| Patients with impaired or compromised eye protective mechanisms in intensive care unit (ICU) are of high risk for developing exposure keratopathy for the reasons of the disorders and treatments they need. Exposure keratopathy is due to loss of eyelid protection and exposure of corneal to the air, causing dry, abrasion, and thus secondary corneal infection, ulceration, perforation, and even blindness, it will seriously affect patient’s quality of life. Ventilated ICU patients who are sedated and paralyzed are prone to incomplete eyelid closure and impaired blinking reflex, which are important risk factors of exposure keratopathy. Previous studies have found the effect of adopting several interventions to prevent exposure keratopathy, such as taping the eyelids, using eye drops, polyethylene covers and so on. However, no single intervention is proven to be effective by now. The integrated intervening measures that including eye cleaning, eye assessment and eyelid closure might be helpful to avoid these complications, there is still no unified standard for preventing exposure keratopathy, although some eye care guidelines have reported already, for example The Agency for Clinical Innovation of New South Wales implemented the guideline of Eye Care for Critically Ill Adults in Australia in 2014. This guideline decleares that all the recommendations need to be cautious to adopt due to lack of high-quality studies, and the scientificity and efficiency of guidelines must be verified in the future. There is no eye care guideline for critically ill patients in China. The present Chinese studies are all restricted in nursing experience, no study has reported in application of international guidelines in clinical nursing in China. Care bundles are a group of interventions with high-level evidence and which clinically proven to improve patient outcomes. These effects are much better than using a single intervention. Care bundles can transform the guidelines into the clinical practices and combine them closely. The study aimed to develop care bundles in prevention of exposure keratopathy in ICU and evaluate the effectiveness. This study based on investigating the KAP of ICU nurses on preventing eye complications, using the concept of cluster-based interventions by engaging in extensive reading of references and clinical practice.Objective1. To investigate the knowledge, attitude and practice of preventing eye complications among ICU nurses and provide the theoretical basis for the unified standard of preventing measures.2. To develop care bundles in prevention of exposure keratopathy in ICU.3. To implement care bundles and evaluate the effectiveness of its interventions on ICU patients.Methods1. Investigating the KAP of ICU nurses on preventing eye complications1.1 ParticipantsIn 2008, data were collected in ICUs in Guangdong Province. A convenience sampling method design, using questionnaires among 30 specialized ICU nurses who were trained by The Health Department of Guangdong province and the Hong Kong Hospital Authority.1.2 ToolsThe questionnaire is divided into three parts. Part 1 the Participants’characteristics; Part 2 A self-designed KAP questionnaire. A pilot study had been conducted and tested the critical ratio of each item of the knowledge (P<0.01), which showed the reaction of participant could be distinguished by each item. The internal consistency of the instruments was evaluated using Cronbach’alpha, which showed adequate reliability for the attitude base (α=0.735) and practice base (a=0.741). In addition, the questionnaire comprises three bases: knowledge base, attitude base and practice base. Knowledge base comprising 13 items (1 point for each item), and its content including the basic knowledge, risk factors and interventions of eye complication, and so on. Attitude base refers to nurses’attitude towards the prevention of eye complication, which comprise of 4 items. Scores range from 4-20. Practice base is regarded to the action which taken by nurses to prevent eye complication, while it comprise of 10 items. Scores range from 10-50. Nurses need to select the cleaning tools, solution and method, and write drown the name of eye drops and ointment which often used in patients. Part 3 a questionnaire was made to investigate the difficulties that nurses had encountered when they implement the interventions.1.3 ProceduresWe started the intervention for sending an Email to the investigator and introducing the purpose, content and methods of the study. When we received reply, the formal questionnaire was going to hand out. At the end of the investigation, we collected all the questionnaires.1.4 Statistical methodsStatistical processing of all data were analyzed using statistical software SPSS20.0, select the inspection level a=0.05, bilateral P<0.05 considered results statistically significant. Data were analyzed using the t test and one-way ANOVA where appropriate.2. Developing care bundles in prevention of exposure keratopathy in ICUTo be eligible for this study, the participants had to meet the following inclusion criteria:① ICU hospitalization more than 24 hours, and with age above 18 years. ② Intervention measures:taking one or more eye care measures; ③ Patient outcomes:judged by the incidence and severity of exposure keratopathy.④ The languages of the reference was limited to English and Chinese, without the year limits. The exclusion criteria are:① under 18 years of age, have a history of eye injury or eye disease.