’consciousness of evidence-based nurse and renew the knowledge though active education. However, there was gap between evidence-based practice and knowledge. The compliance of behavior had problem. Individual care can not be provided according to the characteristics of patients. We should understand the special subject of special evidence-based practice, and take care using critical thinking.3, The effect factor of clinical nursing practice included knowledge, attitude, subjective norms, perceived behavioral control, resource, envirment support, time and so on. The theory of planned behavior could explain and predict clinical behavior of nurse. The intervention could be designed to improve the practice accoding the effect factor of behavior.4, Chinese ICU is short of nursing resource and it is important to arrange the limited nurse reasonably using the special ICU workload measurement tool. According to the ventilated intervention and severity of illness, the ratio of nurse-to-patient could be modulated to fit for patient demand and nurse ability, which are prone to predict of the nursing manpower distribution and promote the evidence-based practice.5, Focusing on the effect factor of behavior, identification of knowledge influenced the perceived behavior] control. Analysis the countermeasure of problem on identification of head-of-bed, our research could not provide sufficient evidence to support its effect on reduction of VAP. However, the trend toward a reduction in the incidence of VAP by increasing the angle of bed head could be observed. For the evidence-based practice of head-of-bed, we should consider the risk of complication and the benefit of different patient, and the standard protocol should need further investigation. |
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