Enfermeria Intensiva最新文献

The Bacteraemia Zero (BZ) Project was the first of the Zero Projects to be implemented in Intensive Care Unit (ICU), achieving a decrease in catheter-related infection rates below those recommended by the quality standards of scientific societies. Following the SARS-CoV-2 pandemic in ICU, a significant increase in these infection rates has been observed. Increase in infection rates and the need to incorporate the best available evidence into clinical practice justifies the need to update the recommendations of the BZ project. A working group formed by members of the different scientific societies considered that the mandatory measures of the project should not be modified due to its proven efficacy. In addition, this group decided to incorporate the following optional measures: use of catheters impregnated with antimicrobials, use of dressings impregnated with chlorhexidine, use of caps with an antiseptic solution in connectors, and daily body hygiene with chlorhexidine.

Patient safety is a priority for all healthcare systems and is especially relevant in critical patients. Despite its relevance and progress, in recent years there are still many patients who suffer adverse events with harm and negative repercussions for professionals and institutions. Zero projects are presented as strategies to reduce infections related to invasive devices and this type of adverse events, demonstrating their remarkable effectiveness. This article presents the main tools to improve safety in daily ICU care and discusses how to involve professionals in the evaluation through safety indicators.

Introduction

COVID-19 patients admitted to critical care units present an intense inflammatory response and the need to replace organs or systems for long periods of time, which facilitates the presence of infectious complications.

Objectives

To present the national rates of infections related to invasive devices (IRDI) in COVID-19 patients, as well as the rates of multi-resistant bacteria (MBR) acquired during their stay in critical care units.

Method

Retrospective analysis of COVID-19 patients included during the first, second and fourth waves of the pandemic in a national observational and multicenter database (ENVIN-HELICS). Pneumonias related to mechanical ventilation (N-MV), urinary tract infections related to urethral catheter (UTI-SU) and primary bacteremia related to central venous catheters (BP-CVC) were recorded, whose rates are presented as incidence density (ID). The BMRs acquired during the stay in the critical care units were recorded and presented as cumulative incidence (CI).

Results

Seven thousand seven hundred seventy-eight patients were included, 1,525 (19.6%) in the first wave of the pandemic, 3,484 (44.8%) in the second, and 2,769 (35.6%) in the fourth. ICU stay of 21 days in the first and second waves and 19.7 days in the fourth. Intra-ICU mortality in the first wave, decreasing from 31% to 26.3% in the second and 18.9% in the fourth. N-MV rates of 14.31, 13.56, and 19.99 episodes per 1,000 days of MV in each wave. UTI-SU rates of 6.54, 5.63 and 7.97 episodes per 1000 days of SU. BP-CVC rates of 12.42, 7.95, and 8.13 per 1,000 CVC days. The BMR rate was 22.9, 15.3, and 15.3 BMR per 100 admitted patients.

Conclusions

High rates of the different IRDI in COVID patients that are maintained in the three waves analyzed. High rates of BMR acquired during the stay in critical care units with a tendency to decrease in the fourth wave.

During the COVID-19 pandemic, the world's healthcare systems were extremely strained. Intensive care units were stretched to capacity and healthcare facilities were forced to set up spaces to care for critically ill patients. Professionals were required to work in strenuous conditions, completely disrupting their work routines.

In this scenario, hand hygiene and the use of gloves by healthcare professionals became a critical point of transmission risk.

The results of the ENVIN study in 2020 and 2021, corresponding to the pandemic period, showed worrying data on the increase in infection rates, with rates rising by 250% at the worst moments of the pandemic. This suggested that excessive risk situations were occurring for the patient. Any preventive strategy must place correct hand hygiene and proper use of gloves among its priority objectives. For this reason, the Project Zero Advisory Board made a series of adaptations and recommendations based on available evidence and expert opinion related to hand hygiene and glove use during the pandemic situation to promote best practice in extreme situations. This article reviews the key aspects of hand hygiene as part of the WHO safety strategy, the main barriers to compliance and the main adaptations proposed by the Advisory Board of the Zero projects.

Evidence shows that training critical care nurses in the prevention of ventilator-associated pneumonia (VAP) and catheter-associated bacteremia (CBB) reduces ICU length of stay and mortality. The Advisory Council of the «Zero Tolerance» Safety Projects of the Ministry of Health proposes to promote such training and the teaching methodology of simulation emerges as optimal for training the necessary skills and knowledge. Simulation-based learning is a student-centered teaching methodology that promotes immediate and participatory feedback between teachers and participants, known as debriefing.