② Abstracts, reviews, summaries of clinical experience, case reports and repetitive articles which lack of complete data. A literature search was conducted in three international databases--PubMed, Science Direct databases and Google Scholar, and three Chinese databases--CNKI, VIP database and Wan Fang data. We first select papers focused on the headline and abstract of articles, and then read the full article. Studies are under priority preference guidelines, Meta analyses and RCT studies.3. To evaluate the effectiveness of care bundles for prevention of exposure keratopathy in ventilated critically ill patients with impaired blinking reflex3.1 ParticipantsBased on the inclusion criteria, a convenient sample of patients were recruited from the ICU, Zhujiang Hospital of Southern Medical University. Patients in the control group were enrolled from July to September in 2014, and patients in the intervention group from January to march in 2015.The inclusion criteria:① ICU hospitalization more than 24 hours;② with an age above 18 years. The patient’s condition should meet all of the following conditions. a) with a reduced or absence of blink reflex (less than 5 times per hour); b) with mechanical ventilation.The exclusion criteria:① with eyelid disease, defects and injuries;② have a history of eye surgery;③ on admission, the result of the corneal fluorescein staining was positive for the first time.The criteria for study termination:① patients are conscious and blink reflex was returned;② positive fluorescein staining;③ have an eye infection;④ The patient was transferred or dead.Loss of follow-up:① The nursing interventions of eye care were less than 24 hours;② the families of the patients put forward to dropout the study.3.2 Methods3.2.1 Interventions3.2.1.1 Control group methods① Nurses should take the routine eye care for the patients according to the eye care guidelines of Department. Including the evaluation of position of eyelid, conjunctival edema, eye clean for 1/4h, or covering the eyes of those can not close eyelids by taping or polyethylene film, dropping eyes of those can not use polyethylene film with chloramphenicol eye drops.② Head nurses or charge nurses should correct the error measures of eye care when making the rounds of the wards aperiodically.③ Patients’ eyes with abnormal conditions should be reported to doctor timely and the nursing documents should be recorded in.3.2.1.2 Intervention group methods① Education for nursesWhen training nurses, we must focus on the whole concept of care, and adopt a way of training that combing the theory and practice. The training covers eye anatomy, eye protection mechanism, the content and methods of care bundles. It needs a total of 4 class hours. The operation training takes the team training form, including the using method of ophthalmic, method and standard of covering polyethylene film, assessment and cleaning method for eyes. The researcher trained the 12-team leaders, and then the leaders trained their corresponding crew. A assessment was taken to ensure the training quality after the training.② The trained nurses implement the interventions on patients according to the care bundles, and the abnormal situation should be reported to the doctor promptly and recorded in the nursing documents.③ To ensure quality of the implementation of eye care interventions, the researcher should audit the eye care interventions daily, report the result weekly, and correct the error behavior timely.3.2.2 Evaluation indicator① The incidence of exposure keratopathy:severity of exposure keratopathy was tested by the fluorescein staining.② The compliance rate of implementation of eye care measures. The measures that keeping the corneal moist and eyelid closure are the evaluation contents. It is compliance, if eye drops or polyethylene film measures was properly performed, otherwise is not compliance. Compliance rate=number of compliance/number of observation.3.2.3 The methods of data collection① The researcher takes the first binocular fluorescein staining examination for the selected patients within 24 hours of admission, assess the patients’situation of eyelid closure and conjunctival edema at the same time, then takes the negative patients into the participant.② The fluorescein staining examination should be taken daily in the first week after admitted to ICU. The assessment of eyes and the implementation of eye care measures should be taken at the same time. The same content should be taken and the fluorescein staining examination weekly until the termination of this study.3.2.4 Statistical methodsStatistical processing of all data were analyzed using statistical software SPSS20.0, select the inspection level a=0.05, bilateral P<0.05 considered results statistically significant. Data were analyzed using the Chi-square test, Mann-Whitney-U test or t-est where appropriate. The time to detection of a fluorescein stain positive result was analyzed by survival analysis with the Kaplan-Meier method. A logrank test was performed to compare curves for the two groups.Result1. The status of KAP of ICU nurses on preventing eye complications① We investigate 450 nurses who were distributed in 21 ICU from 19 Hospital of Guangdong Province. Nurses’ age ranged from 19 to 51 (28.82±5.11) and their work age in ICU was from 1 to 33 (6.10±5.18) years. Most of them obtained Bachelor degree (67.1%) and the primary title (77.6%).