Author Archives: Amy

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About Amy

Clinical Informationist at EUH Branch Library

Is there evidence for optimal frequency for monitoring sedation level?

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Bottom line:  There is little published evidence evaluating frequency of monitoring level sof sedation.

Joanna Briggs did not have any information.

CINAHL and PubMed had guidelines and validation studies evaluating the various sedation assessment scales, but none of that literature addresses how frequently to perform assessments.

DynaMed references recommendations of American Hospital Formulary Service.

Most relevant results

Brook AD, et al.  Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation.  Crit Care Med. 1999 Dec;27(12):2609-15.
Reassessment every 4 hours is part of the protocol; outcomes were reduced time on mechanical ventilator, length of stay in ICU, and rate of tracheostomy for the protocol group compared to the standard care group

DynaMed

Propofol drug information.
Recommends assessing level of sedation at least daily.  See Warning and Precautions>General Precautions>Critical Care Sedation

Guidelines and additional validation studies:

Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.  Crit Care Med. 2002 Jan;30(1):119-41
-recommends using a validated scale to monitor level of sedation, but cites a systematic review of scales to state that there was no gold-standard scale for assessing sedation level at time of these guidelines.  Does not recommend specific frequency for monitoring patients.  Objective Assessment of Sedation section reviews evidence of Motor Activity Assessment Scale, Riker Sedation-Agitation Scale, and Ramsay Scale and Vancouver Interaction and Calmness Scale.  Does not include the Richmond Agitation-Sedation Scale.

Ely EW, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).  JAMA. 2003 Jun 11;289(22):2983-91.
-Confirmed interrater reliability and validity of RASS in medical ICU patients.

Vender JS.  Sedation, analgesia, and neuromuscular blockade in sepsis: an evidence-based review.  Crit Care Med. 2004 Nov;32(11 Suppl):S554-61.
-Includes discussion of scales in context of patients with sepsis

What are nurses’ attitudes toward peer accountability?

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A search of CINAHL and PubMed for these concepts:
peer accountability or peer review or peer evaluation
nurses
attitudes OR psychology OR perspectives OR beliefs

Results

CINAHL – Including these studies
Peer evaluation in nurses’ professional development: a pilot study to investigate the issues.Full Text Available (includes abstract); Vuorinen R; Tarkka M; Meretoja R; Journal of Clinical Nursing, 2000 Mar; 9 (2): 273-81 (journal article – research, tables/charts) ISSN: 0962-1067 PMID: 11111619

Using Synergy in peer review: a staff nurse’s perspective.Detail Only Available (includes abstract); Packard S; Excellence in Nursing Knowledge, 2004 Aug-Sep. (2p)
 

Does frequency of providing stoma and inner canula care reduce rate of VAP in patients with tracheostomy?

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Bottom line:  There is not much evidence available on this question.  Most recommendations are based on expert opinion.

A search of PubMed and CINAHL for these concepts–tracheotomy, tracheostomy, ventilator-associated pneumonia, prevention–revealed one study specifically examining care of the tracheostomy–Eid RC, et al.  Successful prevention of tracheostomy associated pneumonia in step-down units.  Am J Infect Control. 2011 Aug;39(6):500-5.
Intervention included “drainage and discarding of condensate” in the tubing at least 3 times per day, but this doesn’t say specifically changing the tubing. No additional studies identified that evaluated care of the tracheostomy in preventing outcome of ventilator-associated pneumonia.

Tracheostomy: Stoma Care.  Joanna Briggs Institute, 2010.  States that evidence regarding tracheostomy is mostly based on expert opinion as there are not many published studies on tracheostomy procedures and care.

Tracheostomy:  Management – references guideline that relies on expert opinion in recommendation

Cites this small study that found no statistically significant difference in bacterial colonization between patients who had canula changed daily versus those who did not.

Burns SM, et al.  Are frequent inner cannula changes necessary?: A pilot study.  Heart Lung. 1998 Jan-Feb;27(1):58-62.
This small study that found no statistically significant difference in bacterial colonization between patients who had canula changed daily versus those who did not.  Did not look at ventilator-associated pneumonia rates.

What is the standard for changing the inner cannula and performing stoma care in tracheostomies?

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Bottom line:  Recommendations for tracheostomy management include daily cleaning of inner canula, as well as routine cleaning and daily inspections of the stoma.

Summary: 
Tracheostomy: Stoma Care.  Joanna Briggs Institute.  April 26, 2010.
Recommends routine cleaning and daily inspection for signs of infection in the skin around the stoma.  Evidence based on expert opinion.

AACN Procedure Manual, 6th ed, 2011 .
Recommends monitoring skin around stoma for breakdown.

Tracheostomy:  Management.  Joanna Briggs Institute, October 29, 2010.  
Recommends cleaning inner cannula daily based on guidelines that did not cite studies, but relied on expert opinion.

For inpatients, are skin assessments by two staff more accurate than skin assessments by one staff at detecting pressure ulcers and areas at risk for ulcers?

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Bottom line:  Practice guidelines recommend having a standard procedure for assessing and documenting skin and training staff who will be making these assessments, but there is no specific recommendation for the number of staff required for assessing skin.

DynaMed topic on Pressure Ulcers includes a section on prevention screening and section on guidelines.  Prevention/screening section summarizes data on utility of specific structured assessment tools.  There are numerous guidelines, which should document studies on which they base recommendations.  One guideline is Institute for Clinical Systems Improvement (ICSI) guideline on pressure ulcer treatment.

JBI+COnNECT – There are several evidence summaries, but the most relevant ones (ex: Pressure Ulcers: Prevention and Management, seem to  reference the guidelines included in DynaMed, such as that of the Royal College of Nursing.

No identifed recommendations or mention of using more than one person to assess a patient’s skin in the DynaMed or JBI+ information.

PubMed search:  pressure ulcers AND (rater* OR observer*) AND (accura* OR reliabl*)

Yielded studies such as these two that compare use of one nurse to two nurses in documenting skin and found no difference in the number of pressure ulcers documented.  These studies did not address assessment for risk.

Kottner J, Tannen A, Dassen T. Hospital pressure ulcer prevalence rates and number of raters. J Clin Nurs. 2009 Jun;18(11):1550-6.

Kottner J, Tannen A, Halfens R, Dassen T. Does the number of raters influence the pressure ulcer prevalence rate? Appl Nurs Res. 2009 Feb;22(1):68-72.