The objective is to develop technical skills (necessary to carry out a specific procedure) or non-technical skills (communication, leadership, teamwork, situational awareness, decision making, use of resources, safe practice and reduction of adverse events).

The SIMULAZERO course is based on a Objective structured clinical examination (OSCE) composed of two low-fidelity scenarios for training in secretion aspiration technique and catheter insertion respectively and a high-fidelity scenario for the development of non-technical skills.

We describe how to prepare each scenario (clinical case, script for the actors and necessary material) so that the training can be implemented in the intensive care unit itself, as well NEUMOBACT instrument, as the evaluation grid on which to base the development of the debriefing.

The SARS-Cov-2 pandemic has had a negative impact on the implementation of the Zero Pneumonia recommendations and has been accompanied by an increase in rates of ventilator- associated pneumonia (VAP) in intensive care units in Spain. With the aim of reducing the current rates to 7 episodes per 1000 days of MV, the recommendations of the initial project have been updated.

Twenty-seven measures were identified and classified into 12 functional measures (semi- sitting position, strict hand hygiene, airway manipulation training, daily assessment of possible extubation, protocolisation of weaning, early tracheostomy, non-invasive ventilation, microbiological surveillance, tubing change, humidification, respiratory physiotherapy, post- pyloric enteral nutrition), 7 mechanical measures (pneumotap pressure control, subglottic suction tubes, subglottic suctioning of tubes, subglottic suctioning of tubes, post-pyloric enteral nutrition, subglottic suction tubes, small-bore/small-bowel tube nutrition, closed/open circuit secretion suctioning, respiratory filters, tooth brushing, negative pressure techniques for secretion suctioning) and 8 pharmacological (selective digestive decontamination, oropharyngeal decontamination, short course of antibiotics, chlorhexidine mouth hygiene, inhaled antibiotics, antibiotic rotation, probiotics, monoclonal antibodies).

Each measure was analysed independently, by at least two members of the working group, through a systematic review of the literature and an iterative review of recommendations from scientific societies and/or expert groups.

For the classification of the quality of the evidence and strength of the recommendations, the GRADE group proposal was followed. To determine the level of recommendation, each measure was scored by all members of the working group in relation to its effectiveness, tolerability and applicability in Spanish ICUs in the short term. The support of external experts was requested for some of the measures reviewed. Those measures that achieved the highest score were selected.

The negative impact of the pandemic on infection control rates has highlighted the need to resume the implementation of Project Zero (PZ) recommendations. This article first analyses the situation of intensive care units in Spain during the pandemic. Subsequently, it presents the adaptation of the recommendations of each of the four PZs and their degree of compliance and the risk of invasive device-related infections and/or multidrug-resistant bacteraemias. For this purpose, we have taken into account: (i) the document published in October 2020 by the Advisory Board of the Critical Patient Safety Programme, and (ii) the exploratory study conducted, one year later, by the Advisory Board of the PZs, on the leaders of the Projects of the units participating in the ENVIN registry. Finally, based on the findings, five tentative and priority recommendations are formulated.

Introduction

The nursing process is the scientific method specific to the nursing discipline. However, although in recent years it has rapidly expanded in certain areas, this has not been the case in special units such as the intensive care unit.

Objective

To determine the reasons nurses show little awareness of incorporating nursing methodology in Intensive Care Units.

Method

Literature review conducted between November and December 2020 in the databases Pubmed, Cinahl, Cuiden, Lilacs, Cochrane, Sicelo, Web of Science, in addition to a search of grey literature and electronic journals. Boolean operators AND and OR were used and the temporal limiter of the last 10 years (2010-2020) was applied.

Results

A total of 20 articles were selected. Intensive Care Units nurses perceived a lack of knowledge on how to use nursing methodology. This problem begins in university education and continues in the institutions with little continuing education. Nurses’ work overload takes time from being able to use this tool, which is among the lowest of their priorities.

Conclusions

Research studies are required on solutions that, in the nurses’ words, could be useful in tackling this problem, and on the impact that training programmes in methodology have on its application in practice.

Objective

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

Methodology

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

Results

Four significant themes emerged from the analysis: 1) Delirium prevention, 2) Pharmacological treatment, 3) Non-pharmacological treatment, and 4) Barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

Conclusions

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.