② ICU nurses’ percentile scores of eye complications prevention knowledge, attitude and practice were (72.15±13.08), (86.80±9.30) and (65.64±10.12) points respectively. 49.1% of them use cotton swabs as eye cleaning tools, while 42.4% use cotton balls. The normal saline (86.9%) and wiping (92.4%) are used as the main cleaning solution and main cleaning method respectively.Eye drops commonly used in the clinical work are chloramphenicol (58.7%) and Ofloxacin (21.3%). eye ointments commonly used are erythromycin (47.6%) and chlortetracycline (27.6%). Pathways for ICU nurses to get eye complications prevention knowledge are textbooks (68.4%), ICU training (45.3%), academic lectures (32.9%).③ There is a significant difference (P<0.05) in the attitude and behavior between nurses with different degree and titles.④ When choosing difficulties in the interventions,90% of medical staff selected "being not enough to master the prevention knowledge", the 68.9% choice is "The department has no unified operation guidelines",52% choice is" lacking of care instrument", and 48.2% choice is "so busy at work".⑤ A total of 8 ICU (38.1%) has established guidelines for the prevention of eye complications, and the score of attitude and practice of the nurses from these 8 ICU are much higher (P<0.05).⑥ There is no significant correlation among knowledge, attitude and practice in preventing complications (P>0.05), while a significant correlation between attitude and behavior is showed (P<0.05).2. Developing care bundles in prevention of exposure keratopathy in ICU2.1 Results of literature search We finally selected 22 articles, including 19 English articles and 3 Chinese articles. Only 4 studies of eye-care guidelines in ICU were retrieved.2.2 Details of care bundles The care bundles, which integrated with clinical practice, cover eye assessment; eye cleaning; keeping eyelid closure and keeping the cornea moist; avoid bacterial colonization in ocular surface.① Eye assessment Assess the risk factors of exposure keratopathy and the ability of the ability of the patient to maintain eyelid closure every 8 hours. Assess corneal dryness and signs of suspected eye complications every 4 hours. Assess the sign of exposure keratopathy using fluorescein staining examination weekly.② Eye cleaning Cleaning the eyes with saline soaked cotton balls every 4 hours.③ Keeping eyelid closure and the cornea moist For the patients with risk of exposure keratopathy, using polyethylene films cover the eyes. Change the polyethylene films daily or whenever necessary (such as soiled or torn). When polyethylene cover is not applicable, artificial tear is suggecsted to apply to the eyes every 4 hours.④ Avoid bacterial colonization in ocular surface Don’t withdraw the suction catheter across patient’s face after suctioning. The patient with lung infection should use close suction system as far as possible.3. Evaluating the effectiveness of care bundles for prevention of exposure keratopathy in ventilated critically ill patients with impaired blinking reflex① The intervention group enrolled 62 patients who meet standard, but 9 were further excluded. The control group included 65 standard patients and 12 of them were excluded.1 patient excluded because of the eye-care measures given less than 24 hours.12 patients were positive at the first fluorescence staining.② Compared with the intervention group (n=6,11.3%) (patients have occurred exposure keratopathy) and the control group(n=15,28.9%), the difference was statistically significant. (P<0.05). The severity of exposure keratopathy in patients of the two groups is mainly 1 grade (81.5%), and there are no 4-6 grades.③ The incomplete eyelid closure group had a high incidence of exposure keratopathy (P<0.05). Using of sedative drugs and muscle relaxants and conjunctival edema are not the risk factors of exposure keratopathy (P>0.05).④ In terms of the patients in the intervention group, the exposure keratopathy would occur within 4-10 days after admission, and the median is 5 days, which indicates that 50% patients occurred exposure keratopathy 5 days later after admission. However, time of the control group is 2-22 days after admission, the median is 4 days. The time of the two groups had no statistically significant difference (P>0.05).⑤ The difference of compliance rate of two groups on keeping eyelid closure and the cornea moist was statistically significant difference (P<0.05), while the incidence of exposure keratopathy of two groups showed no significant difference (P>0.05) when the grouping variable is whether comply with the interventions.Conclusion① The attitude of ICU nurses about eye complications prevention is acceptable, but the level of knowledge and practice needs to be further improved. This study suggested to strengthen the training of ICU nurse about eye complications knowledge and develop standardized guidelines to reduce the incidence of eye complications in critically ill patients.② Care bundles can reduce the incidence of occurring exposure keratopathy in ventilated patients and lower the severity. Training and audit during implementation of care bundles could improve nurses’adherence to perform preventive measures of eye complications.③ The advantages of care bundles are obvious, for the method is easy to operate, the material is easy to get and the price is very cheap. All of these make care bundles suitable to application in ventilated critically ill patients with impaired blinking reflex. |
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